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Gallagher EJ, Moore H, Lacouture ME, Dent SF, Farooki A, Goncalves MD, Isaacs C, Johnston A, Juric D, Quandt Z, Spring L, Berman B, Decker M, Hortobagyi GN, Kaffenberger BH, Kwong BY, Pluard T, Rao R, Schwartzberg L, Broder MS. Managing hyperglycemia and rash associated with alpelisib: expert consensus recommendations using the Delphi technique. NPJ Breast Cancer 2024; 10:12. [PMID: 38297009 PMCID: PMC10831089 DOI: 10.1038/s41523-024-00613-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 01/03/2024] [Indexed: 02/02/2024] Open
Abstract
Hyperglycemia and rash are expected but challenging adverse events of phosphatidylinositol-3-kinase inhibition (such as with alpelisib). Two modified Delphi panels were conducted to provide consensus recommendations for managing hyperglycemia and rash in patients taking alpelisib. Experts rated the appropriateness of interventions on a 1-to-9 scale; median scores and dispersion were used to classify the levels of agreement. Per the hyperglycemia panel, it is appropriate to start alpelisib in patients with HbA1c 6.5% (diabetes) to <8%, or at highest risk for developing hyperglycemia, if they have a pre-treatment endocrinology consult. Recommend prophylactic metformin in patients with baseline HbA1c 5.7% to 6.4%. Metformin is the preferred first-line anti-hyperglycemic agent. Per the rash panel, initiate prophylactic nonsedating H1 antihistamines in patients starting alpelisib. Nonsedating H1 antihistamines and topical steroids are the preferred initial management for rash. In addition to clinical trial evidence, these recommendations will help address gaps encountered in clinical practice.
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Affiliation(s)
- Emily J Gallagher
- Division of Endocrinology, Diabetes and Bone Disease, Department of Medicine, and Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Heather Moore
- Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Mario E Lacouture
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Susan F Dent
- Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Azeez Farooki
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Division of Endocrinology, Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Marcus D Goncalves
- Division of Endocrinology, Weill Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Claudine Isaacs
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | | | - Dejan Juric
- Massachusetts General Hospital Cancer Center, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Zoe Quandt
- School of Medicine, University of California, San Francisco, CA, USA
| | - Laura Spring
- Massachusetts General Hospital Cancer Center, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Brian Berman
- University of Miami School of Medicine and Center for Clinical and Cosmetic Research, Aventura, FL, USA
| | - Melanie Decker
- Woodland Memorial Hospital, Woodland, CA, and Kaiser Permanente, Sacramento, CA, USA
| | - Gabriel N Hortobagyi
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Bernice Y Kwong
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, USA
| | - Timothy Pluard
- St. Luke's Hospital Koontz Center for Advanced Breast Cancer, Kansas City, MO, USA
| | - Ruta Rao
- Rush Hematology, Oncology and Cell Therapy, Rush University Medical Center, Chicago, IL, USA
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Weintraub MA, Liu D, DeMatteo R, Goncalves MD, Flory JH. Sodium-glucose cotransporter-2 inhibitors for hypergycemia in phosphoinositide 3-kinase pathway inhibition. Breast Cancer Res Treat 2024; 203:85-93. [PMID: 37704834 DOI: 10.1007/s10549-023-07110-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 08/23/2023] [Indexed: 09/15/2023]
Abstract
PURPOSE Phosphoinositide 3-kinase (PI3K) inhibition is used for the treatment of certain cancers, but can cause profound hyperglycemia and insulin resistance, for which sodium-glucose cotransporter-2 (SGLT2) inhibitors have been proposed as a preferred therapy. The objective of this research is to assess the effectiveness and safety of SGLT2 inhibitors for hyperglycemia in PI3K inhibition. METHODS We conducted a single-center retrospective review of adults initiating the PI3K inhibitor alpelisib. Exposure to different antidiabetic drugs and adverse events including diabetic ketoacidosis (DKA) were assessed through chart review. Plasma and point-of-care blood glucoses were extracted from the electronic medical record. Change in serum glucose and the rate of DKA on SGLT2 inhibitor versus other antidiabetic drugs were examined as co-primary outcomes. RESULTS We identified 103 patients meeting eligibility criteria with median follow-up of 92 days after starting alpelisib. When SGLT2 inhibitors were used to treat hyperglycemia, they were associated with a decrease in mean random glucose by -46 mg/dL (95% CI - 77 to - 15) in adjusted linear modeling. Five cases of DKA were identified, two occurring in patients on alpelisib plus SGLT2 inhibitor. Estimated incidence of DKA was: alpelisib plus SGLT2 inhibitor, 48 DKA cases per 100 patient-years (95% CI 6, 171); alpelisib with non-SGLT2 inhibitor antidiabetic drugs, 15 (95% CI 2, 53); alpelisib only, 4 (95% CI 0.1, 22). CONCLUSIONS SGLT2 inhibitors are effective treatments for hyperglycemia in the setting of PI3K inhibition.
