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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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2
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Fujiwara M, Shimizu M, Okano T, Maejima Y, Shimomura K. Successful treatment of nivolumab and ipilimumab triggered type 1 diabetes by using sodium-glucose transporter 2 inhibitor: a case report and systematic review. Front Public Health 2023; 11:1264056. [PMID: 38106883 PMCID: PMC10725247 DOI: 10.3389/fpubh.2023.1264056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/31/2023] [Indexed: 12/19/2023] Open
Abstract
Objective Checkpoint inhibitors (CPIs) can trigger complications related to the autoimmune process such as CPI-triggered diabetes mellitus. The typical treatment for CPI-triggered diabetes is insulin, but a detailed therapeutic method has not yet been established. To prevent severe symptoms and mortality of diabetic ketoacidosis in advanced-stage cancer patients, the establishment of effective treatment of CPI-triggered diabetes, other than insulin therapy, is required. Methods We present a case of a 76-year-old man with CPI-triggered diabetes who was treated with nivolumab and ipilimumab for lung cancer. We also conducted a systematic review of 48 case reports of type 1 diabetes associated with nivolumab and ipilimumab therapy before June 2023. Results The patient's hyperglycemia was not sufficiently controlled by insulin therapy, and after the remission of ketoacidosis, the addition of a sodium-glucose transporter (SGLT) 2 inhibitor, dapagliflozin, improved glycemic control. Most of the reported nivolumab/ipilimumab-induced type 1 diabetes was treatable with insulin, but very few cases required additional oral anti-diabetic agents to obtain good glucose control. Conclusion Although SGLT2 inhibitors have been reported to have adverse effects on ketoacidosis, recent studies indicate that the occurrence of ketoacidosis is relatively rare. Considering the pathological mechanism of CPI-triggered diabetes, SGLT2 inhibitors could be an effective choice if they are administered while carefully monitoring the patient's ketoacidosis.
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Affiliation(s)
- Makoto Fujiwara
- Department of Bioregulation and Pharmacological Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
- Department of Diabetes, Endocrinology and Metabolism, Tsukuba Medical Center, Ibaraki, Japan
| | - Masaru Shimizu
- Department of Bioregulation and Pharmacological Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
- Department of Neurology, Matsumura General Hospital, Fukushima, Japan
| | - Tatsuya Okano
- Department of Bioregulation and Pharmacological Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuko Maejima
- Department of Bioregulation and Pharmacological Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kenju Shimomura
- Department of Bioregulation and Pharmacological Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
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3
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Alalawi M, Bakr AS, Reda R, Sadak KT, Nagy M. Late-onset toxicities of monoclonal antibodies in cancer patients. Immunotherapy 2022; 14:1067-1083. [PMID: 35892252 DOI: 10.2217/imt-2022-0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cancer therapy duration is variable and may take years, adding a new challenge of maintaining the best life quality for cancer survivors. In cancer patients, late-onset toxicities have been reported with monoclonal antibodies and may involve several body organs or systems. They are defined as an autoimmune illnesses that can happen months to years after treatment discontinuation. Late-onset toxicities have become a focus of clinical care and related research. After cancer therapy is completed, the patient should receive longitudinal follow-up to detect these late effects as early as possible. The current review summarizes the recently reported late-onset toxicities of four classes of monoclonal antibodies (anti-CD52, anti-CTLA-4, anti-PD-1 and anti-CD20) with guidance for the diagnostic tools, appropriate management and treatment.
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Affiliation(s)
- Mai Alalawi
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt, Cairo, 57357, 4260102, Egypt.,Department of Pharmaceutical Sciences, Fakeeh College for Medical Sciences, Jeddah, 23323, Saudi Arabia
| | - Abrar Saeed Bakr
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt, Cairo, 57357, 4260102, Egypt.,Department of Clinical Pharmacy, Alexandria Vascular Center, Alexandria, 5431118, Egypt
| | - Rowaida Reda
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt, Cairo, 57357, 4260102, Egypt.,Department of Clinical Pharmacy, Woman Health Hospital, Assiut University, Assiut, 2074020, Egypt
| | - Karim Thomas Sadak
- University of Minnesota Masonic Cancer Center, Minneapolis, MN 55455, USA.,University of Minnesota Masonic Children's Hospital, Minneapolis, MN 55455, USA
| | - Mohamad Nagy
- Department of Pharmaceutical Services, Children's Cancer Hospital Egypt, Cairo, 57357, 4260102, Egypt.,Personalized Medication Management Unit, Children's Cancer Hospital Egypt, Cairo, 57357, 4260102, Egypt
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4
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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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Chiloiro S, Bianchi A, Giampietro A, Milardi D, De Marinis L, Pontecorvi A. The changing clinical spectrum of endocrine adverse events in cancer immunotherapy. Trends Endocrinol Metab 2022; 33:87-104. [PMID: 34895977 DOI: 10.1016/j.tem.2021.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/18/2021] [Accepted: 10/29/2021] [Indexed: 12/15/2022]
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of several malignancies, improving patient survival and quality of life. Endocrinopathies have emerged as a clinically significant group of immune-related adverse events (IRAEs). Although the mechanism of ICI toxicities has not been clarified, inhibition of immune checkpoints reduces immune tolerance to autoantigens, resulting in the development of autoimmunity disorders. We report current evidence regarding endocrine IRAEs that may have diagnostic and therapeutic implications. Management should be focused on a multidisciplinary approach to reach a prompt diagnosis and an appropriate and safe treatment.
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Affiliation(s)
- Sabrina Chiloiro
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy.
| | - Antonio Bianchi
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Antonella Giampietro
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Domenico Milardi
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Laura De Marinis
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
| | - Alfredo Pontecorvi
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Roma, Italy; Unità Operativa Complessa (UOC) Endocrinology and Diabetology, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Roma, Italy
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6
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Fujiwara N, Watanabe M, Katayama A, Noda Y, Eguchi J, Kataoka H, Kagawa S, Wada J. Longitudinal observation of insulin secretory ability before and after the onset of immune checkpoint inhibitor-induced diabetes mellitus: A report of two cases. Clin Case Rep 2021; 9:e04574. [PMID: 34522382 PMCID: PMC8424178 DOI: 10.1002/ccr3.4574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 05/31/2021] [Accepted: 06/16/2021] [Indexed: 01/15/2023] Open
Abstract
Immune checkpoint inhibitor-induced diabetes mellitus is a rare immune-related adverse event. This report illustrates clinical data and insulin secretory ability before and after the onset of immune checkpoint inhibitor-induced diabetes.
