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Immune-checkpoint inhibitors are immuno-modulatory antibodies used in patients with advanced cancers like melanoma, renal cell carcinoma, non-small cell lung cancer, etc. They are associated with a wide array of side effects, commonly known as immune-related adverse events (irAEs), affecting dermatological, gastrointestinal, hepatic, endocrine, and other systems. We present a case of nivolumab-induced adrenal insufficiency in a patient presenting with refractory hypotension. The patient is a 77-year-old caucasian male with metastatic renal cell carcinoma (RCC) on nivolumab therapy, presented to his primary doctor for symptoms of fatigue, weakness, loss of appetite, and dizziness. His initial blood pressure (BP) was noted to be 78/44 mmHg, so he was referred to the emergency department. He received several liters of intravenous (IV) fluid boluses; however, BP consistently stayed in 90s systolic and 40-50 diastolic. The lab investigations showed a low sodium level at 128 mmol/L, blood urea nitrogen (BUN) elevated at 37 mg/dL, creatinine elevated at 2.7 mg/dL. A morning cortisol level was checked; it came back low at 1.3 mcg/dL. Further testing with the cosyntropin stimulation test revealed low basal cortisol of 1 mcg/dL and only a mild increase to 10.20 mcg/dL after the cosyntropin administration. Adrenocorticotrophic hormone (ACTH) was checked that came out to be low

Abstract Study Objective-Heparin Induced Thrombocytopenia (HIT) is a life-threatening immunological response to heparin. The objectives for this study were to determine if the 4T scoring system was being utilized as a tool for predicting HIT, and to look at the costs associated with HIT panels. Methods-This was a retrospective chart review of patients greater than 18 years of age who had HIT panels performed between January 2013 and June 2014 in a community hospital. Any duplicate HIT panels sent during the same admission period were excluded. Study investigators were trained in two 30-minute intervals in the area of data collection and retrospective calculation of 4T score. Results- Of the 154 patients studied, 73 (47.4%) were male, and 81 (52.6%)were female. All patients had a 4T score calculated by study investigators during data analysis, and 1.29% (n=2) had a 4T score calculated before a HIT panel was sent by the team taking care of the patient. 62.3% (n=96) of patients had a low 4T score and 37. 7%( n=58) had an intermediate to high 4T score. Hematology was consulted on 57.7% (n=89) and anticoagulant administration was stopped on 74 % (n=114), while in 26 % ( 40/ 154) heparin was continued despite sending HIT. 25.4%(29/114) were started on alternate anti- coagulants after stopping heparin . Throughout the course of the study, 20 patients died, with only 1 of these patients being HIT positive. If 100 unnecessary HIT panels were performed in a year, the hospital would be charged more than $20,000 by the diagnostic lab. Additional costs include the halting of Heparin administration and starting an alternate anticoagulant such as Argatroban. 24 hour administration of Argatroban costed $1,000 for continuous infusion. HIT panels have a turnaround time of 4-5 days, resulting in the additional charge of $5,000 just for Argatroban administration. A lengthened stay in the hospital due to HIT panel turnaround time is also a source of increased costs. Combined, the ordering of a HIT panel, alternate anticoagulant administration, and bed charges could amount to $40,000 over the course of four days. This time and money could be put to better use treating the underlying disease of the patient, instead of focusing on the testing for HIT. Conclusion-Management of HIT in community hospital was sub-optimal. Lack of utilization of the 4T scoring system led to unnecessary ordering of HIT panels. This increased duration of hospital stay, elevated the cost of treatment, and resulted in the holding of prophylactic anticoagulants. Disclosures No relevant conflicts of interest to declare.