Symptom: Heat or Cold Intolerance

Initial Grading Reminder

CTCAE Grading of Heat/Cold Intolerance:

Grade 2: Symptomatic; thyroid replacement indicated; limiting instrumental ADLs

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly?

Grade the symptom

Ask the patient:

How much difficulty do you have with the heat? With the cold? Is it affecting your ability to function? Are you able to sleep?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Are you having any difficulty swallowing? Do you feel like your heart is going real slow or real fast? Do you feel like yourself mentally (i.e., are you a bit hyper or depressed)?

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

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    Suggested Intervention

    Patients who are affected by the temperature intolerance should be seen.

    Patients with any of the red-flag symptoms should be seen immediately.

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    Nursing Assessment of Potential Causes

    Thyroiditis - Nursing Assessment

    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Look
    • Listen
    • Recognize
    • Does the patient appear unwell?
    • Changes in weight since last visit
      • Appear heavier? Thinner?
    • Changes in hair texture/thickness?
    • Appearing hot/cold?
    • Does the patient look fatigued?
    • Appetite/weight changes?
    • Hot or cold intolerance?
    • Change in energy, mood, or behavior?
    • Palpitations?
    • Increased fatigue?
    • Bowel-related changes?
      • Constipation/diarrhea
    • Skin-related changes?
      • Dry/oily
    • Ensure that patient undergoes thyroid function tests prior to first dose, every 12 weeks while on PD-1 therapy and q3 weeks with ipilimumab
    • High TSH with low free T4 consistent with primary hypothyroidism
    • DDX: secondary hypothyroidism due to hypophysitis, low TSH and low free T4
    • Occasionally thyroiditis with transient hyperthyroidism (low TSH and high free T4) may be followed by more longstanding hypothyroidism (high TSH and low free T4)
    • Other immune-related toxicity?
    • Prior thyroid dysfunction?

    Differential Diagnosis

    What do you suspect is the cause of your heat/cold intolerance?