# 一位接受pembrolizumab治療黑色素瘤的個案出現惡化的疲倦、低血壓、低血鈉和低皮質醇。下列何者是護理師的優先判讀？

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=391871&lang=zh-tw  
> language: zh-TW  
> subject: Medical Emergencies  
> category: PA

## 題目

一位接受pembrolizumab治療黑色素瘤的個案出現惡化的疲倦、低血壓、低血鈉和低皮質醇。下列何者是護理師的優先判讀？

## 選項

1. 免疫相關不良事件（irAE），可能為腦下垂體炎或原發性腎上腺功能不全；暫停pembrolizumab，開始壓力劑量hydrocortisone並進行內分泌評估 **✔ 正確答案**
2. 只有敗血症
3. 與pembrolizumab無關
4. 只有脫水

**正確答案: 1**

## 解析

正確答案(2)：免疫檢查點抑制劑（pembrolizumab、nivolumab、ipilimumab）會引起影響任何器官的免疫相關不良事件——肺炎、結腸炎、肝炎、甲狀腺、垂體炎／腎上腺、心肌炎、腎炎、皮膚炎。內分泌 irAE：垂體炎、腎上腺功能不全、甲狀腺炎、第一型糖尿病。治療：對於中重度 irAE，暫停藥物＋高劑量類固醇；內分泌缺乏常需終身補充。(1,3,4) 診斷錯誤。

## 深入解析

記憶提示 Checkpoint inhibitor會讓全身都發炎：pneumonitis、colitis、hepatitis、thyroiditis、hypophysitis、myocarditis等。第一線是類固醇。

## 臨床情境

情境 62歲男性轉移性黑色素瘤使用pembrolizumab；新出現疲倦、BP 92/60、Na 128、cortisol 2 mcg/dL。

## 重要概念

- **免疫檢查點抑制劑** — Pembrolizumab/nivolumab（PD-1）、atezolizumab/durvalumab（PD-L1）、ipilimumab（CTLA-4）。
- **免疫相關不良事件** — 任何器官都可能出現類自體免疫發炎；以類固醇±其他免疫抑制劑處理。
- **內分泌irAE** — 腦下垂體炎、原發性腎上腺功能不全、甲狀腺炎、T1DM；常需長期荷爾蒙補充。

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