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Affiliation(s)
- Noriko Fujiwara
- Department of Nephrology, Rheumatology, Endocrinology and MetabolismDentistry and Pharmaceutical SciencesOkayama University Graduate School of MedicineOkayamaJapan
- Division of Endocrinology and MetabolismHiroshima Red Cross Hospital and Atomic‐bomb Survivors HospitalHiroshimaJapan
| | - Mayu Watanabe
- Department of Primary Care and Medical EducationDentistry and Pharmaceutical SciencesOkayama University Graduate School of MedicineOkayamaJapan
| | | | - Yohei Noda
- Department of Otolaryngology‐Head and Neck SurgeryDentistry and Pharmaceutical SciencesOkayama University Graduate School of MedicineOkayamaJapan
| | - Jun Eguchi
- Department of Nephrology, Rheumatology, Endocrinology and MetabolismDentistry and Pharmaceutical SciencesOkayama University Graduate School of MedicineOkayamaJapan
| | - Hitomi Kataoka
- Department of Primary Care and Medical EducationDentistry and Pharmaceutical SciencesOkayama University Graduate School of MedicineOkayamaJapan
| | - Shunsuke Kagawa
- Minimally Invasive Therapy CenterOkayama University HospitalOkayamaJapan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and MetabolismDentistry and Pharmaceutical SciencesOkayama University Graduate School of MedicineOkayamaJapan
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Lee S, Tse G. A Patient with Atezolizumab-Induced Autoimmune Diabetes Mellitus Presenting with Diabetic Ketoacidosis. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2021. [DOI: 10.15212/cvia.2021.0007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Atezolizumab, an immune checkpoint inhibitor, is a humanized monoclonal, anti-programmed death ligand 1 (PD-L1) antibody used for the treatment of metastatic urothelial carcinoma that has progressed after chemotherapy.Case Presentation: We describe a patient
with a known history of urothelial carcinoma who presented with diabetic ketoacidosis 6 weeks following his second cycle of atezolizumab. His serum lactate level was slightly elevated (2 mM) and his β-hydroxybutyrate level was elevated (3.9 mM). High anion gap metabolic acidosis secondary
to diabetic ketoacidosis was diagnosed. Subsequent testing demonstrated hemoglobin A1c level of 9.9%, positivity for anti-glutamic acid decarboxylase antibody (0.03 nM, reference range <0.02 nM), and suppressed C-peptide level (0.1 μg/L, reference range 0.9‐7.1 μg/L)
in the absence of detectable anti-islet antigen 2 (IA-2) or anti-insulin antibodies. His initial management included cessation of atezolizumab treatment, intravenous sodium chloride administration, and insulin pump infusion, after which metabolic acidosis gradually resolved. The insulin pump
was subsequently switched to Protaphane at 18 units before breakfast and 8 units before dinner, together with metformin at 1000 mg twice daily. Four weeks later his medication was changed to human isophane insulin plus neutral insulin (70%/30%; Mixtard 30 HM; 26 units/4 units). Linagliptin
at 5 mg was added 1 month later. His hemoglobin A1c level declined to 8.1% 1 year later.Conclusions: PD-L1 inhibitors can induce type 1 diabetes, and patients can present with diabetic ketoacidosis. Blood glucose levels should be regularly monitored in patients who are
prescribed these medications.
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Affiliation(s)
- Sharen Lee
- Cardiovascular Analytics Group, Laboratory of Cardiovascular Physiology, Hong Kong, HKG, China
| | - Gary Tse
- Cardiovascular Analytics Group, Laboratory of Cardiovascular Physiology, Hong Kong, HKG, China
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Lo Preiato V, Salvagni S, Ricci C, Ardizzoni A, Pagotto U, Pelusi C. Diabetes mellitus induced by immune checkpoint inhibitors: type 1 diabetes variant or new clinical entity? Review of the literature. Rev Endocr Metab Disord 2021; 22:337-349. [PMID: 33409866 DOI: 10.1007/s11154-020-09618-w] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 12/16/2022]
Abstract
Immune Check-Point Inhibitors (CPIs) have improved long-term patients' outcomes in several advanced cancers. Diabetes mellitus induced by CPIs (CPI-DM) is considered the second most frequent endocrine CPIs' side effects with a variable prevalence up to 2%. The aim of our study was to identify CPI-DM characteristics and differences from the classical form of diabetes. Therefore, we conducted a structured Pubmed® search collecting publications dated from January 2015 to December 2019. A total of 642 citations were identified and 121 publications met our study criteria. We analyzed 200 case reports, including our 3 cases under publication. The majority of CPI-DM occurred with anti-Programmed cell Death-1 in monotherapy or in combination, although few cases with Programmed cell Death Ligand-1 and Cytotoxic T Lymphocyte Antigen 4 were reported. Generally, CPI-DM arose early (an average of 9 weeks after CPIs starting), but also after the end of CPIs treatment. In all patients, CPI-DM has an acute onset and in 67.5% of cases diabetic ketoacidosis occurs. C-peptide levels were usually and permanently compromised, requiring lifelong insulin therapy. Moreover, autoimmunity and genetic profile was not always helpful. In particular, anti-glutamic acid decarboxylase (anti-GAD) antibodies and Human Leukocyte Antigen (HLA) DR4 were present in only 43.0% and 51.3% of cases respectively. In 51.0% of subjects a mild exocrine impairment coexisted. In short, though CPI-DM has similarities to type 1 diabetes mellitus, it represents a new, largely unknown, clinical entity. In addition, as CPI-DM is a relative frequent side-effect under CPI, a close monitoring of the glucose levels and early signs and symptoms of diabetes in patients affected by neoplasm is recommended.
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Affiliation(s)
- V Lo Preiato
- Endocrinology Unit and Prevention and Care of Diabetes, Department of Medical and Surgical Science (DIMEC), Alma Mater Studiorum, University of Bologna, S. Orsola Hospital, Via Massarenti 9, 40138, Bologna, Italy
| | - S Salvagni
- Division of Medical Oncology, Department of Experimental Diagnostic and Speciality Medicine (DIMES), Alma Mater Studiorum, University of Bologna, S. Orsola Hospital, Bologna, Italy
| | - C Ricci
- Surgical Department, Department of Medical and Surgical Science (DIMEC), Alma Mater Studiorum, University of Bologna, Sant'Orsola Hospital, Bologna, Italy
| | - A Ardizzoni
- Division of Medical Oncology, Department of Experimental Diagnostic and Speciality Medicine (DIMES), Alma Mater Studiorum, University of Bologna, S. Orsola Hospital, Bologna, Italy
| | - U Pagotto
- Endocrinology Unit and Prevention and Care of Diabetes, Department of Medical and Surgical Science (DIMEC), Alma Mater Studiorum, University of Bologna, S. Orsola Hospital, Via Massarenti 9, 40138, Bologna, Italy.
| | - C Pelusi
- Endocrinology Unit and Prevention and Care of Diabetes, Department of Medical and Surgical Science (DIMEC), Alma Mater Studiorum, University of Bologna, S. Orsola Hospital, Via Massarenti 9, 40138, Bologna, Italy
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Kyriacou A, Melson E, Chen W, Kempegowda P. Is immune checkpoint inhibitor-associated diabetes the same as fulminant type 1 diabetes mellitus? Clin Med (Lond) 2021; 20:417-423. [PMID: 32675150 DOI: 10.7861/clinmed.2020-0054] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Pembrolizumab is an anti-cancer drug that targets programmed cell death protein-1 (PD-1) receptors on lymphocytes resulting in their activation against tumour cells. PD-1 receptors are also interspersed in endocrine organs and pembrolizumab use has long been associated with hypophysitis and thyroiditis. Since the introduction of immune checkpoint inhibitors (ICI), several cases of fulminant type 1 diabetes mellitus (FT1DM) have been reported. However, it is unclear if FT1DM and ICI-induced diabetes are the same pathology. We review the existing literature of ICI-induced diabetes to investigate its nature and to what extent it represents type 1A diabetes and/or FT1DM (type 1B diabetes) using an example case. Our review showed that ICI-induced diabetes may be a different entity to FT1DM. Furthermore, there is limited evidence for the management of ICI-induced T1DM. Further research into its pathophysiology will improve management and possibly prevent this burdensome complication.
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Affiliation(s)
- Angelos Kyriacou
- Centre of Endocrinology, Diabetes and Metabolism, Limassol, Cyprus
| | - Eka Melson
- Institute of Metabolism and Systems Research, Birmingham, UK and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Punith Kempegowda
- Institute of Metabolism and Systems Research, Birmingham, UK and University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Abstract
With the increasing use of immune checkpoint inhibitors (ICI) including anti-cytotoxic T lymphocyte associated antigen-4 (CTLA-4) and anti-programmed cell death-1 (PD-1) in cancers, ICI-induced type 1 diabetes has been reported throughout the world. In this review, we aim to summarize the characteristics of this disease and discuss the mechanism of it. As an immune-related adverse event, type 1 diabetes developed after the administration of anti-PD-1 or anti-PD-ligand 1 (PD-L1) in the combination with or without anti-CTLA-4. It usually presented with acute onset, and 62.1% of the reported cases had diabetic ketoacidosis. Only a third of them had positive autoantibodies associated with type 1 diabetes. Susceptible HLA genotypes might be associated. T-cell-stimulation by blocking of the interaction of PD-1 and PD-L1 in pancreatic β cells was the main mechanism involved in the pathology. Insulin was the only effective treatment of ICI-induced type 1 diabetes. In conclusions, ICI-induced type 1 diabetes is a potentially life-threating adverse event after the immunotherapy of cancers. Screening and early recognition is important. Further investigation of the mechanism may help to better understand the pathology of type 1 diabetes.
