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Wu L, Tsang V, Menzies AM, Sasson SC, Carlino MS, Brown DA, Clifton-Bligh R, Gunton JE. Risk Factors and Characteristics of Checkpoint Inhibitor-Associated Autoimmune Diabetes Mellitus (CIADM): A Systematic Review and Delineation From Type 1 Diabetes. Diabetes Care 2023; 46:1292-1299. [PMID: 37220262 DOI: 10.2337/dc22-2202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/27/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Checkpoint inhibitor-associated autoimmune diabetes mellitus (CIADM) is a distinct form of autoimmune diabetes that is a rare complication of immune checkpoint inhibitor therapy. Data regarding CIADM are limited. PURPOSE To systematically review available evidence to identify presentation characteristics and risk factors for early or severe presentations of adult patients with CIADM. DATA SOURCES MEDLINE and PubMed databases were reviewed. STUDY SELECTION English full text articles from 2014 to April 2022 were identified with a predefined search strategy. Patients meeting diagnostic criteria for CIADM with evidence of hyperglycemia (blood glucose level >11 mmol/L or HbA1c ≥6.5%) and insulin deficiency (C-peptide <0.4 nmol/L and/or diabetic ketoacidosis [DKA]) were included for analysis. DATA EXTRACTION With the search strategy we identified 1,206 articles. From 146 articles, 278 patients were labeled with "CIADM," with 192 patients meeting our diagnostic criteria and included in analysis. DATA SYNTHESIS Mean ± SD age was 63.4 ± 12.4 years. All but one patient (99.5%) had prior exposure to either anti-PD1 or anti-PD-L1 therapy. Of the 91 patients tested (47.3%), 59.3% had susceptibility haplotypes for type 1 diabetes (T1D). Median time to CIADM onset was 12 weeks (interquartile range 6-24). DKA occurred in 69.7%, and initial C-peptide was low in 91.6%. T1D autoantibodies were present in 40.4% (73 of 179) and were significantly associated with DKA (P = 0.0009) and earlier time to CIADM onset (P = 0.02). LIMITATIONS Reporting of follow-up data, lipase, and HLA haplotyping was limited. CONCLUSIONS CIADM commonly presents in DKA. While T1D autoantibodies are only positive in 40.4%, they associate with earlier, more severe presentations.
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Affiliation(s)
- Linda Wu
- The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
| | - Venessa Tsang
- University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia Sydney, New South Wales, Australia
| | - Alexander M Menzies
- University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia Sydney, New South Wales, Australia
- Melanoma Institute Australia, Sydney, New South Wales, Australia
- Mater Hospital, Sydney, New South Wales, Australia
| | - Sarah C Sasson
- University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
- Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Sydney, New South Wales, Australia
| | - Matteo S Carlino
- University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
- Melanoma Institute Australia, Sydney, New South Wales, Australia
- Mater Hospital, Sydney, New South Wales, Australia
| | - David A Brown
- The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
- Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Sydney, New South Wales, Australia
| | - Roderick Clifton-Bligh
- University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia Sydney, New South Wales, Australia
| | - Jenny E Gunton
- The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
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Mulla K, Farag S, Moore B, Matharu S, Young K, Larkin J, Popat S, Morganstein DL. Hyperglycaemia following immune checkpoint inhibitor therapy-Incidence, aetiology and assessment. Diabet Med 2023; 40:e15053. [PMID: 36696014 DOI: 10.1111/dme.15053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/11/2022] [Accepted: 01/23/2023] [Indexed: 01/26/2023]
Abstract
AIMS We systematically studied the presence of hyperglycaemia during treatment with Immune Checkpoint Inhibitors (ICPI) for cancer, in those with and without diabetes at baseline, and determined the cause of new-onset hyperglycaemia, METHODS: Retrospective review of electronic records of those receiving an ICPI for melanoma, lung or renal cancer. RESULTS Overall, 959 participants were included. In this study, 103 had diabetes at baseline (10.7%). Those with lung cancer had the highest frequency of diabetes; 131 people had hyperglycaemia (defined as at least one glucose ≥11.1 mmol/L) in the year after starting an ICPI. The incidence was 55% in those with diabetes at baseline, and 8.6% in those without baseline diabetes. Among 74 with new-onset hyperglycaemia (without pre-existing diabetes) 76% was attributable to steroid induced diabetes, with 9.5% due to ICPI Induced diabetes resembling type 1 diabetes. CONCLUSIONS Hyperglycaemia is common in persons receiving an ICPI for cancer, including 8.6% of those without known diabetes. While much of this is due to glucocorticoid use, care is needed to avoid missing those with ICPI-induced diabetes who are at risk of diabetic ketoacidosis, which is a medical emergency.
