Immune-Checkpoint Inhibitors-Induced Type 1 Diabetes Mellitus: From Its Molecular Mechanisms to Clinical Practice

Durvalumab‑induced type 1 diabetes mellitus in lung adenocarcinoma: A case report and literature review

Immune checkpoint inhibitor-induced type 1 diabetes mellitus (ICI-T1DM) is a rare adverse reaction associated with durvalumab. Among the adverse reactions to durvalumab, the incidence of new-onset diabetes is relatively rare, occurring in ~0.2% of cases. The present study reports the case of a 62-year-old woman who developed ICI-T1DM following two cycles of durvalumab, presenting with thirst, polydipsia and polyuria. Laboratory examinations (glycated hemoglobin and glutamic acid decarboxylase antibody), along with consultations from an endocrinologist, led to the patient being diagnosed with ICI-T1DM. Immunotherapy was discontinued, and insulin replacement therapy was initiated. Blood glucose levels were closely monitored using a subcutaneous meter. The onset of diabetic ketoacidosis (DKA) was prevented due to timely treatment. In conclusion, medical oncologists need to be aware that durvalumab, an immunotherapy agent, can induce ICI-T1DM. Therefore, regular monitoring of blood glucose levels and collaborative consultations with endocrinologists are essential for an accurate diagnosis when elevated blood sugar levels are detected. The prompt diagnosis of ICI-T1DM is crucial to prevent the occurrence of DKA.

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.

Immune Checkpoint Inhibitor-Induced Pancreatic Injury (ICI-PI) in Adult Cancer Patients: A Systematic Review and Meta-Analysis

Background: Immune checkpoint inhibitor-induced pancreatic injury (ICI-PI) is a rare immunotoxicity, with limited data on treatment and long-term outcomes. Methods: PubMed, EMBASE, and Cochrane Library were systematically searched for studies reporting ICI-PI in patients with solid malignancies. ICI-PI was defined as pancreatic inflammation post-ICI exposure, diagnosed via radiologic changes or elevated lipase/amylase levels without other underlying causes. The CTCAE grading system was used. The primary objectives were to assess the frequency, severity, serum abnormalities, management, and long-term outcomes. We conducted a proportional single-arm meta-analysis with a random effects model. Results: The analysis included 25 retrospective studies involving 48,704 patients. Tumor types included thoracic/head and neck (38%), skin (26%), genitourinary/gynecological (18%), gastrointestinal (12%), and others (6%). The median age ranged from 56 to 73 years, with a follow-up from 2.5 to 45.9 months. ICI-PI occurred in 3.60% (95% CI: 1.64-6.28%) of patients, with grade ≥ 3 toxicity in 59.45% (95% CI: 35.32-81.37%). The frequency rates of ICI-PI were 1.99% for CTLA4 inhibitors, 5.01% for PD(L)1 inhibitors, and 7.44% for combination ICI therapy (p < 0.01). The median time to onset from treatment initiation ranged from 30 to 390 days, and symptom resolution ranged from 55 to 84 days. Management included corticosteroids (30.20%), intravenous fluids (22.82%), and hospitalization (30.46%). Chronic complications affected 63.54% (95% CI: 29.03-91.56%), including primarily diabetes mellitus (DM 89.45%; 95% CI: 61.88-100.0%) and exocrine pancreatic insufficiency (EPI 10.55%; 95%: 0.0-38.12%). ICI-PI recurrence occurred in 27.2% of those resuming ICI therapy. The objective response rate was 61.7% (95% CI: 55.08-68.17%). Conclusions: ICI-PI, though infrequent, is severe and predisposes patients to chronic complications, including DM and EPI.

Management of Immunotherapy-Induced Type 1 Diabetes

One of the life-threatening adverse effects associated with the use of immune checkpoint inhibitors is β cells destruction resulting in type 1 diabetes. Immune checkpoint inhibitor-induced type 1 diabetes (ICI-T1D) usually has a rapid onset requiring admission to the intensive care unit for the management of diabetic ketoacidosis using an insulin drip protocol. Once stabilized patients with ICI-T1D are started on insulin therapy to mimic usual pancreatic function. Insulin administration may be through multiple daily injections or continuous subcutaneous insulin infusions using an insulin pump. People who develop ICI-T1D will require insulin therapy for life.