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Huang X, Yang M, Wang L, Li L, Zhong X. Sintilimab induced diabetic ketoacidosis in a patient with small cell lung cancer: A case report and literature review. Medicine (Baltimore) 2021; 100:e25795. [PMID: 34106616 PMCID: PMC8133135 DOI: 10.1097/md.0000000000025795] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/11/2021] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Sintilimab is a novel programmed cell death receptor-1 (PD-1) inhibitor approved in the treatment of classical Hodgkin's lymphoma and undergoing clinical trials for various malignancies. As a PD-1 inhibitor, sintilimab is known to cause autoimmune adverse events similar to other PD-1 inhibitors. Diabetic ketoacidosis (DKA) is a rare but severe adverse event of this therapy. PATIENT CONCERNS We report a case of a 59-year-old man who developed DKA after 5 doses of sintilimab for small cell lung cancer. His fasting glycemia level was 14.07 mmol/L, urine ketone bodies were 4+, arterial blood pH was 7.271, bicarbonate was 12.3 mmol/L, and glycated hemoglobin (HbA1c) was 7.4%. Extended investigations revealed that fasting C-peptide was undetectable (<0.003 nmol/L). DIAGNOSIS These laboratory investigations supported the diagnosis of fulminant type 1 diabetes mellitus, but no β-cell related antibodies were positive. INTERVENTIONS After remission of DKA, he was treated with insulin therapy to acquire a normalization of glycemia and the disappearance of symptoms. OUTCOMES Sintilimab was withheld after 6 cycles and was converted to durvalumab to sustain the therapeutic effect. LESSONS This case and associated literature review illustrate the importance of educating and monitoring patients who start PD-1 inhibitor therapy regarding this potentially life-threatening complication.
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Affiliation(s)
| | - Mei Yang
- Department of Endocrinology and Metabolism
| | - Liu Wang
- Department of Endocrinology and Metabolism
| | - Libo Li
- Department of Hematology, The Third People's Hospital of Chengdu, The Second Affiliated Hospital of Chengdu, Chongqing Medical University, Chengdu, China
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Kimura H, Sone T, Araya T, Murata A, Yamamura K, Ohkura N, Hara J, Abo M, Kasahara K. Late-onset programmed cell death protein-1 inhibitor-induced pneumonitis after cessation of nivolumab or pembrolizumab in patients with advanced non-small cell lung cancer: a case series. Transl Lung Cancer Res 2021; 10:1576-1581. [PMID: 33889531 PMCID: PMC8044496 DOI: 10.21037/tlcr-20-582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Awareness of the immune-related adverse event of programmed cell death protein-1 (PD-1) inhibitor-induced pneumonitis is important. Herein, we report the clinical course of 3 patients suspected to have PD-1 inhibitor-induced pneumonitis after cessation of PD-1 inhibitor treatment. In case 1, a 62-year-old man was diagnosed with stage IVA adenocarcinoma. Nivolumab monotherapy was prescribed as second-line therapy and later discontinued due to financial reasons. Seven months after the final administration of nivolumab, the patient developed what we diagnosed as nivolumab-induced pneumonitis. The patient was immediately prescribed prednisolone (1 mg/kg p.o. daily), and the pneumonitis resolved after 1.5 months. In case 2, a 68-year-old man was diagnosed with stage IVB squamous cell carcinoma. Nivolumab monotherapy was prescribed as fourth-line therapy. After the second administration of nivolumab, the patient developed what we diagnosed as nivolumab-induced pneumonitis; nivolumab was discontinued, and the patient was immediately prescribed prednisolone (1 mg/kg p.o. daily). Eight months after the final administration of nivolumab, the patient again developed nivolumab-induced pneumonitis. The pneumonitis resolved without additional medication. In case 3, a 69-year-old man was diagnosed with stage IVB adenocarcinoma. Pembrolizumab monotherapy was initiated as sixth-line therapy, and it was discontinued after 4 cycles due to disease progression. Four months after the final dose of pembrolizumab, the patient developed what we diagnosed as pembrolizumab-induced pneumonitis. The patient immediately received a high intravenous dose of methylprednisolone (1,000 mg per day for three days). The pneumonitis and respiratory failure progressed, and he died 8 weeks after the onset of the pneumonitis. We report pneumonitis after discontinuation of ICIs in 3 patients. We confirm that, although uncommon, PD-1 inhibitor-induced irAEs can develop after treatment discontinuation. Further accumulation of cases and clarification of the clinical features of patients with irAEs, such as the time of onset, imaging findings, and treatment outcomes are needed.
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Affiliation(s)
- Hideharu Kimura
- Respiratory Medicine, Kanazawa University Hospital, Ishikawa, Japan
| | - Takashi Sone
- Respiratory Medicine, Kanazawa University Hospital, Ishikawa, Japan
| | - Tomoyuki Araya
- Department of Respiratory Medicine, National Hospital Organization Kanazawa Medical Center, Kanazawa, Japan
| | - Akari Murata
- Respiratory Medicine, Kanazawa University Hospital, Ishikawa, Japan
| | - Kenta Yamamura
- Respiratory Medicine, Kanazawa University Hospital, Ishikawa, Japan
| | - Noriyuki Ohkura
- Respiratory Medicine, Kanazawa University Hospital, Ishikawa, Japan
| | - Johsuke Hara
- Respiratory Medicine, Kanazawa University Hospital, Ishikawa, Japan
| | - Miki Abo
- Respiratory Medicine, Kanazawa University Hospital, Ishikawa, Japan
| | - Kazuo Kasahara
- Respiratory Medicine, Kanazawa University Hospital, Ishikawa, Japan
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Liu Y, Zhang H, Zhou L, Li W, Yang L, Li W, Li K, Liu X. Immunotherapy-Associated Pancreatic Adverse Events: Current Understanding of Their Mechanism, Diagnosis, and Management. Front Oncol 2021; 11:627612. [PMID: 33732647 PMCID: PMC7959713 DOI: 10.3389/fonc.2021.627612] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/18/2021] [Indexed: 02/05/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) such as anti-programmed death-1 (PD-1) and its ligand PD-L1 and anti-cytotoxic T-lymphocyte antigen 4 (CTLA-4) monoclonal antibodies, are involved in T cell-mediated immune response augmentation and promote anti-tumor immunity. Cancer patients treated with combination of immunotherapy, chemotherapy, radiotherapy, and targeted therapy exhibit superior clinical outcomes and tolerance compared with patients treated with monotherapies. However, immutherapy is associated with several concomitant immune-related adverse events (irAEs). For instance, IrAEs interferes with function of gastrointestinal tract, endocrine, dermatological, nervous system and musculoskeletal systems. ICIs-associated pancreatic injury might causes decrease in endocrine and exocrine pancreatic function, resulting in metabolic and nutritional disorders. Clinicians who administer immune checkpoint inhibitors to cancer patients are diagnosed with hyperglycemia, abdominal pain and steatorrhea. Currently, the precise mechanism of ICIs-associated pancreatic injury has not been fully explored. This paper summarizes incidence, diagnosis, clinical characteristics, potential mechanisms, and treatment management patterns of ICIs-associated pancreatic AEs based on previous studies. In addition, possible management approaches of these adverse effects are presented in this paper. in the findings summarized in this paper lay a basis for management of ICIs-associated pancreatic AEs and expanding future immunotherapy applications.