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Affiliation(s)
- Michael A Weintraub
- New York University Diabetes & Endocrine Associates, 222 East 41st Street, 23rd Floor, New York, NY, 10017, USA
| | - Dazhi Liu
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | - Raymond DeMatteo
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA
| | | | - James H Flory
- Endocrinology Service, Division of Subspecialty Medicine, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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3
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Gao Y, Zhong M, Gan L, Xiang C, Li L, Yan Y. Immune checkpoint inhibitor- and phosphatidylinositol-3-kinase inhibitor-related diabetes induced by antineoplastic drugs: two case reports and a literature review. Front Endocrinol (Lausanne) 2023; 14:1236946. [PMID: 37732122 PMCID: PMC10509015 DOI: 10.3389/fendo.2023.1236946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/17/2023] [Indexed: 09/22/2023] Open
Abstract
Immune checkpoint inhibitor (ICI)- and phosphatidylinositol-3-kinase inhibitor (PI3Ki)-related diabetes mellitus are common side effects of anti-tumor drug use that present mainly as hyperglycemia. Here, we present two case reports of diabetes mellitus caused by the use of tremelimumab and apalutamide, respectively, in cancer treatment, and a comprehensive, comparative review of the literature on these forms of diabetes. Case 1 presented with diabetic ketoacidosis and was diagnosed with ICI-related diabetes mellitus and treated with insulin. Case 2 was diagnosed with PI3Ki-related diabetes mellitus, and her blood glucose level returned to normal with the use of metformin and dapagliflozin. We systematically searched the PubMed database for articles on ICI- and PI3Ki-related diabetes mellitus and characterized the differences in clinical features and treatment between these two forms of diabetes.
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Affiliation(s)
- Yue Gao
- Department of Endocrinology, Xiaogan Hospital Affiliated with Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
- Medical College, Wuhan University of Science and Technology, Wuhan, China
| | - Mingyao Zhong
- Medical College, Wuhan University of Science and Technology, Wuhan, China
| | - Lulu Gan
- Medical College, Wuhan University of Science and Technology, Wuhan, China
| | - Cheng Xiang
- Department of Endocrinology, Xiaogan Hospital Affiliated with Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
| | - Ling Li
- Department of Endocrinology, Xiaogan Hospital Affiliated with Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
| | - Yimin Yan
- Department of Endocrinology, Xiaogan Hospital Affiliated with Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
- Medical College, Wuhan University of Science and Technology, Wuhan, China
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Weintraub MA, Liu D, DeMatteo R, Goncalves MD, Flory J. Sodium-Glucose Cotransporter-2 Inhibitors for Hyperglycemia in Phosphoinositide 3-kinase Pathway Inhibition. Res Sq 2023:rs.3.rs-2655905. [PMID: 36993733 PMCID: PMC10055504 DOI: 10.21203/rs.3.rs-2655905/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Purpose Phosphoinositide 3-kinase (PI3K) inhibition is used for the treatment of certain cancers, but can cause profound hyperglycemia and insulin resistance, for which sodium-glucose cotransporter-2 (SGLT2) inhibitors have been proposed as a preferred therapy. The objective of this research is to assess the effectiveness and safety of SGLT2 inhibitors for hyperglycemia in PI3K inhibition. Methods We conducted a single-center retrospective review of adults initiating the PI3k inhibitor alpelisib. Exposure to different antidiabetic drugs and adverse events including diabetic ketoacidosis (DKA) were assessed through chart review. Plasma and point-of-care blood glucoses were extracted from the electronic medical record. Change in serum glucose and the rate of DKA on SGLT2 inhibitor versus other antidiabetic drugs were examined as co-primary outcomes. Results We identified 103 patients meeting eligibility criteria with median follow-up of 85 days after starting alpelisib. When SGLT2 inhibitors were used to treat hyperglycemia, they were associated with a decrease in mean random glucose by -54 mg/dL (95% CI -99 to -8) in adjusted linear modeling. Five cases of DKA were identified, two occurring in patients on alpelisib plus SGLT2 inhibitor. Estimated incidence of DKA was: alpelisib plus SGLT2 inhibitor, 24 DKA cases per 100 patient-years (95% CI 6, 80); alpelisib with non-SGLT2 inhibitor antidiabetic drugs, 7 (95% CI 0.1, 34); alpelisib only, 4 (95% CI 0.1, 21). Conclusions SGLT2 inhibitors are effective treatments for hyperglycemia in the setting of PI3K inhibition, but given possible adverse events, SGLT2 inhibitors should be used with caution.
