medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/2079-701X-2021-4S-108-113medsovet-6217Research ArticleКЛИНИЧЕСКОЕ НАБЛЮДЕНИЕCLINICAL OBSERVATIONКлинический случай лечения пациента с острой надпочечниковой недостаточностью после комбинированной иммунотерапии (ниволумаб + ипилимумаб). Перспективы возвращения к иммунотерапии после тяжелых осложненийA clinical case of treatment of a patient with acute adrenal insufficiency after combined immunotherapy (nivolumab + ipilimumab). Prospects for a return to immunotherapy after severe complications of immunotherapyhttps://orcid.org/0000-0003-4469-502XЛактионовК. К.LaktionovК. К.

Лактионов Константин Константинович, д.м.н., профессор, заведующий онкологическим отделением лекарственных методов лечения (химиотерапевтическое) № 17

115478, Москва, Каширское шоссе, д. 24

Konstantin K. Laktionov, Dr. Sci. (Med.), Professor, Head of Drug Therapy (Chemotherapeutic) Department No. 17

24, Kashirskoye Shosse, Moscow, 115478

https://orcid.org/0000-0002-7817-8429СаранцеваК. А.SarantsevaК. А.

Саранцева Ксения Андреевна, к.м.н., врач-онколог

115478, Москва, Каширское шоссе, д. 24

Ksenia A. Sarantseva, Cand. Sci. (Med.), Oncologist

24, Kashirskoye Shosse, Moscow, 115478

sarantsevaka@gmail.comhttps://orcid.org/0000-0002-0620-2696ЮдинД. И.YudinD. I.

Юдин Денис Иванович, к.м.н., старший научный сотрудник

115478, Москва, Каширское шоссе, д. 24

Denis I. Yudin, Cand. Sci. (Med.), Senior Researcher

24, Kashirskoye Shosse, Moscow, 115478

https://orcid.org/0000-0002-7897-3422БелоярцеваМ. Ф.BeloyartsevaМ. F.

Белоярцева Мария Феликсовна, к.м.н. врач-эндокринолог

115478, Москва, Каширское шоссе, д. 24

Maria F. Beloyartseva, Cand. Sci. (Med.), Endocrinologist

24, Kashirskoye Shosse, Moscow, 115478

https://orcid.org/0000-0002-9562-9113ЮнаевГ. С.YunaevG. S.

Юнаев Григорий Сергеевич, заведующий отделением реанимации и интенсивной терапии № 2, врач-анестезиолог-реаниматолог

115478, Москва, Каширское шоссе, д. 24

Grigory S. Yunaev, Head of the Rehabilitation and Intensive Care Department No. 2, Anesthesiologist-Intensivist

24, Kashirskoye Shosse, Moscow, 115478

Национальный медицинский исследовательский центр онкологии имени Н.Н. БлохинаРоссияBlokhin National Medical Research Center of OncologyRussian Federation20211206202104S108113Copyright © Лактионов К.К., Саранцева К.А., Юдин Д.И., Белоярцева М.Ф., Юнаев Г.С., 20212021Лактионов К.К., Саранцева К.А., Юдин Д.И., Белоярцева М.Ф., Юнаев Г.С.Laktionov К.К., Sarantseva К.А., Yudin D.I., Beloyartseva М.F., Yunaev G.S.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-sovet.pro/jour/article/view/6217

Ингибиторы контрольных точек, а также их комбинации все шире входят в повседневную практику онколога. Однако учитывая механизм действия, его использование может быть связано с побочными иммунными эффектами, которые могут осложнять клиническое течение и прогноз заболевания. По мере роста числа зарегистрированных показаний для назначения ингибиторов PD-1, PD-L1, CTLA-4 и их комбинаций, увеличивается частота сообщений о развитии редких осложнений, связанных с иммунотерапией, среди которых особо следует выделить группу аутоиммунных эндокринопатий. Такие осложнения, как гипофизит, гипо- и гипертиреоз встречаются достаточно часто, сравнительно легко поддаются коррекции и обычно не приводят к отмене терапии. Механизмы, лежащие в основе иммунного повреждения органов-мишеней, остаются малоизученными. Первичная надпочечниковая недостаточность – редкое и потенциально жизнеугрожающее осложнение, которое за счет неспецифических симптомов может быть распознано слишком поздно. Развитие надпочечниковой недостаточности отмечено всего у 0,7% пациентов в рандомизированных клинических исследованиях. На сегодняшний день не существует единой тактики для выявления и лечения этого осложнения. Ведение таких пациентов возможно только мультидисциплинарной командой, имеющей в своем составе эндокринолога. Мы представляем клинический случай развития надпочечниковой недостаточности на фоне комбинированной химиоиммунотерапии и результаты лечения пациента после лечения. 

Checkpoint inhibitors, as well as their combinations, are increasingly included in the daily practice of the oncologist. However, given the mechanism of action, its use may be associated with immune side effects that can complicate the clinical course and prognosis of patients. As the number of reported indications for the administration of PD-1, PD-L1, CTLA-4 inhibitors increases, the rate of reports of rare complications associated with immunotherapy increases. Among the complications, it is worth highlighting the group of autoimmune endocrinopathies. Such complications of immunotherapy as hypophysitis, hypo- and hyperthyroidism are quite common, are relatively easy to correct and usually do not lead to discontinuation of therapy. The mechanisms underlying immune damage to target organs remain poorly understood. Primary adrenal insufficiency is a rare and potentially life-threatening complication that, due to non-specific symptoms, may be recognized too late. The development of adrenal insufficiency was noted in only 0.7% of patients in randomized clinical trials. To date, there is no single tactic for identifying and treating this complication. The management of such patients is possible only by a multidisciplinary team that includes an endocrinologist. We present a clinical case of the development of adrenal insufficiency on the background of combined chemo-immunotherapy and the results of the patient’s treatment after its resolution. 

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The authors declare that there are no conflicts of interest present.