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Narumoto K, Oda N, Mitani R, Takata I. Atezolizumab-Induced Type 1 Diabetic Ketoacidosis in a Patient With Small Cell Lung Cancer and Pre-existing Type 2 Diabetes Mellitus. Cureus 2024; 16:e57024. [PMID: 38681275 PMCID: PMC11046427 DOI: 10.7759/cureus.57024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
In this report, we present a case of a 70-year-old male with small cell lung cancer (SCLC) and pre-existing type 2 diabetes mellitus (T2DM) who developed type 1 diabetic ketoacidosis (DKA) following treatment with atezolizumab plus chemotherapy. Despite well-controlled T2DM with oral hypoglycemic agents, the initiation of immune checkpoint inhibitors (ICIs) led to rapid deterioration into insulin-dependent status due to ICI-induced type 1 diabetes mellitus (T1DM). Vigilant monitoring for hyperglycemia and timely intervention is crucial during ICI therapy, considering the potentially life-threatening complications. Although the patient achieved extended progression-free survival (PFS) post-treatment, re-administration of atezolizumab resulted in a bullous pemphigoid-like rash, necessitating discontinuation of the drug and corticosteroid treatment. The impact of recurring immune-related adverse events (irAEs) on treatment efficacy warrants further investigation.
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Affiliation(s)
- Kohei Narumoto
- Internal Medicine, Fukuyama City Hospital, Fukuyama, JPN
| | - Naohiro Oda
- Internal Medicine, Fukuyama City Hospital, Fukuyama, JPN
| | - Reo Mitani
- Internal Medicine, Fukuyama City Hospital, Fukuyama, JPN
| | - Ichiro Takata
- Internal Medicine, Fukuyama City Hospital, Fukuyama, JPN
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Al-Taie A, Sheta N. Clinically Approved Monoclonal Antibodies-based Immunotherapy: Association With Glycemic Control and Impact Role of Clinical Pharmacist for Cancer Patient Care. Clin Ther 2024; 46:e29-e44. [PMID: 37932154 DOI: 10.1016/j.clinthera.2023.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/17/2023] [Accepted: 10/13/2023] [Indexed: 11/08/2023]
Abstract
PURPOSE Compared with more conventional, nonspecific therapy options, such as radiotherapy and chemotherapy, monoclonal antibodies (mAbs) constitute a crucial approach of cancer treatment. Multiple autoimmune diseases have been observed during treatment with mAb medications, including autoimmune diabetes mellitus (DM). This study provides a narrative review of clinically approved mAbs in cancer treatment and focuses on the development of hyperglycemia and DM arising from using these therapies. Furthermore, it highlights the critical role of oncology clinical pharmacists in the management of autoimmune DM and patient care while using these medications in an oncology setting. METHODS An extensive literature search was conducted using various sources of electronic databases, such as Scopus, Embase, Web of Science, and PubMed, and search engines, such as Google Scholar, for studies on mAb classification, types, mechanisms of action, pharmacokinetic properties, current clinical applications, and the associated common adverse effects with significant recommendations for patient care in an oncology setting, along with focusing on the proposed mechanisms and clinical studies that reported the association of DM after the use of these therapies. FINDINGS There are 4 types (murine, chimeric, humanized, and human) and 3 classes (unconjugated, conjugated, and bispecific) of mAbs with several mechanisms of action that can destroy cancer cells, including preventing tumor cell survival cascades, inhibiting tumor growth by interfering with tumor angiogenesis, evading programmed cell death, and bypassing immune checkpoints. However, multiple endocrinopathies, autoimmune diseases, and complications were reported from the use of these medications, including the development of autoimmune DM and diabetic ketoacidosis. These autoimmune disorders were reported most with the use of immune checkpoint inhibitors, including inhibitors of the programmed cell death protein 1 (nivolumab and pembrolizumab), its ligand (atezolizumab, avelumab, and durvalumab), and cytotoxic T-lymphocyte-associated protein 4 (ipilimumab). IMPLICATIONS mAbs are considered important approaches for the treatment of many cancer types. However, a high incidence of hyperglycemia, type 1 DM, and diabetic ketoacidosis is observed with the use of these medications, particularly immune checkpoint inhibitors. It is important for oncologic clinical pharmacists to be involved in addressing these autoimmune disorders from the use of these immunotherapies via the provision of patient education, medication adherence support, close monitoring, and follow-up, which will lead to better health-related outcomes and improved patient quality of life.