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Affiliation(s)
| | - Dazhi Liu
- Memorial Sloan Kettering Cancer Center
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5
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Dutka M, Bobiński R, Francuz T, Garczorz W, Zimmer K, Ilczak T, Ćwiertnia M, Hajduga MB. SGLT-2 Inhibitors in Cancer Treatment-Mechanisms of Action and Emerging New Perspectives. Cancers (Basel) 2022; 14. [PMID: 36497303 DOI: 10.3390/cancers14235811] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/11/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022] Open
Abstract
A new group of antidiabetic drugs, sodium-glucose cotransporter 2 inhibitors (SGLT-2 inhibitors), have recently been shown to have anticancer effects and their expression has been confirmed in many cancer cell lines. Given the metabolic reprogramming of these cells in a glucose-based model, the ability of SGLT-2 inhibitors to block the glucose uptake by cancer cells appears to be an attractive therapeutic approach. In addition to tumour cells, SGLT-2s are only found in the proximal tubules in the kidneys. Furthermore, as numerous clinical trials have shown, the use of SGLT-2 inhibitors is well-tolerated and safe in patients with diabetes and/or heart failure. In vitro cell culture studies and preclinical in vivo studies have confirmed that SGLT-2 inhibitors exhibit antiproliferative effects on certain types of cancer. However, the mechanisms of this action remain unclear. Even in those tumour cell types in which SGLT-2 is present, there is sometimes an SGLT-2-independent mechanism of anticancer action of this group of drugs. This article presents the current state of knowledge of the potential mechanisms of the anticancer action of SGLT-2 inhibitors and their possible future application in clinical oncology.
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Leung M, Rodrigues P, Roitman D. Ketoacidosis in a Patient with Type 2 Diabetes Requiring Alpelisib: Learnings and Observations Regarding Alpelisib Initiation and Rechallenge. Onco Targets Ther 2022; 15:1309-1315. [PMID: 36330532 PMCID: PMC9624212 DOI: 10.2147/ott.s370244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/09/2022] [Indexed: 11/06/2022] Open
Abstract
Background Diabetic ketoacidosis (DKA) is a rare complication of alpelisib, but cases of DKA are reported. Alpelisib's safety in patients with long-standing, suboptimally controlled diabetes is unclear since clinical trials of alpelisib did not include them. Case A case is presented on a patient with metastatic breast cancer and type 2 diabetes admitted for DKA eleven days after starting alpelisib. Since DKA is implicated in antihyperglycemics that inhibit sodium-glucose cotransporter-2 (SGLT2) inhibitors, her empagliflozin was discontinued. Alpelisib was also held since it was recently initiated. After the DKA resolved, she was discharged and restarted alpelisib. Within 4 hours of taking the first dose, the patient developed a second episode of DKA, and alpelisib treatment was stopped permanently. Conclusion Patients with long-standing type 2 diabetes are at high risk of alpelisib-induced Grade 3 and 4 hyperglycemia, including DKA. It is essential to communicate with non-oncology stakeholders about the risk of DKA with alpelisib as it can be overlooked for more common causes. Restarting alpelisib can result in severe hyperglycemia or DKA within 24 hours of the first dose. In this population, the risks associated with rechallenging alpelisib must be heavily weighed against its benefits. Before restarting alpelisib, a thorough evaluation of the appropriateness of the patient's antihyperglycemics and diet must occur to anticipate and mitigate a second event. Antihyperglycemics independent of the PI3K/AKT/mTOR pathway may be preferred agents. A plan should be in place to quickly respond to rising glycemia and early referral to a diabetologist or endocrinologist is recommended. Continuous glucose monitoring and hospital admission are recommended during rechallenge. A better understanding of alpelisib-induced hyperglycemia, especially in patients with diabetes, is required to navigate alpelisib treatment safely. Emphasis should be placed on patient education of symptoms and monitoring parameters.