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Affiliation(s)
- Ya Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Hao Zhang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Li Zhou
- Core Facilities, West China Hospital, Sichuan University, Chengdu, China
| | - Weichun Li
- CAAC Academy, Civil Aviation Flight University of China, Guanghan, China
| | - Le Yang
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Wen Li
- Lung Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Kezhou Li
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Xubao Liu
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
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14
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Zezza M, Kosinski C, Mekoguem C, Marino L, Chtioui H, Pitteloud N, Lamine F. Combined immune checkpoint inhibitor therapy with nivolumab and ipilimumab causing acute-onset type 1 diabetes mellitus following a single administration: two case reports. BMC Endocr Disord 2019; 19:144. [PMID: 31870373 PMCID: PMC6929418 DOI: 10.1186/s12902-019-0467-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 12/02/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The use of immune checkpoint inhibitor (ICI) therapy is becoming a standard of care for several cancers. Monoclonal antibodies targeting cytotoxic T-lymphocyte antigen-4 (CTLA-4) and programmed cell death protein 1 (PD-1) or its ligand (PD-L1) cause a broad spectrum of autoimmune adverse events. ICI-induced type 1 diabetes mellitus (T1DM) is extremely rare (< 1%) but potentially life-threatening. It appears to be more common with PD-1 blockade (or combination immunotherapy) than with anti-CTLA-4 therapy, often during the first three to six months of therapy. CASES PRESENTATION We report an acute onset T1DM with severe inaugural diabetic ketoacidosis (DKA) and remarkably elevated Glutamic Acid Decarboxylase antibody (GADA) titres following a single administration of combined ICI therapy with nivolumab (anti-PD-1) and ipilimumab (anti-CTLA-4) in two adult patients with advanced metastatic melanoma. In these cases, the time to diabetes onset was remarkably short (two and five weeks), and one presented with fulminous T1DM in a previous long-standing type 2 diabetes mellitus. CONCLUSIONS Oncological patients treated with combination therapy of anti-PD-1 and anti-CTLA-4 can develop a particular pattern of T1DM, with very rapid onset within a few weeks after starting ICI therapy, even in the presence of an existing type 2 diabetes. ICI-induced T1DM is a medical emergency in presence of severe inaugural DKA and requires a collaboration between specialists and primary care physicians, as well as patient education, for early diagnosis and supportive care.
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Affiliation(s)
- Marco Zezza
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital (CHUV), University of Lausanne, Av. de La Sallaz 8, 1011, Lausanne, Switzerland
| | - Christophe Kosinski
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital (CHUV), University of Lausanne, Av. de La Sallaz 8, 1011, Lausanne, Switzerland
| | - Carine Mekoguem
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital (CHUV), University of Lausanne, Av. de La Sallaz 8, 1011, Lausanne, Switzerland
| | - Laura Marino
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital (CHUV), University of Lausanne, Av. de La Sallaz 8, 1011, Lausanne, Switzerland
| | - Haithem Chtioui
- Service of Clinical Pharmacology, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Nelly Pitteloud
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital (CHUV), University of Lausanne, Av. de La Sallaz 8, 1011, Lausanne, Switzerland
| | - Faiza Lamine
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital (CHUV), University of Lausanne, Av. de La Sallaz 8, 1011, Lausanne, Switzerland.
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Abstract
Acute type 1 diabetes (AD1) is a rare but definitive immune-related adverse event associated with anti-PD1. Most of the reported cases are close to what has been described as "fulminant type 1 diabetes." We sought to determine whether anti-PD1 could impair glycoregulation and whether occurrence of AD1 could be anticipated by prior glycemic changes. Fasting glycemia collected before, under, and after treatment in melanoma patients treated with anti-PD1 over a period of 36 months were retrospectively analyzed. Glycemic trend analyses were performed using linear regression analysis. In total, 1470 glucose values were monitored in 163 patients treated for a mean duration of 5.96 months. Three patients developed an AD1 (1, 84%). Two other cases were observed in the same period in a still-blinded trial of anti-PD1 versus ipilimumab. All cases of AD1 occurred in patients with a normal pretreatment glycemia, and there was no detectable drift of glycemia before ketoacidosis onset. In 4 of 5 cases of AD1, the HLA subgroups were DRB01* 03 or 04, known to increase type 1 diabetes risk in the general population. In the 28 patients with preexisting type 2 diabetes, there was a slight trend for glycemia increase with anti-PD1 infusions (0.05 mmol/L/infusion P=0.004). In the 132 patients with normal pretreatment glycemia, there was a slight trend for a decrease of glycemia with anti-PD1 infusions (-0.012/mmol/L/infusion P=0.026). These data suggest that the monitoring of glycemia under anti-PD1 cannot help to anticipate AD1, and there is no general tendency to glycemic disorder. HLA genotyping before treatment may help to focus surveillance in patients with the HLA DRB1*03/04 group.
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16
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de Filette JMK, Pen JJ, Decoster L, Vissers T, Bravenboer B, Van der Auwera BJ, Gorus FK, Roep BO, Aspeslagh S, Neyns B, Velkeniers B, Kharagjitsingh AV. Immune checkpoint inhibitors and type 1 diabetes mellitus: a case report and systematic review. Eur J Endocrinol 2019; 181:363-374. [PMID: 31330498 PMCID: PMC6709545 DOI: 10.1530/eje-19-0291] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/19/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To better define the rare adverse event (AE) of diabetes mellitus associated with immune checkpoint inhibitors (ICIs). DESIGN AND METHODS We report the case of a lung cancer patient with diabetic ketoacidosis (DKA) and autoimmune thyroiditis during pembrolizumab treatment. We provide a systematic review of all published cases (PubMed/Web of Science/Cochrane, through November 2018) of autoimmune diabetes mellitus related to blockade of the cytotoxic T-lymphocyte antigen 4 (CTLA-4)-, programmed cell death 1 (PD-1) receptor or its ligand (PD-L1) or combination (ICI) therapy. RESULTS Our literature search identified 90 patient cases (our case excluded). Most patients were treated with anti-PD-1 or anti-PD-L1 as monotherapy (79%) or in combination with CTLA-4 blockade (15%). On average, diabetes mellitus was diagnosed after 4.5 cycles; earlier for combination ICI at 2.7 cycles. Early-onset diabetes mellitus (after one or two cycles) was observed during all treatment regimens. Diabetic ketoacidosis was present in 71%, while elevated lipase levels were detected in 52% (13/25). Islet autoantibodies were positive in 53% of patients with a predominance of glutamic acid decarboxylase antibodies. Susceptible HLA genotypes were present in 65% (mostly DR4). Thyroid dysfunction was the most frequent other endocrine AE at 24% incidence in this patient population. CONCLUSION ICI-related diabetes mellitus is a rare but often life-threatening metabolic urgency of which health-care professionals and patients should be aware. Close monitoring of blood glucose and prompt endocrine investigation in case of hyperglycemia is advisable. Predisposing factors such as HLA genotype might explain why some individuals are at risk.
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Affiliation(s)
| | - Joeri J Pen
- Diabetes Clinic, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Lore Decoster
- Department of Medical Oncology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Thomas Vissers
- Medical Library, Haaglanden Medical Center, Hague, The Netherlands
| | - Bert Bravenboer
- Department of Endocrinology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | | | - Frans K Gorus
- Diabetes Research Center, Vrije Universiteit Brussel, Brussels, Belgium
| | - Bart O Roep
- Department of Immunohematology & Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
- Department of Diabetes Immunology, Diabetes & Metabolism Research Institute, City of Hope, Duarte, California, USA
| | - Sandrine Aspeslagh
- Department of Medical Oncology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Bart Neyns
- Department of Medical Oncology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Brigitte Velkeniers
- Department of Endocrinology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Aan V Kharagjitsingh
- Department of Endocrinology, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Diabetes Clinic, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Diabetes Research Center, Vrije Universiteit Brussel, Brussels, Belgium
- Section Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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17
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Farina KA, Kane MP. Programmed Cell Death-1 Monoclonal Antibody Therapy and Type 1 Diabetes Mellitus: A Review of the Literature. J Pharm Pract 2019; 34:133-140. [PMID: 31269868 DOI: 10.1177/0897190019850929] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Two Food and Drug Administration-approved programmed cell death-1 (PD-1) inhibitors, nivolumab (Opdivo®), and pembrolizumab (Keytruda®), are indicated for treatment-resistant malignancies. Inhibition of PD-1 also inhibits T-cell peripheral tolerance, enhancing autoimmunity. Various autoimmune conditions have been reported with the use of these agents, including type 1 diabetes mellitus (T1DM). This article reviews literature regarding the development of T1DM in patients treated with PD-1 inhibitors and identifies strategies for the appropriate identification, monitoring, and follow-up of these patients. Published cases of T1DM related to PD-1 inhibitor therapy were identified using PubMed. Eighty-three identified publications were reviewed, of which 37 publications involving 42 cases of anti-PD-1 therapy-induced T1DM were identified. The average age of patients at presentation was 62 years and 59.5% were male. The mean number of PD-1 inhibitor doses received was 5, with a mean time to presentation of 11 weeks. Initial presentation of diabetic ketoacidosis was reported in 69% of cases, with an average blood glucose of 660 mg/dL and an average HbA1c of 8.7%. The exact mechanism PD-1 inhibitor therapy-induced T1DM is unknown. Blood glucose monitoring is recommended for all patients receiving anti-PD-1 therapy. Further research is needed to delineate the frequency of this adverse effect, as well as to evaluate potential risk factors and ideal management strategies.