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Affiliation(s)
- Anmar Al-Taie
- Clinical Pharmacy Department, Faculty of Pharmacy, Istinye University, Istanbul, Türkiye.
| | - Najat Sheta
- Clinical Pharmacy Department, Faculty of Pharmacy, Istinye University, Istanbul, Türkiye
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Bhanderi H, Khalid F, Bodla ZH, Muhammad T, Du D, Meghal T. Autoimmune diabetes from pembrolizumab: A case report and review of literature. World J Clin Oncol 2023; 14:535-543. [PMID: 38059185 PMCID: PMC10696214 DOI: 10.5306/wjco.v14.i11.535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/13/2023] [Accepted: 10/30/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND Immunotherapy, specifically the use of checkpoint inhibitors such as pembrolizumab, has become an important tool in personalized cancer therapy. These inhibitors target proteins on T-cells that regulate the immune response against tumor cells. Pembrolizumab, which targets the programmed cell death 1 receptor on T-cells, has been approved for the treatment of metastatic melanoma and non-small cell lung cancer. However, it can also lead to immune-related side effects, including pneumonitis, colitis, thyroid abnormalities, and rare cases of type 1 diabetes. CASE SUMMARY The case presented involves an adult patient in 30s with breast cancer who developed hyperglycemia after receiving pembrolizumab treatment. The patient was diagnosed with diabetic ketoacidosis and further investigations were performed to evaluate for new-onset type 1 diabetes. The patient had a history of hypothyroidism and a family history of breast cancer. Treatment for diabetic ketoacidosis was initiated, and the patient was discharged for close follow-up with an endocrinologist. CONCLUSION This literature review highlights the occurrence of diabetic ketoacidosis and new-onset type 1 diabetes in patients receiving pembrolizumab treatment for different types of cancer. Overall, the article emphasizes the therapeutic benefits of immunotherapy in cancer treatment, particularly pembrolizumab, while also highlighting the potential side effect of immune-related diabetes that can occur in a small percentage of patients. Here we present a case where pembrolizumab lead to development of diabetes after a few cycles highlighting one of the rare yet a serious toxicity of the drug.
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Affiliation(s)
- Hardikkumar Bhanderi
- Department of Internal Medicine, Monmouth Medical Center, Long branch, NJ 07740, United States
| | - Farhan Khalid
- Department of Internal Medicine, Monmouth Medical Center, Long branch, NJ 07740, United States
| | - Zubair Hassan Bodla
- Department of Internal Medicine, University of Central Florida College of Medicine, Gainesville, FL 32303, United States
| | - Tayyeb Muhammad
- Department of Internal Medicine, Monmouth Medical Center, Long branch, NJ 07740, United States
| | - Doantrang Du
- Department of Internal Medicine, Monmouth Medical Center, Long branch, NJ 07740, United States
| | - Trishala Meghal
- Department of Hematology-Oncology, Monmouth Medical Center, Long Branch, NJ 07740, United States
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Qiu J, Luo S, Yin W, Li X, Zhou Z. Clinical and immunological characteristics of PD-1 associated fulminant type 1 diabetes mellitus. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2023; 48:49-58. [PMID: 36935177 PMCID: PMC10930557 DOI: 10.11817/j.issn.1672-7347.2023.220290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Indexed: 03/21/2023]
Abstract
OBJECTIVES Programmed death 1 (PD-1) associated fulminant type 1 diabetes (PFD) is a rare acute and critical in internal medicine, and its clinical characteristics are still unclear. This study aims to analyze the clinical characteristics of PFD patients to improve clinical diagnosis and treatment. METHODS We retrospectively analyzed the clinical data of 10 patients with PFD admitted to the Second Xiangya Hospital of Central South University, combined with the data of 66 patients reported in the relevant literature, analyzed and summarized their clinical and immunological characteristics, and compared the patients with PFD with different islet autoantibody status. RESULTS Combined with our hospital and literature data, a total of 76 patients with PFD were reported, with the age of (60.9±12.1) years old, 60.0% male and body mass index of (22.1±5.2) kg/m2. In 76 patients, the most common tumors were lung cancer (43.4%) and melanoma (22.4%). Among PD-1 inhibitors, the most common drugs are nivolumab (37.5%) and pembrolizumab (38.9%). 