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Affiliation(s)
- Mova Leung
- Cancer Care Program, North York General Hospital, Toronto, Ontario, Canada,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada,Correspondence: Mova Leung, Email
| | - Paulina Rodrigues
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Daryl Roitman
- Cancer Care Program, North York General Hospital, Toronto, Ontario, Canada
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Liu D, Weintraub MA, Garcia C, Goncalves MD, Sisk AE, Casas A, Harding JJ, Harnicar S, Drilon A, Jhaveri K, Flory JH. Characterization, management, and risk factors of hyperglycemia during PI3K or AKT inhibitor treatment. Cancer Med 2022; 11:1796-1804. [PMID: 35212193 PMCID: PMC9041081 DOI: 10.1002/cam4.4579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/31/2021] [Accepted: 01/03/2022] [Indexed: 12/19/2022] Open
Abstract
Purpose The phosphoinositide 3‐kinase (PI3K)/protein kinase B (AKT) pathway controls insulin sensitivity and glucose metabolism. Hyperglycemia is one of the most common on‐target adverse effects (AEs) of PI3K/AKT inhibitors. As several PI3K and AKT inhibitors are approved by the United States Food and Drug Administration or are being studied in clinical trials, characterizing this AE and developing a management strategy is essential. Methods Patients with hematologic or solid malignancies treated at Memorial Sloan Kettering Cancer Center with a PI3K or AKT inhibitor were included in this retrospective analysis. A search for patients experiencing hyperglycemia was performed. The frequency, management interventions and outcomes were characterized. Results Four hundred and ninety‐one patients with 10 unique cancer types who received a PI3K or AKT inhibitor were included. Twelve percent of patients required a dose interruption, 6% of patients required a dose reduction and 2% of patients were hospitalized to manage hyperglycemia. No events occurred among patients receiving β‐, γ‐, or δ‐ specific PI3K inhibitor. There was one case where the PI3K or AKT inhibitor was permanently discontinued due to hyperglycemia. Metformin was the most commonly used antidiabetic medication, followed by insulin, sodium‐glucose transport protein 2 (SGLT2) inhibitors, and sulfonylurea. SGLT2 inhibitors were associated with the greatest reductions in blood sugar, followed by metformin. At least one case of euglycemic diabetic ketoacidosis (DKA) occurred in a patient on PI3K inhibitor and SGLT2 inhibitor. Body mass index ≥ 25 and HbA1c ≥ 5.7 are were independently significant predictors of developing hyperglycemia. Conclusion Hyperglycemia is one of the major on‐target side effects of PI3K and AKT inhibitors. It is manageable with antidiabetic medications, treatment interruption and/or dose modification. We summarize pharmacological interventions that may be considered for PI3K/AKT inhibitor induced hyperglycemia. SGLT2‐inhibitor may be a particularly effective second‐line option after metformin but there is a low risk of euglycemic DKA, which can be deadly. To our knowledge, our report is the largest study of hyperglycemia in patients receiving PI3K/AKT inhibitors.