Pathophysiology, diagnosis, and management of immune checkpoint inhibitor-induced diabetes mellitus

Immune Checkpoint Inhibitors (ICIs) have revolutionized cancer treatment, offering hope for patients with various malignancies. However, along with their remarkable anticancer effects, ICIs can also trigger immune-related adverse events (irAEs). One such noteworthy complication is the development of Diabetes Mellitus (DM), which particularly resembles Type 1 Diabetes Mellitus (T1DM). The aim of this review is to provide insights into the epidemiology, pathophysiology, diagnostic issues, and treatment considerations of ICI-induced DM (ICI-DM), emphasizing the importance of early recognition and management to mitigate adverse outcomes. Although still rare, the incidence has increased with the widespread use of ICIs, especially PD-1/PD-L1 blockers (from 0.2% to 1.9%). Factors affecting the development of ICI-DM, such as specific ICIs, patient demographics, and genetic predispositions, are discussed. The complex interplay between immune dysregulation and pancreatic β-cell destruction contributes to diagnostic challenges, with presentations varying from asymptomatic hyperglycemia to diabetic ketoacidosis (DKA). Management strategies prioritize meticulous glycemic and electrolyte regulation along with tailored intravenous insulin therapy in cases of DKA. DM remission is rare, therefore treatment with both long-acting insulin at bedtime and short-acting insulin before meals is needed in longterm. Total daily insulin requirements can be estimated at 0.3-0.4 units/kg/day for most patients as a starting dose.

Immune checkpoint inhibitor-related type 1 diabetes incidence, risk, and survival association

AIM/INTRODUCTION

Although immune checkpoint inhibitor-related type 1 diabetes mellitus (ICI-T1DM) is a rare condition, it is of significant concern globally. We aimed to elucidate the precise incidence, risk factors, and impact of ICI-T1DM on survival outcomes.

MATERIALS AND METHODS

The study is a large retrospective cohort study, performed using the DeSC Japanese administrative claims database comprising 11 million patients. The database population is reportedly similar to the entire population of Japan. Patients administered ICI between 2014 and 2022 were enrolled in the study, including 21,121 patients. The risk factors for ICI-T1DM development and their characteristics were evaluated by logistic regression analysis. Development of a new irAE after the day following the first administration of ICI was set as the study outcome.

RESULTS

ICI-T1DM was observed in 102 (0.48%) of the 21,121 patients after ICI initiation. PD-(L)1 and CTLA-4 combination therapy was associated with an increased risk of ICI-T1DM compared with PD-1 monotherapy (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.21-4.58; P = 0.01). Patients with a prior diagnosis of diabetes mellitus (OR, 1.59; 95% CI, 1.03-2.46; P = 0.04) or hypothyroidism (OR, 2.48; 95% CI, 1.39-4.43; P < 0.01) also exhibited an increased risk of ICI-T1DM. The Kaplan-Meier analysis revealed that patients with ICI-T1DM showed higher survival rates than those without (log-lank test, P < 0.01). Multivariable Cox regression analysis demonstrated that ICI-T1DM development was associated with lower mortality (hazard ratio, 0.60; 95% CI, 0.37-0.99; P = 0.04).

CONCLUSIONS

Collectively, the results of this study demonstrate the precise incidence and risk factors of ICI-T1DM. The development of ICI-T1DM, like other irAEs, is associated with higher survival rates.

Diabetic ketoacidosis and hyperglycaemic hyperosmolar syndrome in patients with cancer: A multicentre study

BACKGROUND

Diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar syndrome (HHS) are life-threatening complications of diabetes mellitus. However, limited data about DKA and HHS are available in patients with cancer. The current study aimed to determine characteristics and outcomes of patients with cancer who were admitted with DKA/HHS in a mid-size Canadian city.

METHODS

Consecutive adult patients with an active cancer who were admitted with DKA or HHS from January 2008 to December 2020 in the city of Saskatoon, Saskatchewan, Canada were retrospectively evaluated. A univariate logistic regression analysis was performed to examine the correlation of various clinical variables with hospital mortality.

RESULTS

During the study period 6,555 patients with diabetes and cancer were admitted in one of the three tertiary care hospitals. Among them 33 (0.5 %) eligible patients with DKA or HHS with a median age of 60 years (range 36-94 years) were identified. In 36 % of patients, DKA or HHS was the presenting manifestation of newly diagnosed diabetes. Of all patients, 66 % developed DKA and 73 % had an advanced cancer. Overall, 52 % patients received a systemic cancer therapy prior to the admission, and 41 % received steroids. Ten (42 %) of 24 patients with an advanced cancer died, compared to none of the nine patients with an early-stage cancer (p = 0.032). No clinical factors significantly correlated with hospital mortality.

CONCLUSIONS

Although DKA or HHS is uncommon in patients with diabetes and cancer, it is the manifestation of undiagnosed diabetes in about one-third of patients with cancer. It has been associated with high hospital mortality in patients with advanced cancer.

Fulminant type 1 diabetes mellitus: a neglected but high-risk adverse event associated with immune checkpoint inhibitors

BACKGROUND

Immune checkpoint inhibitor (ICI) therapy has revolutionized cancer treatment but is associated with fulminant type 1 diabetes mellitus (FT1DM). Our study aims to investigate the association between ICI therapy and FT1DM using the FDA Adverse Event Reporting System (FAERS) database.