82.2% of PFD patients developed diabetes ketoacidosis. The median onset time from PD-1 related inhibitor treatment to hyperglycemia was 95 (36.0, 164.5) d, and the median treatment cycle before the onset of diabetes was 6 (2.3, 8.0) cycles. 26% (19/73) of PFD patients had positive islet autoantibodies, and the proportion of ketoacidosis in the positive group was significantly higher than that in the negative group (100.0% vs 75.0%, P<0.05). The onset time and infusion times of diabetes after PD-1 inhibitor treatment in the autoantibody positive group were significantly lower than those in the autoantibody negative group (28.5 d vs 120.0 d; 2 cycles vs 7 cycles, both P<0.001). CONCLUSIONS After initiation of tumor immunotherapy, it is necessary to be alert to the occurrence of adverse reactions of PFD, and the onset of PFD with islet autoantibody positive is faster and more serious than that of patients with autoantibodies negative. Detection of islet autoantibodies and blood glucose before and after treatment with PD-1 inhibitors is of great value for early warning and prediction of PFD.
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Affiliation(s)
- Junlin Qiu
- Department of Metabolism and Endocrinology, Second Xiangya Hospital, Central South University; Ministry of Education, Key Laboratory of Diabetes Immunology (Central South University); National Clinical Research Center for Metabolic Diseases, Changsha 410011, China.
| | - Shuoming Luo
- Department of Metabolism and Endocrinology, Second Xiangya Hospital, Central South University; Ministry of Education, Key Laboratory of Diabetes Immunology (Central South University); National Clinical Research Center for Metabolic Diseases, Changsha 410011, China.
| | - Wenfeng Yin
- Department of Metabolism and Endocrinology, Second Xiangya Hospital, Central South University; Ministry of Education, Key Laboratory of Diabetes Immunology (Central South University); National Clinical Research Center for Metabolic Diseases, Changsha 410011, China
| | - Xia Li
- Department of Metabolism and Endocrinology, Second Xiangya Hospital, Central South University; Ministry of Education, Key Laboratory of Diabetes Immunology (Central South University); National Clinical Research Center for Metabolic Diseases, Changsha 410011, China
| | - Zhiguang Zhou
- Department of Metabolism and Endocrinology, Second Xiangya Hospital, Central South University; Ministry of Education, Key Laboratory of Diabetes Immunology (Central South University); National Clinical Research Center for Metabolic Diseases, Changsha 410011, China
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Lin C, Li X, Qiu Y, Chen Z, Liu J. PD-1 inhibitor-associated type 1 diabetes: A case report and systematic review. Front Public Health 2022; 10:885001. [PMID: 35991054 PMCID: PMC9389003 DOI: 10.3389/fpubh.2022.885001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/22/2022] [Indexed: 12/01/2022] Open
Abstract
Objective This study aimed to summarize the clinical characteristics of programmed death receptor 1 (PD-1) inhibitor-associated type 1 diabetes so as to improve the ability of clinicians to correctly diagnose and treat it. Methods We reported a case of a 70-year-old woman with gastric cancer who developed hyperosmolar hyperglycemic coma during camrelizumab (a PD-1 inhibitor) treatment and was diagnosed with PD-1 inhibitor-associated type 1 diabetes. We conducted a systematic review of 74 case reports of type 1 diabetes associated with PD-1 inhibitor therapy published before June 2022. Results The patient developed type 1 diabetes with hyperosmolar hyperglycemic coma after receiving camrelizumab chemotherapy for 6 months (9 cycles). We searched 69 English articles comprising 75 patients, all of whom had been treated with a PD-1 inhibitor (nivolumab or pembrolizumab) and progressed to diabetes after an average of 6.11 (1–28) cycles. Nivolumab combined with ipilimumab (a cytotoxic T lymphocyte-associated protein 4 inhibitor) had the shortest onset (4.47 cycles on average). A total of 76% (57/75) of patients developed diabetic ketoacidosis (DKA) at onset, and 50.67% (38/75) of patients had C-peptide <0.1 ng/mL. Most of the patients were tested for insulin autoantibodies, with a positive rate of 33.33% (23/69); of these, 86.96% (20/23) were tested for glutamate decarboxylase antibody and 46.67% (35/75) were tested for human leukocyte antigen (HLA). HLA-DR4 was the most common type. Conclusions The progression of type 1 diabetes induced by PD-1 inhibitors is relatively rapid. Islet failure often occurs when detected, seriously endangering patients' lives. Patients treated with PD-1 inhibitors should closely monitor their plasma glucose level during treatment to detect, diagnose, and treat diabetes on time.