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Affiliation(s)
- Dazhi Liu
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michael A Weintraub
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Christine Garcia
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Marcus D Goncalves
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Ann Elizabeth Sisk
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alissa Casas
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - James J Harding
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Stephen Harnicar
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alexander Drilon
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Komal Jhaveri
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - James H Flory
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Medicine, Weill Cornell Medical College, New York, New York, USA
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Ekanayake P, Gerwer J, Mccowen K. ALPELISIB - INDUCED HYPERGLYCEMIA. Acta Endocrinol (Buchar) 2022; 18:115-117. [PMID: 35975254 PMCID: PMC9365413 DOI: 10.4183/aeb.2022.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
CONTEXT Phosphoinositide-3-kinase (PI3K) pathway inhibitors are increasingly used as targeted therapy in malignancies. We discuss here three cases of PI3K inhibitor induced hyperglycemia and discuss the mechanism of action of these medications and treatment of this class side effect. OBJECTIVES Alpelisib (Piqray) is the newest PI3K inhibitor used in conjunction with Fulvestrant to treat specific types of breast cancer. Since PI3K is a critical mediator of insulin signaling, hyperglycemia is an on-target, unfortunate side effect of this treatment. We present a case series of severe hyperglycemia induced by the alpelisib in three women without a history of diabetes. DESIGN All three women in this study had hormone receptor (HR) positive, human epidermal growth factor receptor 2 (Her2) negative, PI3K mutated breast cancer. They were referred to our clinic by Oncology for alpelisib-induced hyperglycemia. SUBJECTS AND METHODS Review of laboratory values and glucometer values were conducted during each visit allowing treatment decisions. Two of these women are actively managed by us for their diabetes. One woman recently died due to progression of malignancy. RESULTS All three women presented with new onset of severe hyperglycemia after the initiation of PI3K inhibitor, alpelisib. At least one case noted maximal glucose elevation in the hours following drug ingestion. In another, cessation of Alpelisib reversed the hyperglycemia within the span of one week. CONCLUSION Hyperglycemia induced by PI3K inhibitors can be recalcitrant and might necessitate interruption of chemotherapy. Optimal glucose-lowering therapy remains unclear as exogenous insulin has the theoretical potential to overcome PI3K inhibition.
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Affiliation(s)
- P.S. Ekanayake
- University of California San Diego - Division of Endocrinology, Diabetes and Metabolism, La Jolla, California, United States
- Veterans Affairs Medical Center - Division of Endocrinology, Diabetes and Metabolism, La Jolla, California, United States
| | - J. Gerwer
- University of California San Diego - Division of Endocrinology, Diabetes and Metabolism, La Jolla, California, United States
- Veterans Affairs Medical Center - Division of Endocrinology, Diabetes and Metabolism, La Jolla, California, United States
| | - K. Mccowen
- University of California San Diego - Division of Endocrinology, Diabetes and Metabolism, La Jolla, California, United States
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Goncalves MD, Farooki A. Management of Phosphatidylinositol-3-Kinase Inhibitor-Associated Hyperglycemia. Integr Cancer Ther 2022; 21:15347354211073163. [PMID: 35075945 PMCID: PMC8793384 DOI: 10.1177/15347354211073163] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/06/2021] [Accepted: 12/22/2021] [Indexed: 11/15/2022] Open
Abstract
Phosphatidylinositol-3-kinase (PI3K) pathway hyperactivation has been associated with the development of cancer and treatment resistance. PI3K inhibitors are now used to treat hormone receptor-positive (HR+), human epidermal growth factor receptor-2-negative (HER2-), PIK3CA-mutated advanced breast cancer. Hyperglycemia, a frequently observed adverse event with PI3K inhibitors (PI3Ki), is regarded as an on-target effect because inhibition of the PI3K pathway has been shown to decrease glucose transport and increase glycogenolysis and gluconeogenesis. PI3Ki-induced hyperglycemia results in a compensatory increase in insulin release, which has been shown to reduce the efficacy of treatment by reactivating the PI3K pathway in preclinical models. Patients with an absolute or relative deficiency in insulin, and those with insulin resistance or pancreatic dysfunction, may experience exacerbated or prolonged hyperglycemia. Therefore, the effective management of PI3Ki-associated hyperglycemia depends on early identification of patients at risk, frequent monitoring to allow prompt recognition of hyperglycemia and its sequelae, and initiating appropriate management strategies. Risk factors for the development of hyperglycemia include older age (≥75 years), overweight/obese at baseline, and family history of diabetes. Consultation with an endocrinologist is recommended for patients considered high risk. The management of PI3Ki-induced hyperglycemia requires an integrative approach that combines diets low in carbohydrates and glucose-lowering medications. Medications that do not affect the PI3K pathway are preferred as the primary and secondary agents for the management of hyperglycemia. These include metformin, sodium-glucose co-transporter 2 inhibitors, thiazolidinediones, and α-glucosidase inhibitors. Insulin should only be considered as a last-line agent for PI3Ki-associated hyperglycemia due to its stimulatory effect of PI3K signaling. Clinical studies show that alpelisib-associated hyperglycemia is reversible and manageable, rarely leading to treatment discontinuation. Management of PI3Ki-associated hyperglycemia in patients with breast cancer should focus on the prevention of acute and subacute complications of hyperglycemia, allowing patients to remain on anticancer treatment longer.