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Affiliation(s)
- Kyle A Farina
- 1091Albany College of Pharmacy and Health Sciences, Albany, NY, USA
| | - Michael P Kane
- Department of Pharmacy Practice, 1091Albany College of Pharmacy and Health Sciences, Albany, NY, USA
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18
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Taylor A, Rudd CE. Commentary: Small Molecule Inhibition of PD-1 Transcription is an Effective Alternative to Antibody Blockade in Cancer Therapy. ACTA ACUST UNITED AC 2019; 3:9-12. [PMID: 31111120 PMCID: PMC6525092 DOI: 10.29245/2578-3009/2019/1.1167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Alison Taylor
- Leeds Institute of Medical Research, University of Leeds, School of Medicine, Wellcome Trust Brenner Building, St James's University Hospital, LEEDS LS9 7TF, UK
| | - Christopher E Rudd
- Division of Immunology-Oncology Research Center, Maisonneuve-Rosemont Hospital, Montreal, Quebec H1T 2M4, Canada.,Département de Medicine, Université de Montréal, Montreal, Quebec H3C 3J7, Canada
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19
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Bajwa R, Cheema A, Khan T, Amirpour A, Paul A, Chaughtai S, Patel S, Patel T, Bramson J, Gupta V, Levitt M, Asif A, Hossain MA. Adverse Effects of Immune Checkpoint Inhibitors (Programmed Death-1 Inhibitors and Cytotoxic T-Lymphocyte-Associated Protein-4 Inhibitors): Results of a Retrospective Study. J Clin Med Res 2019; 11:225-236. [PMID: 30937112 PMCID: PMC6436564 DOI: 10.14740/jocmr3750] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 02/13/2019] [Indexed: 12/11/2022] Open
Abstract
In recent years the use of immunomodulating therapy to treat various cancers has been on the rise. Three checkpoint inhibitors have been approved by the Food and Drug Administration (ipilimumab, pembrolizumab and nivolumab). The use of these drugs comes with serious adverse events related to excessive immune activation, collectively known as immune-related adverse events (irAEs). We conducted a system-based review of 139 case reports/case series that have described these adverse events between January 2016 and April 2018, found in the PubMed database. There was a broad spectrum of presentations, doses and checkpoint inhibitors used. The most common check point inhibitor observed in our literature review was nivolumab. The most common adverse effects encountered were colitis (14/139), hepatitis (11/139), adrenocorticotropic hormone insufficiency (12/139), hypothyroidism (7/139), type 1 diabetes (22/139), acute kidney injury (16/139) and myocarditis (10/139). The treatment most commonly consisted of cessation of the immune checkpoint inhibitor, initiation of steroids and supportive therapy. This approach provided a complete resolution in a majority of cases; however, there were many that developed long-term adverse events with deaths reported in a few cases. The endocrine system was the mostly commonly affected with the development of type 1 diabetes mellitus or diabetic ketoacidosis being the most frequently reported adverse events. While immunomodulating therapy is a significant advance in the management of various malignancies, it is capable of serious adverse effects. Because the majority of the cases developed pancreatic dysfunction within five cycles of therapy, in addition to the evaluation of other systems, pancreatic function should be closely monitored to minimize adverse impact on patients.
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Affiliation(s)
- Ravneet Bajwa
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Anmol Cheema
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Taimoor Khan
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Alireza Amirpour
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Anju Paul
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Saira Chaughtai
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Shrinil Patel
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Tejas Patel
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Joshua Bramson
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Varsha Gupta
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Michael Levitt
- Department of Hematology/Oncology, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Arif Asif
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
| | - Mohammad A Hossain
- Department of Medicine, Jersey Shore University Medical Center, Neptune, NJ, USA
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20
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Takeno A, Yamamoto M, Morita M, Tanaka S, Kanazawa I, Yamauchi M, Kaneko S, Sugimoto T. Late-onset isolated adrenocorticotropic hormone deficiency caused by nivolumab: a case report. BMC Endocr Disord 2019; 19:25. [PMID: 30782163 PMCID: PMC6381704 DOI: 10.1186/s12902-019-0335-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 01/09/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors including nivolumab, an anti-programmed cell death protein 1 antibody, are recently developed cancer immunotherapy agents. Immune checkpoint inhibitors are known to cause autoimmune-related side effects including endocrine dysfunctions. However, there are few reports on late-onset isolated adrenocorticotropic hormone (ACTH) deficiency caused by nivolumab. CASE PRESENTATION The patient was a 72-year-old female. When she was 64 years old, she was diagnosed with malignant melanoma of the left thigh accompanied by left inguinal lymph node metastases, and she received several courses of chemotherapy for malignant melanoma followed by the resection of these lesions. At 71 years of age, multiple metastases were found and treatment with nivolumab 2 mg/kg every 3 weeks was initiated. Six months later, replacement with levothyroxine was started because of hypothyroidism following mild transient thyrotoxicosis. Eleven months after the beginning of nivolumab, the treatment was discontinued because of tumor expansion. Four months after the discontinuation of nivolumab, general malaise and appetite loss worsened, and 2 months later, hyponatremia (Na; 120-127 mEq/L) and hypoglycemia (fasting plasma glucose; 62 mg/dL) appeared. Her ACTH and cortisol levels were extremely low (ACTH; 9.6 pg/mL, cortisol; undetectable). Challenge tests for anterior pituitary hormones showed that responses of ACTH and cortisol secretion to corticotropin-releasing hormone were disappeared, although responses of other anterior pituitary hormones were preserved. Thus, she was diagnosed with isolated ACTH deficiency. Her symptoms were improved after treatment with hydrocortisone. CONCLUSIONS The present report showed a case of late-onset isolated ACTH deficiency accompanied by hyponatremia, which was diagnosed 6 months after the discontinuation of nivolumab. The effects of nivolumab last for a long time and the side effects of nivolumab can also appear several months after discontinuation of the drug. Repeated monitoring of serum sodium levels may be a beneficial strategy to find the unexpected development of adrenal insufficiency even after discontinuation of nivolumab.
