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Abstract
Objective To report the first case of diabetic ketoacidosis (DKA) and its management in a patient with diet-controlled prediabetes and metastatic breast cancer treated with alpelisib, a PI3K (phosphatidylinosiotol-3-kinase) inhibitor. Methods Literature on the topic is reviewed. The case is that of a 66-year-old female with diet-controlled prediabetes and metastatic breast carcinoma who had initiated alpelisib 2 weeks prior to being admitted for diabetic ketoacidosis. Results Admission laboratory examination revealed a blood sugar of 1137 mg/dL, an anion gap of 25, large ketones in urine, and positive acetone in serum. The HbA1c level was 9.4% (79 mmol/mol) on admission, which had been 6.3% (45 mmol/mol) seven months earlier. She was discharged on subcutaneous insulin and instructed to discontinue alpelisib. Alpelisib was restarted 2 days later, which exacerbated her hyperglycemia within 24 hours. In the following months, her hyperglycemia was successfully managed with insulin and a SGLT 2 inhibitor. Unfortunately, her breast cancer progressed, ultimately leading to discontinuation of alpelisib. Blood sugar levels returned to a nondiabetic range upon discontinuation of alpelisib, and she is currently off all antihyperglycemic agents. Conclusion Although PI3KCA inhibitors remain a promising drug in patients with metastatic breast cancer who have not responded to previous treatment, patients must be closely monitored for adverse effects such as hyperglycemia. Hyperglycemia could be a potentially limiting side effect of alpelisib. The optimal management of hyperglycemia induced by alpelisib warrants further research.
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Herat LY, Magno AL, Rudnicka C, Hricova J, Carnagarin R, Ward NC, Arcambal A, Kiuchi MG, Head GA, Schlaich MP, Matthews VB. SGLT2 Inhibitor-Induced Sympathoinhibition: A Novel Mechanism for Cardiorenal Protection. JACC Basic Transl Sci 2020; 5:169-179. [PMID: 32140623 PMCID: PMC7046513 DOI: 10.1016/j.jacbts.2019.11.007] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/19/2019] [Accepted: 11/19/2019] [Indexed: 02/09/2023]
Abstract
SGLT2 inhibitors improve cardiovascular outcomes. SGLT2 inhibitor–induced sympathetic nervous system inhibition may be an underlying mechanism. Chemical denervation in neurogenic hypertensive mice reduces renal SGLT2 expression. SGLT2 inhibition lowered blood pressure and resulted in significantly reduced tyrosine hydroxylase and norepinephrine levels in the kidney tissue of neurogenic hypertensive mice. Crosstalk between the sympathetic nervous system and SGLT2 regulation appears as a key mechanism of the cardiorenal protective effects demonstrated with SGLT2 inhibition.
Recent clinical trial data suggest a cardiorenal protective effect of sodium glucose cotransporter 2 (SGLT2) inhibition. We demonstrate that chemical denervation in neurogenic hypertensive Schlager (BPH/2J) mice reduced blood pressure, improved glucose homeostasis, and reduced renal SGLT2 protein expression. Inhibition of SGLT2 prevented weight gain, reduced blood pressure, significantly reduced elevations of tyrosine hydroxylase and norepinephrine, and protects against endothelial dysfunction. These findings provide evidence for significant crosstalk between activation of the sympathetic nervous system and SGLT2 regulation and possible ancillary effects on endothelial function, which may contribute to the observed cardiorenal protective effects of SGLT2 inhibition.
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Affiliation(s)
- Lakshini Y Herat
- Dobney Hypertension Centre, School of Biomedical Science, Royal Perth Hospital Unit, University of Western Australia, Perth, Australia
| | - Aaron L Magno
- Research Centre, Royal Perth Hospital, Perth, Australia
| | | | - Jana Hricova
- Dobney Hypertension Centre, School of Biomedical Science, Royal Perth Hospital Unit, University of Western Australia, Perth, Australia
| | - Revathy Carnagarin
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, University of Western Australia, Perth, Australia
| | - Natalie C Ward
- School of Medicine, Royal Perth Hospital, University of Western Australia, Perth, Australia.,School of Public Health, Curtin University, Perth, Australia.,Curtin Health Innovation Research Institute, Curtin University, Perth, Australia
| | - Angelique Arcambal
- School of Medicine, Royal Perth Hospital, University of Western Australia, Perth, Australia.,Université de La Réunion, Saint-Denis, Réunion, France
| | - Marcio G Kiuchi
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, University of Western Australia, Perth, Australia
| | - Geoff A Head
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, University of Western Australia, Perth, Australia.,Department of Cardiology and Department of Nephrology, Royal Perth Hospital, Perth, Australia
| | - Vance B Matthews
- Dobney Hypertension Centre, School of Biomedical Science, Royal Perth Hospital Unit, University of Western Australia, Perth, Australia
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