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Affiliation(s)
| | - Azeez Farooki
- Memorial Sloan Kettering Cancer Center,
New York, NY, USA
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10
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Sahakian N, Cattieuw L, Ramillon-Cury C, Corroller ABL, Silvestre-Aillaud P, Béliard S, Valéro R. SGLT2 inhibitors as potentially helpful drugs in PI3K inhibitor-induced diabetes: a case report. Clin Diabetes Endocrinol 2021; 7:17. [PMID: 34281618 PMCID: PMC8290528 DOI: 10.1186/s40842-021-00125-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 06/16/2021] [Indexed: 01/14/2023] Open
Abstract
Background Hyperglycemia is the most common side-effect of phosphatidylinositol 3-kinase (PI3K) inhibitors that are approved for the treatment of some advanced or metastatic breast cancers. This side-effect is likely due to the central role of PI3K in insulin signalling. Here we report the use of a sodium-glucose cotransporter 2 (SGLT2) inhibitor to manage severe hyperglycemia. Case presentation We describe a 74-year-old woman who developed severe uncontrolled hyperglycemia after commencing alpelisib, a new oral PI3K inhibitor indicated for a metastatic breast cancer, despite taking oral anti-diabetic drugs, metformin and vildagliptin, combined with intravenous insulin infusion of up to 250 units/day. The introduction of the SGLT2 inhibitor dapagliflozin rapidly improved blood glucose with a drastic reduction in insulin dosage, from 250 to 12 units/day, and without significant side-effects. Conclusions We report the successful management of hyperglycemia induced by alpelisib using a SGLT2 inhibitor without the need to discontinue effective cancer treatment.
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Affiliation(s)
- Nicolas Sahakian
- Department of Nutrition, Metabolic Diseases and Endocrinology, University Hospital La Conception, 147 boulevard Baille, 13005, Marseille, France
| | - Lauranne Cattieuw
- Department of Nutrition, Metabolic Diseases and Endocrinology, University Hospital La Conception, 147 boulevard Baille, 13005, Marseille, France
| | - Clotilde Ramillon-Cury
- Department of Nutrition, Metabolic Diseases and Endocrinology, University Hospital La Conception, 147 boulevard Baille, 13005, Marseille, France
| | - Audrey Bégu-Le Corroller
- Department of Nutrition, Metabolic Diseases and Endocrinology, University Hospital La Conception, 147 boulevard Baille, 13005, Marseille, France
| | - Pascale Silvestre-Aillaud
- Department of Nutrition, Metabolic Diseases and Endocrinology, University Hospital La Conception, 147 boulevard Baille, 13005, Marseille, France
| | - Sophie Béliard
- Department of Nutrition, Metabolic Diseases and Endocrinology, University Hospital La Conception, 147 boulevard Baille, 13005, Marseille, France.,Aix Marseille Univ, APHM, INSERM, INRAE, C2VN, 27 boulevard Jean Moulin, 13005, Marseille, France
| | - René Valéro
- Department of Nutrition, Metabolic Diseases and Endocrinology, University Hospital La Conception, 147 boulevard Baille, 13005, Marseille, France. .,Aix Marseille Univ, APHM, INSERM, INRAE, C2VN, 27 boulevard Jean Moulin, 13005, Marseille, France. .,Service de Nutrition, Maladies Métaboliques Et Endocrinologie, Centre Hospitalo-Universitaire de La Conception, 147 Boulevard Baille, 13005, Marseille, France.