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Liu J, Shi Y, Liu X, Zhang D, Zhang H, Chen M, Xu Y, Zhao J, Zhong W, Wang M. Clinical characteristics and outcomes of immune checkpoint inhibitor-induced diabetes mellitus. Transl Oncol 2022; 24:101473. [PMID: 35905639 PMCID: PMC9334308 DOI: 10.1016/j.tranon.2022.101473] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/06/2022] [Accepted: 06/26/2022] [Indexed: 11/07/2022] Open
Abstract
This article summarized a total of 172 published cases of immune checkpoint inhibitor (ICI)-induced diabetes mellitus (DM). Found that glutamic acid decarboxylase antibodies positivity is related to an earlier onset of ICI-induced diabetes and a higher frequency of diabetic ketoacidosis development. Presented a case of ICI-induced DM following obvious lipase and amylase elevation and discussed possible relationship between ICI-associated injuries to pancreatic exocrine function and endocrine function.
Objective To better understand immune checkpoint inhibitor (ICI)-induced diabetes mellitus (DM) in cancer patients. Design and method We present a case of ICI-induced diabetic ketoacidosis (DKA) and conduct a systematic review of the PubMed and Web of Science databases up to September 2021 to identify all published cases of ICI-induced diabetes. Results In addition to our case, a total of 171 published cases were identified during the literature search. Summary and statistical analyzes were conducted for all 172 cases. The median onset time from ICI initiation to DM diagnosis was 12 weeks (range: 0–122). DKA was present in 67.4% (116/172) of the cases, and low C-peptide levels were detected in 91.8% (123/134), indicating an acute onset of diabetes. Patients with positive glutamic acid decarboxylase antibodies (GADA) had an earlier onset of ICI-induced diabetes (median time 7 weeks vs. 16 weeks for GADA-negative patients, p < 0.001) and a higher frequency of DKA development (82.8 vs. 62.1%, p = 0.006). All but two patients developed insulin-dependent diabetes permanently. Immunotherapy rechallenge was reported in 53 cases after glycemia was well controlled. Conclusion ICI-induced DM is a serious adverse event that often presents with life-threatening ketoacidosis. GADA positivity is related to an earlier onset of ICI-induced diabetes and a higher frequency of DKA development. Close monitoring of glucose levels is needed in patients receiving ICI treatment. ICI-induced DM is usually insulin-dependent since damage to β cells is irreversible. On the premise of well-controlled glycemia, immunotherapy rechallenge is feasible.
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Affiliation(s)
- Jia Liu
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuequan Shi
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaoyan Liu
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dongming Zhang
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haoran Zhang
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Minjiang Chen
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Xu
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Zhao
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Zhong
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mengzhao Wang
- Department of Respiratory and Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Mai K, Fassnacht M, Führer-Sakel D, B. Honegger J, M. Weber M, Kroiss M. The Diagnosis and Management of Endocrine Side Effects of Immune Checkpoint Inhibitors. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:arztebl.m2021.0143. [PMID: 33724917 PMCID: PMC8378258 DOI: 10.3238/arztebl.m2021.0143] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/01/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The immunologically mediated side effects of immune checkpoint inhibitors (CPI) often involve the endocrine system as well, and they can even be fatal, as in the case of unrecognized hypophysitis. Distinguishing such side effects from tumor-related changes is often difficult, because their clinical features can be nonspecific. METHODS This review is based on publications retrieved by a selective search in PubMed, with special attention to international recommendations. RESULTS Depending on their target molecules, the CPI now in use differ from one another in the incidence of side effects such as autoimmune thyroid disease (4-16%), hypophysitis (0.1- 18%), adrenalitis (0.7-8%), and autoimmune diabetes mellitus (0.5-2%). The typical clinical warning signs and laboratory constellations of hypophysitis include exhaustion, hyponatremia, and headache. Hypo- and hyperthyroidism and primary adrenocortical insufficiency likewise have nonspecific manifestations. Autoimmune diabetes mellitus often takes a fulminant course. Patients being treated with CPI should be monitored at close intervals, at least as frequently as the administration of the drug, so that endocrine side effects can be recognized in time. In case of doubt, glucocorticoid supplementation should be given whenever hypocortisolism is suspected, even before endocrine evaluation is completed and the results are available. Interrupting or discontinuing CPI treatment is rarely indicated. CONCLUSION With the increasing number of patients being treated with CPI, more and more physicians from a wide variety of specialties, not necessarily working in specialized centers, now have to consider immunologically mediated endocrine side effects in the differential diagnosis, and treat them properly when they arise. These things should be done in collaboration with endocrinologists. The ongoing study of such side effects of the CPI now in use, and of those that will be introduced in the future, is important and will lead to improved understanding.