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Affiliation(s)
- Ayumu Takeno
- Internal Medicine 1, Shimane University Faculty of Medicine, 89-1, Enya-cho, Izumo, Shimane 693-8501 Japan
| | - Masahiro Yamamoto
- Internal Medicine 1, Shimane University Faculty of Medicine, 89-1, Enya-cho, Izumo, Shimane 693-8501 Japan
| | - Miwa Morita
- Internal Medicine 1, Shimane University Faculty of Medicine, 89-1, Enya-cho, Izumo, Shimane 693-8501 Japan
| | - Sayuri Tanaka
- Internal Medicine 1, Shimane University Faculty of Medicine, 89-1, Enya-cho, Izumo, Shimane 693-8501 Japan
| | - Ippei Kanazawa
- Internal Medicine 1, Shimane University Faculty of Medicine, 89-1, Enya-cho, Izumo, Shimane 693-8501 Japan
| | - Mika Yamauchi
- Internal Medicine 1, Shimane University Faculty of Medicine, 89-1, Enya-cho, Izumo, Shimane 693-8501 Japan
| | - Sakae Kaneko
- Department of Dermatology, Shimane University Faculty of Medicine, 89-1, Enya-cho, Izumo, Shimane 693-8501 Japan
| | - Toshitsugu Sugimoto
- Internal Medicine 1, Shimane University Faculty of Medicine, 89-1, Enya-cho, Izumo, Shimane 693-8501 Japan
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21
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Chang LS, Barroso-Sousa R, Tolaney SM, Hodi FS, Kaiser UB, Min L. Endocrine Toxicity of Cancer Immunotherapy Targeting Immune Checkpoints. Endocr Rev 2019; 40:17-65. [PMID: 30184160 PMCID: PMC6270990 DOI: 10.1210/er.2018-00006] [Citation(s) in RCA: 316] [Impact Index Per Article: 63.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 06/07/2018] [Indexed: 12/13/2022]
Abstract
Immune checkpoints are small molecules expressed by immune cells that play critical roles in maintaining immune homeostasis. Targeting the immune checkpoints cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and programmed death 1 (PD-1) with inhibitory antibodies has demonstrated effective and durable antitumor activity in subgroups of patients with cancer. The US Food and Drug Administration has approved several immune checkpoint inhibitors (ICPis) for the treatment of a broad spectrum of malignancies. Endocrinopathies have emerged as one of the most common immune-related adverse events (irAEs) of ICPi therapy. Hypophysitis, thyroid dysfunction, insulin-deficient diabetes mellitus, and primary adrenal insufficiency have been reported as irAEs due to ICPi therapy. Hypophysitis is particularly associated with anti-CTLA-4 therapy, whereas thyroid dysfunction is particularly associated with anti-PD-1 therapy. Diabetes mellitus and primary adrenal insufficiency are rare endocrine toxicities associated with ICPi therapy but can be life-threatening if not promptly recognized and treated. Notably, combination anti-CTLA-4 and anti-PD-1 therapy is associated with the highest incidence of ICPi-related endocrinopathies. The precise mechanisms underlying these endocrine irAEs remain to be elucidated. Most ICPi-related endocrinopathies occur within 12 weeks after the initiation of ICPi therapy, but several have been reported to develop several months to years after ICPi initiation. Some ICPi-related endocrinopathies may resolve spontaneously, but others, such as central adrenal insufficiency and primary hypothyroidism, appear to be persistent in most cases. The mainstay of management of ICPi-related endocrinopathies is hormone replacement and symptom control. Further studies are needed to determine (i) whether high-dose corticosteroids in the treatment of ICPi-related endocrinopathies preserves endocrine function (especially in hypophysitis), and (ii) whether the development of ICPi-related endocrinopathies correlates with tumor response to ICPi therapy.
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Affiliation(s)
- Lee-Shing Chang
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Romualdo Barroso-Sousa
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Sara M Tolaney
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - F Stephen Hodi
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Ursula B Kaiser
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Le Min
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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22
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Venetsanaki V, Boutis A, Chrisoulidou A, Papakotoulas P. Diabetes mellitus secondary to treatment with immune checkpoint inhibitors. ACTA ACUST UNITED AC 2019; 26:e111-e114. [PMID: 30853817 DOI: 10.3747/co.26.4151] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cancer immunotherapy has been one of the highlights in the advancement of cancer care. Certain immune checkpoint inhibitors bind to PD-1 on T cells and mediate an antitumour immune response. Given that immune checkpoint inhibitors are becoming part of standard care, a new class of adverse events-immune-related adverse events-has emerged. Among them is endocrine toxicity, most commonly targeting the thyroid, pituitary, or adrenal glands. New-onset diabetes mellitus has been reported in fewer than 1% of patients. We present a patient with type 1 diabetes mellitus secondary to immunotherapy, together with an overview of the associated literature. Patients who develop type 1 diabetes mellitus experience a rapid course, and diabetic ketoacidosis is commonly the presenting symptom. Insulin is currently the treatment of choice; oral antidiabetics or corticosteroids do not assist in management. Several predictive factors are under investigation, but physician awareness and prompt management are key to a positive outcome.
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Affiliation(s)
- V Venetsanaki
- First Department of Clinical Oncology, Theagenio Hospital, Thessaloniki, Greece
| | - A Boutis
- First Department of Clinical Oncology, Theagenio Hospital, Thessaloniki, Greece
| | - A Chrisoulidou
- Department of Endocrinology, Theagenio Hospital, Thessaloniki, Greece
| | - P Papakotoulas
- First Department of Clinical Oncology, Theagenio Hospital, Thessaloniki, Greece
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23
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Tan MH, Iyengar R, Mizokami-Stout K, Yentz S, MacEachern MP, Shen LY, Redman B, Gianchandani R. Spectrum of immune checkpoint inhibitors-induced endocrinopathies in cancer patients: a scoping review of case reports. Clin Diabetes Endocrinol 2019; 5:1. [PMID: 30693099 PMCID: PMC6343255 DOI: 10.1186/s40842-018-0073-4] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/29/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Since 2011 six immune checkpoint inhibitors (ICI) have been approved to treat patients with many advanced solid tumor and hematological malignancies to improve their prognosis. Case reports of their endocrine immune-related adverse events [irAEs]) are increasingly published as more real-world patients with these malignancies are treated with these drugs. They alert physicians of a drug's AEs (which may change during a drug's life cycle) and contribute to post-marketing safety surveillance. Using a modified framework of Arksey and O'Malley, we conducted a scoping review of the spectrum and characteristics of ICI-induced endocrinopathies case reports before and after ICIs are marketed. METHODS In July 2017, we searched, without date and language restrictions, 4 citation databases for ICI-induced endocrinopathies. We also hand-searched articles' references, contents of relevant journals, and ran supplemental searches to capture recent reports through January 2018. For this study, a case should have information on type of cancer, type of ICI, clinical presentation, biochemical tests, treatment plus temporal association of ICI initiation with endocrinopathies. Two endocrinologists independently extracted the data which were then summarized and categorized. RESULTS One hundred seventy nine articles reported 451 cases of ICI-induced endocrinopathies - 222 hypopituitarism, 152 thyroid disorders, 66 diabetes mellitus, 6 primary adrenal insufficiencies, 1 ACTH-dependent Cushing's syndrome, 1 hypoparathyroidism and 3 diabetes insipidus cases. Their clinical presentations reflect hormone excess or deficiency. Some were asymptomatic and others life-threatening. One or more endocrine glands could be affected. Polyglandular endocrinopathies could present simultaneously or in sequence. Many occur within 5 months of therapy initiation; a few occurred after ICI was stopped. Mostly irreversible, they required long-term hormone replacement. High dose steroids were used when non-endocrine AEs coexisted or as therapy in adrenal insufficiency. There was variability of information in the case reports but all met the study criteria to make a diagnosis. CONCLUSIONS The spectrum of ICI-induced endocrinopathies is wide (5 glands affected) and their presentation varied (12 endocrinopathies). Clinical reasoning integrating clinical, biochemical and treatment information is needed to properly diagnose and manage them. Physicians should be vigilant for their occurrence and be able to diagnose, investigate and manage them appropriately at onset and follow-up.
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Affiliation(s)
- Meng H. Tan
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
| | - Ravi Iyengar
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
- Present address: Endocrinology, Rush University Medical Center, 1725 West Harrison Street, Chicago, IL 60612 USA
| | - Kara Mizokami-Stout
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
| | - Sarah Yentz
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Mark P. MacEachern
- Taubman Health Sciences Library, University of Michigan, 1135 Catherine Street, Ann Arbor, MI 48109 USA
| | - Li Yan Shen
- Affiliated Hospital of QingDao University, QingDao, 16 Jiangsu Road, Sinan Qu, Qingdao, Shi, Shandong Sheng China
| | - Bruce Redman
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Roma Gianchandani
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106 USA
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24
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A Case of Drug-Induced Severe Endocrinopathies: What Providers in the Emergency Department Need to Know. Adv Emerg Nurs J 2018; 40:16-20. [PMID: 29384770 DOI: 10.1097/tme.0000000000000173] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The purpose of this article is to present a discussion of immune checkpoint inhibitors (ICIs) that are relatively new, yet growing, form of cancer therapy. Immune checkpoint inhibitors increase host immune response against neoplastic cells. Strengthened immunological response increases the potential for adverse events such as life-threatening endocrinopathies. The case of a 66-year-old man with metastatic melanoma treated with nivolumab and ipilimumab presented to the emergency department with marked hyperglycemia and elevated anion gap 19 days after receiving both agents is discussed. The patient received a diagnosis of immune-mediated diabetes requiring ongoing insulin even after discontinuation of ICIs. As treatment with this class of agents expands, emergency department providers will need to become familiar with the identification of their adverse reactions to provide the proper management of care.
