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Wiebke Arlt Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK

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the Society for Endocrinology Clinical Committee The Society for Endocrinology, 22 Apex Court, Woodlands, Bradley Stoke, Bristol, UK

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Jeremy Turner Norfolk and Norwich University Hospital, Colney Lane, Norwich, UK

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Neil Gittoes Centre for Endocrinology, Diabetes and Metabolism, University Hospitals Birmingham & University of Birmingham, Birmingham Health Partners, Birmingham, UK

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Peter Selby Department of Medicine, Manchester Royal Infirmary, Manchester, UK

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the Society for Endocrinology Clinical Committee4 The Society for Endocrinology, Woodlands, Bradley Stoke, Bristol, UK

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Stephen Ball Department of Endocrinology, Central Manchester University Hospitals Foundation Trust, Manchester Royal Infirmary, Manchester, UK

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Julian Barth Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Blood Sciences, Leeds, UK

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Miles Levy Department of Endocrinology, University Hospitals of Leicester, Leicester Royal Infirmary, Leicester, UK

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the Society for Endocrinology Clinical Committee The Society for Endocrinology, 22 Apex Court, Woodlands, Bradley Stoke, Bristol, UK

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Jeremy Turner Norfolk and Norwich University Hospital, Colney Lane, Norwich, UK

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Neil Gittoes Centre for Endocrinology, Diabetes and Metabolism, University Hospitals Birmingham & University of Birmingham, Birmingham Health Partners, Birmingham, UK

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Peter Selby Department of Medicine, Manchester Royal Infirmary, Manchester, UK

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the Society for Endocrinology Clinical Committee The Society for Endocrinology, 22 Apex Court, Woodlands, Bradley Stoke, Bristol, UK

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Jennifer Walsh The Mellanby Centre for Bone Research, The Medical School, The University of Sheffield, Sheffield, UK

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Neil Gittoes Centre for Endocrinology, Diabetes and Metabolism, University Hospitals Birmingham & University of Birmingham, Birmingham Health Partners, Birmingham, UK

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Peter Selby Department of Medicine, Manchester Royal Infirmary, Manchester, UK

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the Society for Endocrinology Clinical Committee The Society for Endocrinology, 22 Apex Court, Woodlands, Bradley Stoke, Bristol, UK

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Stephanie E Baldeweg Department of Endocrinology, University College Hospital, London, UK
National Hospital for Neurology and Neurosurgery, London, UK

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Mark Vanderpump Physicians’ Clinic, London, UK

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Will Drake Department of Endocrinology, St Bartholomew’s Hospital, London, UK

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Narendra Reddy Endocrinology/General Medicine, University Hospitals Coventry and Warwickshire NHS Trust, University of Warwick, Coventry, UK

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Andrew Markey The Lister Hospital, London, UK

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Gordon T Plant Department of Endocrinology, University College Hospital, London, UK
National Hospital for Neurology and Neurosurgery, London, UK

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Michael Powell National Hospital for Neurology and Neurosurgery, London, UK

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Saurabh Sinha Royal Hallamshire Hospital, Sheffield, UK

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John Wass Department of Endocrinology, Oxford Centre for Diabetes Endocrinology and Metabolism, The Churchill, Oxford University, Oxford, UK

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the Society for Endocrinology Clinical Committee The Society for Endocrinology, 22 Apex Court, Woodlands, Bradley Stoke, Bristol, UK

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C E Higham Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK

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A Olsson-Brown The Clatterbridge Cancer Centre, Bebbington, Wirral, UK
The University of Liverpool, Brownlow Hill, Liverpool, UK

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P Carroll Department of Endocrinology, Guy’s & St. Thomas’ NHS Foundation Trust, London, UK

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T Cooksley Department of Acute Medicine, UHSM and Christie Hospital NHS Foundation Trust, Manchester, UK

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J Larkin Skin Unit, Royal Marsden Hospital, London, UK

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P Lorigan Department of Medical Oncology, Christie Hospital NHS Foundation Trust, Manchester, UK

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D Morganstein Department of Endocrinology, Chelsea and Westminster Hospital, London, UK

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P J Trainer Department of Endocrinology, Christie Hospital NHS Foundation Trust, Manchester, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK

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the Society for Endocrinology Clinical Committee The Society for Endocrinology, Starling House, 1600 Bristol Parkway North, Bristol, UK

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Immunotherapy treatment with checkpoint inhibitors (CPI) (CTLA-4 and PD-1 inhibitors) significantly improves survival in a number of cancers. Treatment can be limited by immune-mediated adverse effects including endocrinopathies such as hypophysitis, adrenalitis, thyroiditis and diabetes mellitus. If endocrinopathies (particularly hypocortisolemia) are not recognized early, they can be fatal. The diagnosis and management of endocrinopathies can be complicated by simultaneous multi-organ immune adverse effects. Here, we present Endocrine Emergency Guidance for the acute management of the endocrine complications of checkpoint inhibitor therapy, the first specialty-specific guidance with Endocrinology, Oncology and Acute Medicine input and endorsed by the Society for Endocrinology Clinical Committee. We present algorithms for management: endocrine assessment and management of patients in the first 24 hours who present life-threateningly unwell (CTCAE grade 3–4) and the appropriate management of mild-moderately unwell patients (CTCAE grade 1–2) presenting with features compatible with an endocrinopathy. Other important considerations in relation to hypohysitis and the maintenance of glucocorticoid therapy are discussed.

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S E Baldeweg Department of Diabetes and Endocrinology, University College London NHS Foundation Trust and Univeristy College London, London, UK

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S Ball Department of Medicine and Endocrinology, Manchester University Foundation Trust & Manchester Academic Health Science Centre Manchester, Manchester, UK

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A Brooke Royal Devon and Exeter NHS Foundation Trust, Exeter, UK

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H K Gleeson Department of Endocrinology, Queen Elizabeth Hospital, Birmingham, UK

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M J Levy University of Leicester and University of Leicester Hospitals Trust, Leicester, UK

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M Prentice Croydon Health Services NHS Trust, Croydon, UK

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J Wass Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology & Metabolism, Oxford, UK

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the Society for Endocrinology Clinical Committee The Society for Endocrinology, Starling House, 1600 Bristol Parkway North, Bristol, UK

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Cranial diabetes insipidus (CDI) is a treatable chronic condition that can potentially develop into a life-threatening medical emergency. CDI is due to the relative or absolute lack of the posterior pituitary hormone vasopressin (AVP), also known as anti-diuretic hormone. AVP deficiency results in uncontrolled diuresis. Complete deficiency can lead to polyuria exceeding 10 L/24 h. Given a functioning thirst mechanism and free access to water, patients with CDI can normally maintain adequate fluid balance through increased drinking. Desmopressin (DDAVP, a synthetic AVP analogue) reduces uncontrolled water excretion in CDI and is commonly used in treatment. Critically, loss of thirst perception (through primary pathology or reduced consciousness) or limited access to water (through non-availability, disability or inter-current illness) in a patient with CDI can lead to life-threatening dehydration. This position can be further exacerbated through the omission of DDAVP. Recent data have highlighted serious adverse events (including deaths) in patients with CDI. These adverse outcomes and deaths have occurred through a combination of lack of knowledge and treatment failures by health professionals. Here, with our guideline, we recommend treatment pathways for patients with known CDI admitted to hospital. Following these guidelines is essential for the safe management of patients with CDI.

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