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Wang J, Osada T, Morse MA, Calzone F, Yan H, Thai D, Lyerly HK. Targeting the glucagon receptor signaling pathway as a novel strategy to counteract PI3K inhibitor induced hyperglycemia while sustaining tumor PI3K inhibition. Leuk Lymphoma 2021; 62:1761-1764. [PMID: 33576297 DOI: 10.1080/10428194.2021.1881504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Jie Wang
- Department of Medicine, Duke Cancer Institute, Durham, NC, USA
| | - Takuya Osada
- Department of Surgery, Duke Cancer Institute, Durham, NC, USA
| | - Michael A Morse
- Department of Medicine, Duke Cancer Institute, Durham, NC, USA
| | | | - Hai Yan
- REMD Biotherapeutics, Camarillo, CA, USA
| | - Dung Thai
- REMD Biotherapeutics, Camarillo, CA, USA
| | - H Kim Lyerly
- Department of Surgery, Duke Cancer Institute, Durham, NC, USA
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Affiliation(s)
- I R Bass
- Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A Tiersten
- Division of Hematology and Medical Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - K Trlica
- Division of Hematology and Medical Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A Ryncarz
- Division of Hematology and Medical Oncology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - B Adler
- Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - E J Gallagher
- Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Perry RJ, Rabin-Court A, Song JD, Cardone RL, Wang Y, Kibbey RG, Shulman GI. Dehydration and insulinopenia are necessary and sufficient for euglycemic ketoacidosis in SGLT2 inhibitor-treated rats. Nat Commun 2019; 10:548. [PMID: 30710078 PMCID: PMC6358621 DOI: 10.1038/s41467-019-08466-w] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 01/07/2019] [Indexed: 12/15/2022] Open
Abstract
Sodium-glucose transport protein 2 (SGLT2) inhibitors are a class of anti-diabetic agents; however, concerns have been raised about their potential to induce euglycemic ketoacidosis and to increase both glucose production and glucagon secretion. The mechanisms behind these alterations are unknown. Here we show that the SGLT2 inhibitor (SGLT2i) dapagliflozin promotes ketoacidosis in both healthy and type 2 diabetic rats in the setting of insulinopenia through increased plasma catecholamine and corticosterone concentrations secondary to volume depletion. These derangements increase white adipose tissue (WAT) lipolysis and hepatic acetyl-CoA content, rates of hepatic glucose production, and hepatic ketogenesis. Treatment with a loop diuretic, furosemide, under insulinopenic conditions replicates the effect of dapagliflozin and causes ketoacidosis. Furthermore, the effects of SGLT2 inhibition to promote ketoacidosis are independent from hyperglucagonemia. Taken together these data in rats identify the combination of insulinopenia and dehydration as a potential target to prevent euglycemic ketoacidosis associated with SGLT2i. The use of sodium-glucose transport protein 2 (SGLT2) inhibitors for the treatment of diabetes has been associated with euglycemic ketoacidosis and increased glucose production and glucagon secretion. Here Perry et al. show that these effects rely on both insulinopenia and dehydration, and thus suggest ways to manage the side effects associated with the use of SGLT2 inhibitors.
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Affiliation(s)
- Rachel J Perry
- Departments of Internal Medicine, Yale University School of Medicine, P.O. Box 208020, TAC S269, New Haven, CT, 06519, USA.,Departments of Cellular and Molecular Physiology, Yale University School of Medicine, P.O. Box 208020, TAC S269, New Haven, CT, 06519, USA
| | - Aviva Rabin-Court
- Departments of Internal Medicine, Yale University School of Medicine, P.O. Box 208020, TAC S269, New Haven, CT, 06519, USA
| | - Joongyu D Song
- Departments of Internal Medicine, Yale University School of Medicine, P.O. Box 208020, TAC S269, New Haven, CT, 06519, USA
| | - Rebecca L Cardone
- Departments of Internal Medicine, Yale University School of Medicine, P.O. Box 208020, TAC S269, New Haven, CT, 06519, USA
| | - Yongliang Wang
- Departments of Internal Medicine, Yale University School of Medicine, P.O. Box 208020, TAC S269, New Haven, CT, 06519, USA
| | - Richard G Kibbey
- Departments of Internal Medicine, Yale University School of Medicine, P.O. Box 208020, TAC S269, New Haven, CT, 06519, USA.,Departments of Cellular and Molecular Physiology, Yale University School of Medicine, P.O. Box 208020, TAC S269, New Haven, CT, 06519, USA
| | - Gerald I Shulman
- Departments of Internal Medicine, Yale University School of Medicine, P.O. Box 208020, TAC S269, New Haven, CT, 06519, USA. .,Departments of Cellular and Molecular Physiology, Yale University School of Medicine, P.O. Box 208020, TAC S269, New Haven, CT, 06519, USA.
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