METHODS

We conducted a retrospective analysis from the first quarter of 2004 to the first quarter of 2023. The disproportionality analysis incorporating the reporting odds ratio (ROR) and information component (IC) was performed to assess the magnitude of the adverse event signal between ICIs and FT1DM.

RESULTS

A total of 520 cases of FT1DM were identified in association with ICI therapy, representing 75.9% of all FT1DM cases reported in the FAERS database. Descriptive analyses revealed a predominance in males (60.2%) and the elderly (70.6%). The median time to onset was 69 days and 337 patients (64.81%) were hospitalized while 35 (6.73%) cases resulted in death. Disproportionality analysis showed a strong signal for FT1DM with ICI treatment (ROR 438.84) versus other drugs.

CONCLUSION

These findings provide compelling evidence linking ICI therapy to the development of FT1DM, underscoring the need for clinical vigilance and early intervention strategies to optimize patient outcomes while leveraging the remarkable therapeutic potential of cancer immunotherapy.

Diabetes and the associated complications: The role of antioxidants in diabetes therapy and care

Diabetes mellitus (DM) is a chronic metabolic disorder characterized by high blood sugar levels (hyperglycemia). Poorly managed diabetes can lead to complications affecting multiple organ systems. Antioxidants play a crucial role in reducing oxidative stress caused by reactive oxygen species (ROS), primarily triggered by uncontrolled high blood sugar levels in diabetes. Antioxidants like vitamin C, E, selenium, and alpha-lipoic acid, when used as supplements, have shown promise in reducing oxidative stress markers and improving antioxidant status in laboratory and animal studies and diabetic patients. Antioxidant supplementation may help reduce the risk of diabetic complications such as neuropathy, nephropathy, retinopathy, and cardiovascular disease. Additionally, antioxidants also have anti-inflammatory properties, which could be beneficial in reducing inflammation associated with diabetes. Antioxidant supplementation has been shown to enhance endothelial function, insulin sensitivity, and glucose metabolism, thereby aiding in glycemic control and overall diabetic management. Combining antioxidants with certain medications may have therapeutic benefits, such as effectively neutralizing free radicals and enhancing the regulation of antioxidant defense systems. This review presents an update on diabetes, the sources of free radical generation, the body's natural defense mechanisms, the clinical evidence regarding using antioxidants in managing diabetic complications, and the potential new therapeutic approaches. Overall, antioxidant supplementation may offer some benefits in managing diabetic complications. However, further studies are needed to understand the mechanisms of action, determine the optimal supplementation, explore potential interactions with other medications, and conduct long-term studies to establish the possible use of antioxidants for optimal benefits in diabetes care.

Fulminant Type 1 Diabetes Mellitus Leading to Diabetic Ketoacidosis and Mesenteric Ischemia With Necrosis Following Pembrolizumab Administration: A Case Report

Immune checkpoint inhibitors (ICIs), such as pembrolizumab, have revolutionized cancer therapy but can lead to severe immune-related adverse events (irAEs). We present a case of fulminant type 1 diabetes mellitus (T1DM) with diabetic ketoacidosis (DKA) and mesenteric ischemia in a 78-year-old woman with recurrent stage IIIC1 cervical cancer treated with pembrolizumab. Thirty-four days after initiating a pembrolizumab-containing regimen, she presented with vomiting, severe hyperglycemia, metabolic acidosis, and strongly positive urine ketones. Laboratory findings confirmed complete insulin deficiency, leading to a diagnosis of fulminant T1DM and DKA, requiring intensive insulin therapy. Despite treatment, her condition rapidly deteriorated, with worsening DKA, hyperglycemia, gastrointestinal bleeding, and extensive mucosal necrosis identified through endoscopy and imaging. The patient ultimately progressed to septic shock and died the same day. Fulminant T1DM is characterized by abrupt β-cell destruction and rapid DKA onset. In this case, DKA likely contributed to mesenteric ischemia, a severe vascular complication. This is the first reported case of fulminant T1DM, DKA, and mesenteric ischemia following pembrolizumab. The case underscores the importance of vigilance, early recognition, and multidisciplinary management of irAEs to prevent fatal outcomes.