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25
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Clotman K, Janssens K, Specenier P, Weets I, De Block CEM. Programmed Cell Death-1 Inhibitor-Induced Type 1 Diabetes Mellitus. J Clin Endocrinol Metab 2018; 103:3144-3154. [PMID: 29955867 DOI: 10.1210/jc.2018-00728] [Citation(s) in RCA: 138] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 06/22/2018] [Indexed: 12/11/2022]
Abstract
CONTEXT Pembrolizumab (Keytruda; Merck Sharp & Dohme) is a humanized IgG4 monoclonal antibody used in cancer immunotherapy. It targets the programmed cell death-1 (PD-1) receptor, which is important in maintaining self-tolerance. However, immune checkpoint blockade is associated with a risk for immune-related adverse events (irAEs) potentially affecting the endocrine organs. Type 1 diabetes mellitus is a rare irAE of PD-1 inhibitors, occurring in 0.2% of cases. EVIDENCE ACQUISITION Systematic search of four databases (MEDLINE, Embase, Web of Science, and Cochrane Library) using the search terms "diabetes" or "ketoacidosis" and "pembrolizumab," "nivolumab," "PD-1 inhibitor," or "immunotherapy." Included were articles published in English between 1 January 2012 and 1 January 2018. The search was supplemented by bibliographic searches of the complete reference lists of all included papers. EVIDENCE SYNTHESIS We provide an overview of all published cases (n = 42) of PD-1 inhibitor-induced type 1 diabetes mellitus to date, including a well-characterized case of islet cell antibody and glutamic acid decarboxylase antibody-positive diabetes mellitus, in a patient with a diabetes-prone HLA genotype. She presented with diabetic ketoacidosis during pembrolizumab therapy for a metastatic uveal melanoma. Furthermore, we discuss potential pathogenic mechanisms, clinical presentation, prognostic markers (β-cell antibodies and HLA type), treatment, and a screening protocol. CONCLUSIONS Because the use of immunotherapy will increase, it is essential that all clinicians are aware of diabetic ketoacidosis as a rare and life-threatening side effect of immunotherapy. Blood glucose monitoring during anti-PD-1 therapy is necessary.
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MESH Headings
- Aged
- Antibodies, Monoclonal, Humanized/adverse effects
- Antibodies, Monoclonal, Humanized/pharmacology
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/pharmacology
- Antineoplastic Agents, Immunological/therapeutic use
- Diabetes Mellitus, Type 1/chemically induced
- Diabetes Mellitus, Type 1/immunology
- Female
- Humans
- Immunotherapy/adverse effects
- Melanoma/drug therapy
- Prognosis
- Programmed Cell Death 1 Receptor/antagonists & inhibitors
- T-Lymphocytes/drug effects
- T-Lymphocytes/immunology
- Uveal Neoplasms/drug therapy
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Affiliation(s)
- Katrien Clotman
- Department of Endocrinology, Diabetology & Metabolism, Antwerp University Hospital, Edegem, Belgium
- Department of Endocrinology-Nephrology, Algemeen Ziekenhuis Klina Hospital, Brasschaat, Belgium
| | - Katleen Janssens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Pol Specenier
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Oncology, Antwerp University Hospital, Edegem, Belgium
| | - Ilse Weets
- Diabetes Research Center, Brussels Free University, Brussels, Belgium
| | - Christophe E M De Block
- Department of Endocrinology, Diabetology & Metabolism, Antwerp University Hospital, Edegem, Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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26
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Sakai G, Saito D, Nakajima R, Hatano M, Noguchi Y, Kurihara S, Katayama S, Inoue I, Noda M, Shimada A. Intrinsic insulin secretion capacity might be preserved by discontinuing anti-programmed cell death protein 1 antibody treatment in 'anti-programmed cell death protein 1 antibody-induced' fulminant type 1 diabetes. J Diabetes Investig 2018; 9:448-449. [PMID: 29504279 PMCID: PMC5835468 DOI: 10.1111/jdi.12662] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/20/2017] [Accepted: 03/22/2017] [Indexed: 11/29/2022] Open
Abstract
Intrinsic insulin secretion capacity may be preserved by discontinuing anti-PD-1 antibody treatment in 'anti-PD-1 antibody-induced'fulminant type 1 diabetes.
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Affiliation(s)
- Gota Sakai
- Department of Endocrinology and Diabetes, Saitama Medical University, Moroyama, Iruma Saitama, Japan
| | - Daigo Saito
- Department of Endocrinology and Diabetes, Saitama Medical University, Moroyama, Iruma Saitama, Japan
| | - Ritsuko Nakajima
- Department of Endocrinology and Diabetes, Saitama Medical University, Moroyama, Iruma Saitama, Japan
| | - Masako Hatano
- Department of Endocrinology and Diabetes, Saitama Medical University, Moroyama, Iruma Saitama, Japan
| | - Yuichi Noguchi
- Department of Endocrinology and Diabetes, Saitama Medical University, Moroyama, Iruma Saitama, Japan
| | - Susumu Kurihara
- Department of Endocrinology and Diabetes, Saitama Medical University, Moroyama, Iruma Saitama, Japan
| | - Shigehiro Katayama
- Department of Endocrinology and Diabetes, Saitama Medical University, Moroyama, Iruma Saitama, Japan
| | - Ikuo Inoue
- Department of Endocrinology and Diabetes, Saitama Medical University, Moroyama, Iruma Saitama, Japan
| | - Mitsuhiko Noda
- Department of Endocrinology and Diabetes, Saitama Medical University, Moroyama, Iruma Saitama, Japan
| | - Akira Shimada
- Department of Endocrinology and Diabetes, Saitama Medical University, Moroyama, Iruma Saitama, Japan
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Gauci ML, Boudou P, Baroudjian B, Vidal-Trecan T, Da Meda L, Madelaine-Chambrin I, Basset-Seguin N, Bagot M, Pages C, Mourah S, Resche-Rigon M, Pinel S, Sassier M, Rouby F, Eftekhari P, Lebbé C, Gautier JF. Occurrence of type 1 and type 2 diabetes in patients treated with immunotherapy (anti-PD-1 and/or anti-CTLA-4) for metastatic melanoma: a retrospective study. Cancer Immunol Immunother 2018; 67:1197-1208. [PMID: 29808365 PMCID: PMC11028208 DOI: 10.1007/s00262-018-2178-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 05/24/2018] [Indexed: 12/13/2022]
Abstract
Anti-PD-1 and anti-CTLA-4 antibodies cause immune-related side effects such as autoimmune type 1 diabetes (T1D). It has also been suggested that by increasing TNF-α, IL-2 and IFN-γ production, anti-PD-1 and/or anti-CTLA-4 treatment could affect pancreatic beta cell function and insulin sensitivity. This study was based on a retrospective observational analysis from 2 July 2014 to 27 June 2016, which evaluated the occurrence of T1D and changes in glycemia and C-reactive protein (CRP) plasma concentrations in patients undergoing anti-PD-1 and/or anti-CTLA-4 treatment for melanoma at the Saint Louis Hospital. All cases of T1D that developed during immunotherapy registered in the French Pharmacovigilance Database (FPVD) were also considered. Among the 132 patients included, 3 cases of T1D occurred. For the remaining subjects, blood glucose was not significantly affected by anti-PD-1 treatment, but CRP levels (mg/l) significantly increased during anti-PD-1 treatment (p = 0.017). However, 1 case of type 2 diabetes (T2D) occurred (associated with a longer therapy duration). Moreover, glycemia of patients pretreated (n = 44) or concomitantly treated (n = 8) with anti-CTLA-4 tended to increase during anti-PD-1 therapy (p = 0.068). From the FPVD, we obtained 14 cases of T1D that occurred during immunotherapy and were primarily characterized by the rapidity and severity of onset. In conclusion, in addition to inducing this rare immune-related diabetes condition, anti-PD-1 treatment appears to increase CRP levels, a potential inflammatory trigger of insulin resistance, but without any short-term impact on blood glucose level.