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Affiliation(s)
- Knut Mai
- Department of Endocrinology, Diabetes and Nutrition, Charité–Universitätsmedizin Berlin: Prof. Dr. med. Knut Mai
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University of Würzburg, University Hospital Würzburg, Würzburg: Prof. Dr. med. Martin Fassnacht, Prof. Dr. med. Dr. rer. nat. Matthias Kroiss
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg: Prof. Dr. med. Martin Fassnacht, Prof. Dr. med. Dr. rer. nat. Matthias Kroiss
| | - Dagmar Führer-Sakel
- Department of Endocrinology, Diabetology and Metabolism, Essen University Hospital, University of Duisburg-Essen: Prof. Dr. med. Dr. rer. nat. Dagmar Führer-Sakel
| | - Jürgen B. Honegger
- Department of Neurosurgery, Tübingen University Hospital: Prof. Dr. med. Jürgen B. Honegger
| | - Matthias M. Weber
- Department of Internal Medicine I, Endocrinology, Johannes Gutenberg University Hospital Mainz: Prof. Dr. med. Matthias M. Weber
| | - Matthias Kroiss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University of Würzburg, University Hospital Würzburg, Würzburg: Prof. Dr. med. Martin Fassnacht, Prof. Dr. med. Dr. rer. nat. Matthias Kroiss
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg: Prof. Dr. med. Martin Fassnacht, Prof. Dr. med. Dr. rer. nat. Matthias Kroiss
- Department of Internal Medicine IV, Ludwig-Maximilians-University Munich: Prof. Dr. med.Dr. rer. nat. Matthias Kroiss
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Lopes AR, Russo A, Li AY, McCusker MG, Kroopnick JM, Scilla K, Mehra R, Rolfo C. Development of autoimmune diabetes with severe diabetic ketoacidosis and immune-related thyroiditis secondary to durvalumab: a case report. Transl Lung Cancer Res 2020; 9:2149-2156. [PMID: 33209634 PMCID: PMC7653143 DOI: 10.21037/tlcr-20-408] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Immune-mediated endocrinopathies are among the most frequent immune-related adverse events (irAEs) with immune checkpoint inhibitors (ICIs) targeting programmed death-ligand 1 (PD-L1)/PD-1. However, the development of auto-immune diabetes is an uncommon event during PD(L)-1 blockade, either as monotherapy or in combination therapy. Here we report a case of a 75-year-old male with a mediastinal recurrence from a stage IA squamous cell carcinoma of the lung previously treated with stereotactic body radiotherapy (SBRT) who early developed a severe diabetic ketoacidosis (DKA) caused by new-onset auto-immune diabetes, with positive glutamic acid decarboxylase (GAD65) autoantibodies, during durvalumab consolidation therapy after concurrent chemoradiation. The patient had no personal or family history of diabetes or auto-immune diseases and was admitted after the second cycle of durvalumab to the intensive care unit (ICU) with severe DKA. During his hospitalization, insulin and fluid therapy were started and the patient had a favorable clinical course. Durvalumab treatment was interrupted and thyroiditis was verified during follow-up, without anti-thyroid antibodies, that progressed to subsequent hypothyroidism with need of thyroid hormone replacement therapy. This case highlights the rare irAE of autoimmune type 1 diabetes during anti-PD(L)-1 therapy, which can be life-threatening and requires adequate patient education and prompt medical treatment within a multidisciplinary team, including endocrinology and emergency medicine. Besides its low incidence, this case show how irAE must be taken in account about decision of ICI treatment, especially in curative setting, as they can be potentially fatal and impair overall survival. Furthermore, as reported in the present case, multiple endocrine irAEs can occur in the same patient either simultaneously or sequentially, suggesting that active surveillance is needed in those who develop endocrinopathies as a result of ICI treatment. Immune-mediated endocrinopathies are generally irreversible and cause life-long morbidity, which must be taken into consideration when deciding on further lines of treatment.
