Infrequent liver injury from cemiplimab in patients with advanced cutaneous squamous cell carcinoma

Cemiplimab and diabetic ketoacidosis: a case report of a rare endocrinopathy associated with immune checkpoint inhibitors

Background

Immune checkpoint inhibitors (ICIs) have revolutionised the cancer treatment landscape in the last decades, improving the outcome of several tumours, such as cutaneous squamous cell carcinoma (cSCC). ICIs are antibodies blocking several immune checkpoint pathways, as cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) and programmed cell death 1 (PD-1) with its ligand PD-L1. However, the activation of immune response can cause a broad range of side effects, called immune-related adverse events (irAEs). Endocrine irAEs are mainly represented by thyroid dysfunctions (thyrotoxicosis or hypothyroidism) and hypophysitis, while adrenal insufficiency and diabetes mellitus (DM) are less common. Diabetic ketoacidosis (DKA) is a potential life-threatening presentation of ICI-induced insulin-dependent DM (IDDM). This report presents a rare case of DKA and IDDM secondary to anti-PD-1 antibody cemiplimab therapy, and this is the third described in the literature to date.

Case presentation

We describe the case of a 62-year-old female patient with metastatic perianal squamous cell carcinoma who developed DKA and IDDM after the fifth cycle of cemiplimab. Hyperglycemia (1187 mg/dL), metabolic acidosis (pH 7.27) with bicarbonate levels of 11.9 mmol/L, arterial partial pressure of carbon dioxide of 25.7 mmHg with increased anion gap (equal to 25), and hyperketonuria were present. Adequate glycaemic control was difficult to maintain, and intravenously therapy (insulin, sodium bicarbonate, potassium, and fluids) was required for a long time. Subcutaneous basal-bolus insulin treatment was started, but glycaemic control was scarce, also due to the concomitant administration of prednisone for immune-related hepatotoxicity, until the subject's death.

Conclusion

This report underlines the importance of the awareness on endocrine irAEs with ICIs, particularly life-threatening DKA. A baseline assessment of glycemia and glycated hemoglobin is mandatory, and we recommend a close monitoring of glycemic trend over time during ICIs therapy. Patients and their caregivers should be informed and counselled to recognise DKA signs and symptoms.

Steroid-refractory immune checkpoint inhibitor (ICI) hepatitis and ICI rechallenge: A systematic review and meta-analysis

BACKGROUND

In recent years, the use of immune checkpoint inhibitors (ICIs) has become a cornerstone in cancer treatment. However, this has also resulted in the emergence of immune-related adverse events, notably ICI hepatitis, posing a significant clinical challenge. While steroids are the primary treatment, there are increasing cases of steroid-refractory ICI hepatitis. Our objective is to investigate the management of ICI hepatitis and its response to steroid treatment.

METHODS

PubMed/MEDLINE, EMBASE, and CENTRAL databases were searched in July 2023 based on keywords including ICIs (anti-Programmed cell death protein 1/Programmed Death-Ligand 1, anti-CTLA-4, and anti-LAG3) and hepatitis.

RESULTS

A total of 4358 studies were screened, and 44 studies were included in this systematic review. One thousand eight hundred fifty-six patients with ICI hepatitis were included (grade 1-2: 31.7%, grade 3-4: 56.0%, and unknown: 12.3%) with 1184 patients who received corticosteroid treatment. The duration of treatment and dosage varied considerably across the studies. Mycophenolate mofetil was the predominant agent used in 68 out of 82 cases (82.9%), followed by infliximab and azathioprine. A summary estimate of the proportion of steroid-refractory hepatitis in a random effects model was 16% (95% CI: 11%-23%). An estimated 40% (95% CI: 30%-51%) of patients of all patients with ICI hepatitis were rechallenged with an ICI, and of those rechallenged, there was an estimated 22% (95% CI: 15%-30%) recurrence.

CONCLUSIONS

Corticosteroids are the primary treatment for ICI hepatitis, with mycophenolate mofetil used as a secondary option for steroids-refractory cases. Current practices mostly rely on expert consensus, highlighting the need for further research to validate and optimize these treatments, particularly for steroid-resistant cases.