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Affiliation(s)
- Kaenat Mulla
- Beta Cell Diabetes Unit, Chelsea and Westminster Hospital, London, UK
| | | | - Benedict Moore
- Beta Cell Diabetes Unit, Chelsea and Westminster Hospital, London, UK
| | | | - Kate Young
- Skin Unit, Royal Marsden Hospital, London, UK
| | | | | | - Daniel Laurence Morganstein
- Beta Cell Diabetes Unit, Chelsea and Westminster Hospital, London, UK
- Lung Unit, Royal Marsden Hospital, London, UK
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Rodríguez de Vera-Gómez P, Piñar-Gutiérrez A, Guerrero-Vázquez R, Bellido V, Morales-Portillo C, Sancho-Márquez MP, Espejo-García P, Gros-Herguido N, López-Gallardo G, Martínez-Brocca MA, Soto-Moreno A. Flash Glucose Monitoring and Diabetes Mellitus Induced by Immune Checkpoint Inhibitors: An Approach to Clinical Practice. J Diabetes Res 2022; 2022:4508633. [PMID: 36387939 PMCID: PMC9652069 DOI: 10.1155/2022/4508633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/01/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES The aim of this study is to investigate in depth diabetes mellitus associated with immune checkpoint inhibitors (DM-ICIs) by analysing a case series. We also evaluated the clinical impact of flash glucose monitoring (FGM) systems in the management of this entity. METHODS We conducted an observational cohort study of DM-ICIs diagnosed in two hospitals in Seville (Spain). Patients with a new diagnosis of diabetes mellitus (DM) or with sudden worsening of preexisting DM after starting treatment with ICIs, with a random 5 hour-postprandial C-peptide value of <0.6 nmol/L and without possibility of subsequent withdrawal of insulin treatment, were included. RESULTS A total of 7 cases were identified, mostly males (n = 6; 85.7%), with a mean age of 64.9 years. The mean glycated hemoglobin (HbA1c) upon diagnosis was 8.1%, with diabetic ketoacidosis (DKA) observed in 6 cases (85.7%). Subcutaneous flash glucose monitoring (FGM) systems were used in six cases, with a mean follow-up period of 42.7 weeks. During the first 90 days of use, mean average glucose was 167.5 mg/dL, with a coefficient of variation (CV) of 34.6%. The mean time in the range 70-180 mg/dL (TIR) was 59.7%, with a mean time above range (TAR) 181-250 mg/dL of 27.8% and a mean TAR > 250 mg/dL of 10.2%. The mean time below range (TBR) 54-69 mg/dL was 2%, while the mean TBR < 54 mg/dL was 0.3%. The mean glucose management indicator (GMI) was 7.3%. No significant differences were observed in FGM values for the following 90 days of follow-up. A progressive improvement in all parameters of glycaemic control was observed between the first month of FGM use and the sixth month of FGM use. Of note, there was a decrease in mean CV (40.6% to 34.1%, p = 0.25), mean TAR 181-250 (30.3% to 26%, p = 0.49), mean TAR > 250 mg/dL (16.3% to 7.7%, p = 0.09), mean TBR 54-69 mg/dL (5.2% to 2%, p = 0.16), and mean TBR < 54 mg/dL (1.8% to 0.2%, p = 0.31), along with an increase in mean values of TIR 70-180 mg/dL (46.5% to 60.5%, p = 0.09). The lack of statistical significance in the differences observed in the mean FGM values over the follow-up period may be related to the small sample size. CONCLUSION DM-ICI is recognised by a state of sudden-onset insulinopenia, often associated with DKA. The use of FGM systems may be a valid option for the effective management of DM-ICIs and for the prevention of severe hyperglycaemic and hypoglycaemic episodes in this condition.
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Affiliation(s)
| | - Ana Piñar-Gutiérrez
- Endocrinology and Nutrition Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Raquel Guerrero-Vázquez
- Endocrinology and Nutrition Department, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Virginia Bellido
- Endocrinology and Nutrition Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | | | | | - Noelia Gros-Herguido
- Endocrinology and Nutrition Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Gema López-Gallardo
- Endocrinology and Nutrition Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - Alfonso Soto-Moreno
- Endocrinology and Nutrition Department, Hospital Universitario Virgen del Rocío, Seville, Spain
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Wu L, Tsang VHM, Sasson SC, Menzies AM, Carlino MS, Brown DA, Clifton-Bligh R, Gunton JE. Unravelling Checkpoint Inhibitor Associated Autoimmune Diabetes: From Bench to Bedside. Front Endocrinol (Lausanne) 2021; 12:764138. [PMID: 34803927 PMCID: PMC8603930 DOI: 10.3389/fendo.2021.764138] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/30/2021] [Indexed: 12/14/2022] Open
Abstract
Immune checkpoint inhibitors have transformed the landscape of oncological therapy, but at the price of a new array of immune related adverse events. Among these is β-cell failure, leading to checkpoint inhibitor-related autoimmune diabetes (CIADM) which entails substantial long-term morbidity. As our understanding of this novel disease grows, parallels and differences between CIADM and classic type 1 diabetes (T1D) may provide insights into the development of diabetes and identify novel potential therapeutic strategies. In this review, we outline the knowledge across the disciplines of endocrinology, oncology and immunology regarding the pathogenesis of CIADM and identify possible management strategies.
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Affiliation(s)
- Linda Wu
- Centre for Diabetes, Obesity and Endocrinology, The Westmead Institute for Medical Research, Sydney, NSW, Australia
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia
- Department of Endocrinology, Westmead Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- *Correspondence: Linda Wu,
| | - Venessa H. M. Tsang
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Sarah C. Sasson
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Immunology, Westmead Hospital, Sydney, NSW, Australia
- NSW Health Pathology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney, NSW, Australia
| | - Alexander M. Menzies
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
| | - Matteo S. Carlino
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Melanoma Institute Australia, The University of Sydney, Sydney, NSW, Australia
- Department of Medical Oncology, Westmead Hospital, Sydney, NSW, Australia
| | - David A. Brown
- Centre for Diabetes, Obesity and Endocrinology, The Westmead Institute for Medical Research, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Immunology, Westmead Hospital, Sydney, NSW, Australia
- NSW Health Pathology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney, NSW, Australia
| | - Roderick Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jenny E. Gunton
- Centre for Diabetes, Obesity and Endocrinology, The Westmead Institute for Medical Research, Sydney, NSW, Australia
- Department of Endocrinology, Westmead Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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