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Affiliation(s)
- Ana Rita Lopes
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA.,Portuguese Institute of Oncology (IPO), Porto, Portugal
| | - Alessandro Russo
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA.,Medical Oncology Unit, A.O. Papardo, Messina, Italy
| | - Andrew Y Li
- Department of Medicine, Division of General Internal Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Michael G McCusker
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jeffrey Myles Kroopnick
- University of Maryland Center for Diabetes and Endocrinology, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA
| | - Katherine Scilla
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ranee Mehra
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christian Rolfo
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
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Bai X, Lin X, Zheng K, Chen X, Wu X, Huang Y, Zhuang Y. Mapping endocrine toxicity spectrum of immune checkpoint inhibitors: a disproportionality analysis using the WHO adverse drug reaction database, VigiBase. Endocrine 2020; 69:670-681. [PMID: 32507965 PMCID: PMC7447663 DOI: 10.1007/s12020-020-02355-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/15/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Our study aimed to map endocrine toxicity spectrum of immune checkpoint inhibitors (ICIs). METHODS We obtained data from VigiBase, between January 1, 2011 and March 6, 2019. All endocrine adverse drug reactions (ADRs) were classified by group queries according to the Medical Dictionary for Regulatory Activities. Disproportionality analysis was performed with information component (IC) and reporting odds ratio (ROR). We used IC to identify meaningful endocrinopathies associated with ICIs and ROR to compare differences between ICI subgroups of ADRs. IC025 (lower end of the 95% confidence interval of IC) is considered significant if larger than 0. RESULTS In all, 6089 reports for endocrinopathies associated with ICIs were involved, with a male to female ratio of 1.5:1. The disproportionality analysis indicated significance of not only common endocrinopathies: thyroid dysfunction, hypophysitis/hypopituitarism, adrenal insufficiency, T1DM, fulminant T1DM (IC025: 4.12-6.62), but also rare endocrinopathies: hypoparathyroidism, diabetes insipidus, hypogonadism (IC025: 1.56-2.04). Increased risk of ADR reporting emerged in anti-CTLA-4 (e.g., hypophysitis/hypopituitarism, adrenal insufficiency) or in anti-PD-1/PD-L1 (e.g., thyroid dysfunction, T1DM, fulminant T1DM). In general, combination therapy (anti-CTLA-4 plus anti-PD-1/PD-L1) had a stronger association with endocrinopathies than monotherapy (ROR: 2.8, 95% CI: 2.5-3.1). Onset time of common endocrinopathies differed between different ICI therapies, typically within 12 weeks in anti-CTLA-4 monotherapy but diffusely ranging from 0 to 48 weeks in anti-PD-1 monotherapy. CONCLUSIONS Our study shows rising reporting frequencies of endocrinopathies caused by ICIs, especially aggravated in combination therapy. Clinicians should be early aware of latent endocrine toxicity and different onset time of endocrinopathies when implementing ICI therapies.
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Affiliation(s)
- Xuefeng Bai
- Department of Endocrinology, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, Fujian Province, China
| | - Xiahong Lin
- Department of Endocrinology, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, Fujian Province, China.