Cemiplimab for the Treatment of Advanced Cutaneous Squamous Cell Carcinoma: Appropriate Patient Selection and Perspectives

Five percent of patients with cutaneous squamous cell carcinoma develop locally advanced or metastatic disease that is not amenable to definitive surgical or radiation therapy. Cemiplimab, an antibody against programmed death receptor-1, was approved in the United States for the treatment of locally advanced and metastatic cutaneous squamous cell carcinoma in 2018. We performed a literature review on the use of cemiplimab in cutaneous squamous cell carcinoma, with an emphasis on efficacy, safety and tolerability, patient selection, and future directions. Embase and PubMed were searched for relevant terms, and 23 peer-reviewed journal articles presenting primary data on cemiplimab treatment in 5 or more subjects with cutaneous squamous cell carcinoma were included and summarized. Objective response rates in locally advanced and metastatic disease ranged from 42.9% to 50.8% in Phase I/II clinical trials and 32-77% (median 58%) in post-approval observational studies. Phase II trials looking at neoadjuvant use also had favorable response rates. Real-world studies demonstrated cemiplimab efficacy in periorbital tumors, tumors with large caliber perineural invasion, and tumors in solid organ transplant recipients. Cemiplimab was safe and well-tolerated in most patients. While side effects such as fatigue, diarrhea, pruritus, and rash were fairly common, only 9.8% of adverse events required cessation of therapy in phase II trials. Severe adverse events were primarily immune-mediated, including pneumonitis, myocarditis, myositis, and autoimmune hepatitis; the risk of treatment-related death was 3% in clinical trials. Further research on cemiplimab therapy in cutaneous squamous cell carcinoma is needed, and trials are now underway to obtain Phase IV long-term real-world data, further data on adjuvant and neoadjuvant use, and additional data in special populations such as stem cell and solid organ transplant recipients.

Cemiplimab-Associated Sinusoidal Obstruction Syndrome

A 58-year-old woman developed new-onset recurrent ascites after the recent initiation of cemiplimab for the treatment of advanced basal cell carcinoma. A comprehensive serological workup for viral, metabolic, and autoimmune causes was unrevealing. Transjugular liver biopsy demonstrated parenchymal changes consistent with a diagnosis of sinusoidal obstruction syndrome. While this is a condition commonly observed in patients after hematopoietic stem cell transplantation or use of chemotherapeutic agents, it should also be considered in patients who develop new-onset liver dysfunction after the initiation of checkpoint inhibitors.

Hepatotoxicity Associated with Immune Checkpoint Inhibitors in Clinical Practice: A Study Leveraging Data from the US Food and Drug Administration's Adverse Event Reporting System

PURPOSE

Immune checkpoint inhibitors (ICIs) are a promising option for the treatment of patients with various cancers. Emerging case reports have raised awareness on hepatotoxicity, a potentially fatal adverse event (AE) that may be associated with the use of ICIs. This study assessed the potential association between ICIs and hepatotoxicity through the mining of data from the US Food and Drug Administration's AE Reporting System (FAERS).

METHODS

A total of 9,217,181 AEs reported in the period from quarter 1 of 2004 to quarter 3 of 2021 were assessed. Information components (ICs) and reporting odds ratios (RORs) were used to evaluate the association between the use of ICIs and hepatotoxicity.

FINDINGS

A total of 52,463 AE reports listed ICIs, used alone or in combination, as a suspected drug. Of these, 1481 cases were related to both ICIs and hepatotoxicity. The use of ICIs was significantly associated with hepatotoxicity compared to all other drugs, making it a safety signal (IC = 1.43 [95% CI, 1.36-1.51]; ROR = 2.78 [95% CI, 2.64-2.93]). With monotherapy, all ICIs, except tremelimumab, were associated with liver damage. The most commonly prescribed combination therapy was nivolumab + ipilimumab (321 cases) with a significant signal detected. Notably, ICI use was significantly associated with hepatic failure (IC = 1.24 [95% CI, 1.06-1.42]; ROR = 2.40 [95% CI, 2.13-2.72]). The risk for ICI-associated hepatotoxicity (including hepatic failure) was greater with ICI combination therapy than with ICI monotherapy. All subgroups by sex and age also showed significant associations between ICI use and hepatotoxicity.

IMPLICATIONS

A significant association was detected between ICI use and hepatotoxicity. The risk for hepatotoxicity (including hepatic failure) was greater with ICI combination therapy compared with ICI monotherapy. (Clin Ther. 2023;45:XXX-XXX) © 2023 Elsevier Inc.