Pembrolizumab-Induced Insulin-Dependent Diabetes Mellitus in a Patient With Triple-Negative Breast Cancer: A Rare Immune-Related Adverse Event

A 68-year-old female patient with a background of triple-negative breast carcinoma on pembrolizumab with no history of diabetes presented to the emergency department with fatigue, polyuria, nausea, dizziness, shortness of breath, dry mouth, and increased thirst. She had recently received the third dose of the second cycle of neoadjuvant combination chemotherapy and immunotherapy (pembrolizumab/carboplatin/paclitaxel) and was due to receive the next dose. Initial assessment revealed hyperglycemia with ketosis without acidosis. The patient was treated with fluid resuscitation and insulin infusion under the diabetic ketoacidosis (DKA) guidelines of the hospital and was eventually transitioned to a basal-bolus insulin regimen, which was continued after discharge. Based on the temporal relationship between pembrolizumab therapy and the onset of diabetes, along with the patient's persistent insulin dependence, a diagnosis of immune checkpoint inhibitor-induced diabetes mellitus (ICI-DM) was established. The patient has clinically improved, chemotherapy and immunotherapy have been discontinued, and surgical intervention is planned. This case highlights the importance of recognizing ICI-DM as a rare immune-related adverse event in patients who receive immunotherapy with programmed cell death protein-1 (PD-1)/programmed cell death ligand-1 (PD-L1) inhibitors.

Type 1 diabetes: immune pathology and novel therapeutic approaches

Type 1 diabetes (T1D) is characterized by the progressive destruction of insulin-producing beta cells in the pancreas. Despite improvements in insulin monitoring techniques, there remains no cure for T1D. Individuals with T1D require lifelong insulin therapy and some develop life-threatening complications. T1D is a complex, multifactorial, autoimmune condition. Understanding why people get T1D and how it progresses has advanced our knowledge of the disease and led to the discovery of specific targets that can be therapeutically manipulated to halt or reverse the course of T1D. Scientists investigating the potential of immunotherapy treatment for the treatment have recently had some encouraging results. Teplizumab, an anti-CD3 monoclonal antibody that has been approved by the FDA, delays the onset of clinical T1D in patients ≥ 8 years of age with preclinical T1D and improves beta cell function. Therapies targeting beta cell health, vitality, and function are now thought to be an essential component of successful combination therapy for T1D. The idea that the beta cells themselves may influence their own destruction during the development of T1D is a notion that has recently been gaining acceptance in the field. Researchers have recently made remarkable strides in beta cell replacement therapy and beta cell regeneration techniques. This review offers a detailed exploration of the pathophysiological mechanisms of T1D. It discusses the intricate interplay of factors leading to T1D development and the innovative approaches being explored to discover new treatments and a cure for the millions of people living with T1D worldwide.

Complete response to tremelimumab plus durvalumab treatment in hepatocellular carcinoma with a bile duct tumor thrombus: A case report

Tremelimumab plus durvalumab (Dur/Tre) is the first-line treatment for advanced hepatocellular carcinoma (HCC) worldwide. The present report describes the case of a 68-year-old man diagnosed with advanced HCC and a bile duct tumor thrombus (BDTT) who achieved a complete response to Dur/Tre therapy. The BDTT progressed to the bifurcation of the left and right hepatic ducts. Over time, both the tumors and BDTT progressively decreased in size, and a complete response was confirmed using the Response Evaluation Criteria in Solid Tumors (version 1.1.) 6 months after treatment administration. Subsequently, immune-related adverse events, including type 1 diabetes mellitus and diabetic ketoacidosis, emerged, leading to treatment discontinuation. The patient was undergoing outpatient follow-up in a drug-free state with no signs of recurrence 290 days after the initial administration of Dur/Tre. Although long-term and meticulous observations are required, the present findings could influence the choice of systemic chemotherapy for advanced HCC.

Immune checkpoint inhibitor‑associated diabetes mellitus in patients with HCC: Report of three cases and literature review

Treatment with immune checkpoint inhibitors (ICIs) is steadily becoming the standard of care for hepatocellular carcinoma (HCC), with an increasing number of immune-related adverse events (irAEs). However, only a small number of reports on the occurrence of diabetes mellitus (DM) in patients with HCC treated with ICIs have been published. In the present study, the clinical manifestations, laboratory findings, treatment and prognosis of three patients with advanced HCC were reported, who suffered immune-related DM when receiving treatment with ICIs. Furthermore, the relevant literature was reviewed in order to summarize clinical manifestations, possible mechanisms, diagnosis, prognosis of rechallenge and recommended management options, as well as clinical treatment suggestions. ICI-induced diabetes is rare but irAEs are potentially fatal, as diabetic ketoacidosis (DKA) is often the first manifestation. The incidence of immune-related DM is 0.86% and among those cases, the incidence of DKA is 59%. The combination of two ICIs markedly increases the risk. The human leukocyte antigen genotype, islet autoantibodies and autoreactive T cell-mediated β-cell destruction may be linked to the occurrence of immune-related DM. Patient education and clinicians' awareness of ICI-related DM are good management options. Adequate clinical judgment, close monitoring and early detection are also needed to decide whether to continue immunotherapy or to rechallenge it, so as to achieve the maximum benefit of clinical treatment.