- Department of Medical Administration, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, Fujian Province, China.
| | - Kainan Zheng
- Data Mining Working Group, China Telecom Co., Ltd (Quanzhou Branch), No. 105 Citong Road, Fengze District, Quanzhou, Fujian Province, China
| | - Xiaoyu Chen
- Department of Endocrinology, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, Fujian Province, China
| | - Xiaohong Wu
- Department of Endocrinology, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, Fujian Province, China
| | - Yinqiong Huang
- Department of Endocrinology, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, Fujian Province, China
| | - Yong Zhuang
- Department of Endocrinology, The Second Affiliated Hospital of Fujian Medical University, No. 950 Donghai Street, Fengze District, Quanzhou, Fujian Province, China
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Haque W, Ahmed SR, Zilbermint M. Nivolumab-induced autoimmune diabetes mellitus and hypothyroidism in a patient with rectal neuroendocrine tumor. J Community Hosp Intern Med Perspect 2020; 10:338-339. [PMID: 32850092 PMCID: PMC7427449 DOI: 10.1080/20009666.2020.1771126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/15/2020] [Indexed: 11/24/2022] Open
Abstract
We present a rare case of autoimmune diabetes mellitus and hypothyroidism in an elderly man initiated on nivolumab two months prior to admission for treatment of a high-grade neuroendocrine rectal tumor. This patient presented to a local community hospital with one-week history of severe nausea, thirst, and bilateral leg edema. Biochemical studies confirmed the diagnosis of diabetic ketoacidosis in the setting of autoimmune diabetes mellitus and primary hypothyroidism, likely due to nivolumab use. This case illustrates an acute complication due to secondary diabetes mellitus in the setting of a novel anticancer agent. There are three key takeaways for physicians managing patients on nivolumab. First, there should be a discussion of the benefits and risks of immunomodulatory therapy. Second, patients should be tested for immunological and other markers before being started on checkpoint inhibitors. Third, oncologists must be aware of the signs and symptoms of life-threatening hyperglycemia and severe hypothyroidism. Additional studies are needed to identify those patients at highest risk for autoimmune complications.
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Affiliation(s)
- Waqas Haque
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- JThe University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Shabina R. Ahmed
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Community Physicians, Bethesda, MD, USA
| | - Mihail Zilbermint
- Johns Hopkins Community Physicians, Bethesda, MD, USA
- Suburban Hospital, Bethesda, MD, USA
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Li W, Wang H, Chen B, Zhao S, Zhang X, Jia K, Deng J, He Y, Zhou C. Anti PD-1 monoclonal antibody induced autoimmune diabetes mellitus: a case report and brief review. Transl Lung Cancer Res 2020; 9:379-388. [PMID: 32420079 PMCID: PMC7225154 DOI: 10.21037/tlcr.2020.03.05] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Nowadays, immune checkpoint inhibitor therapy has been used in more and more cancer patients. These agents were associated with immune-related adverse effects, and autoimmune diabetes mellitus is one of them. And it is not common but can be potentially fatal. Anti PD-1 monoclonal antibody is a humanized IgG4 antibody against PD-1, which has been applied in advanced non-small cell lung cancer (NSCLC) treatment. In this paper, we reported the case of autoimmune diabetes mellitus induced by anti PD-1 monoclonal antibody in NSCLC treatment. Here is a 73-year-old male patient with no diabetes history who had anti PD-1 monoclonal antibody 200 mg every 3 weeks for NSCLC treatment. After 10 cycles of the therapy, his blood glucose level elevated and he suffered diabetic ketoacidosis (DKA). And his C-peptide was significantly decreased with negative relative auto-antibodies. Combined with his medical history and the laboratory examination, anti PD-1 monoclonal antibody induced autoimmune diabetes mellitus was diagnosed. After recovering from DKA and controlling his blood glucose, his anti PD-1 therapy was continued and he still got some benefit. This report suggested that glycemic monitoring is imperative during this anti PD-1 monoclonal antibody treatment. Moreover, after controlling the blood glucose level, continuing the immune therapy could still be benefit and safe for the patient.
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Affiliation(s)
- Wei Li
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Hao Wang
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Bin Chen
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Sha Zhao
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Xiaoshen Zhang
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Keyi Jia
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Juan Deng
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China.,Tongji University, Shanghai 200433, China
| | - Yayi He
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
| | - Caicun Zhou
- Department of Medical Oncology, Shanghai Pulmonary Hospital, Tongji University Medical School Cancer Institute, Tongji University School of Medicine, Shanghai 200433, China
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