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Affiliation(s)
- Marie-Léa Gauci
- AP-HP Dermatology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, 1, Avenue Claude Vellefaux, 75010, Paris, France.
| | - Philippe Boudou
- AP-HP Hormonology Department, Saint-Louis Hospital, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Barouyr Baroudjian
- AP-HP Dermatology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Tiphaine Vidal-Trecan
- AP-HP Diabetology Department, Lariboisière Hospital, INSERM U1138; Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Laetitia Da Meda
- AP-HP Dermatology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Isabelle Madelaine-Chambrin
- AP-HP Pharmacology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Nicole Basset-Seguin
- AP-HP Dermatology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Martine Bagot
- AP-HP Dermatology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Cécile Pages
- AP-HP Dermatology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Samia Mourah
- AP-HP Pharmacogenomic Laboratory, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Matthieu Resche-Rigon
- AP-HP Statistics Department, Saint-Louis Hospital, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Sylvine Pinel
- AP-HP Regional Pharmacologilance Center, Fernand Widal Hospital, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Marion Sassier
- Regional Pharmacovigilance Center of Caen, Caen University Hospital, Caen, France
| | - Franck Rouby
- Department of Clinical Pharmacology, Regional Pharmacovigilance Center of Marseille, Aix-Marseille University, Marseille, France
| | - Pirayeh Eftekhari
- AP-HP Regional Pharmacologilance Center, Fernand Widal Hospital, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Céleste Lebbé
- AP-HP Dermatology Department, Saint-Louis Hospital, INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, 1, Avenue Claude Vellefaux, 75010, Paris, France
| | - Jean-François Gautier
- AP-HP Diabetology Department, Lariboisière Hospital, INSERM U1138; Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
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28
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Smati S, Buffier P, Bouillet B, Archambeaud F, Vergès B, Cariou B. Expert opinion on immunotherapy induced diabetes. ANNALES D'ENDOCRINOLOGIE 2018; 79:545-549. [PMID: 30126628 DOI: 10.1016/j.ando.2018.07.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Immunotherapy often incurs side-effects, mainly involving the skin, digestive tract and endocrine system. The most frequent endocrine side-effects involve the pituitary and thyroid glands. Cases of insulin-dependent diabetes, whether autoimmune or not (type 1 or 1B) have been reported with PD-1/PD-L1 inhibitors, alone or in association with anti-CTLA-4 antibodies, and were systematically associated with sudden-onset insulinopenia, frequently leading to ketoacidosis or fulminant diabetes, requiring first-line insulin therapy. This adverse effect has not so far been reported with anti-CTLA-4 monotherapy.
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Affiliation(s)
- Sarra Smati
- Department of endocrinology, l'institut du thorax, CHU Nantes, 44000 Nantes, France.
| | - Perrine Buffier
- Service d'endocrinologie, diabétologie, maladies métaboliques, CHU Dijon, hôpital François Mitterrand, 21034 Dijon cedex, France
| | - Benjamin Bouillet
- Service d'endocrinologie, diabétologie, maladies métaboliques, CHU Dijon, hôpital François Mitterrand, 21034 Dijon cedex, France
| | | | - Bruno Vergès
- Service d'endocrinologie, diabétologie, maladies métaboliques, CHU Dijon, hôpital François Mitterrand, 21034 Dijon cedex, France
| | - Bertrand Cariou
- Department of endocrinology, l'institut du thorax, CHU Nantes, 44000 Nantes, France
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29
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Characteristics and clinical course of type 1 diabetes mellitus related to anti-programmed cell death-1 therapy. Diabetol Int 2018; 10:58-66. [PMID: 30800564 DOI: 10.1007/s13340-018-0362-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 06/24/2018] [Indexed: 12/16/2022]
Abstract
Aims We conducted a national survey to clarify the characteristics and clinical course of type 1 diabetes related to anti-programmed cell death-1 therapy. Methods We analyzed the detailed data of 22 patients that were collected using a Japan Diabetes Society survey and a literature database search. Results Among the 22 patients, 11 (50.0%) met the criteria for fulminant type 1 diabetes and 11 (50.0%) met the criteria for acute-onset type 1 diabetes. The average patient age was 63 years. The mean duration between the date of the first anti-PD-1 antibody injection and development of type 1 diabetes was 155 days and ranged from 13 to 504 days. Flu-like symptoms, abdominal symptoms, and drowsiness were observed in 27.8, 31.6, and 16.7% patients, respectively. Mean ± standard deviation or median (first quartile-third quartile) glucose levels, HbA1c levels, urinary C-peptide immunoreactivity levels, and fasting serum C-peptide immunoreactivity levels were 617 ± 248 mg/dl, 8.1 ± 1.3%, 4.1 (1.4-9.4) μg/day, and 0.46 (0.20-0.70) ng/ml, respectively. Seventeen of 20 patients (85.0%) developed ketosis, and 7 of 18 patients (38.9%) developed diabetic ketoacidosis. Ten of 19 patients (52.6%) showed at least one elevated pancreatic enzyme level at the onset and two of seven patients showed this elevation before diabetes onset. Only one of 21 patients was anti-glutamic acid decarboxylase antibody positive. Conclusions Anti-programmed cell death-1 antibody-related type 1 diabetes varies from typical fulminant type 1 diabetes to acute-onset type 1 diabetes. However, diabetic ketoacidosis was frequently observed at the onset of diabetes. An appropriate diagnosis and treatment should be provided to avoid life-threatening metabolic alterations.
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30
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Galligan A, Xu W, Fourlanos S, Nankervis A, Chiang C, Mant AM, Parente P, Rischin D, Krishnamurthy B, Sandhu S, Colman PG. Diabetes associated with immune checkpoint inhibition: presentation and management challenges. Diabet Med 2018; 35:1283-1290. [PMID: 29908076 DOI: 10.1111/dme.13762] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND In recent years, immune checkpoint blockade has become a standard therapy for a wide range of cancers. Adverse events including endocrinopathies result from the induction of autoimmunity. CASE REPORT We report a case series of nine individuals who presented with immunotherapy-induced type 1 diabetes between 2015-2017. DISCUSSION Onset of diabetes occurred within 12 weeks of commencing therapy. Anti- GAD antibodies were present in six people. Retrospective testing of islet antibodies in pre-treatment samples was possible in two people and this revealed anti-GAD seroconversion in the first and high anti-GAD titres pre and post-treatment in the second person. Six people had high risk HLA haplotypes. Clinical and genetic factors are described and compared with previously published cases. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- A Galligan
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital
| | - W Xu
- Division of Cancer Medicine, Peter MacCallum Cancer Centre
| | - S Fourlanos
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital
| | - A Nankervis
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital
| | - C Chiang
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital
- Division of Cancer Medicine, Peter MacCallum Cancer Centre
| | - A M Mant
- Cancer Services, Eastern Health, Monash University
| | - P Parente
- Cancer Services, Eastern Health, Monash University
| | - D Rischin
- Division of Cancer Medicine, Peter MacCallum Cancer Centre
- Sir Peter MacCallum Department of Oncology, University of Melbourne
| | | | - S Sandhu
- Division of Cancer Medicine, Peter MacCallum Cancer Centre
- Sir Peter MacCallum Department of Oncology, University of Melbourne
| | - P G Colman
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital
- Division of Cancer Medicine, Peter MacCallum Cancer Centre
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Abstract
INTRODUCTION The prognosis of recurrent/metastatic (R/M) squamous cell carcinoma of the head and neck (HNSCC) after failure of first line chemotherapy is dismal. Until the publication of the results of CheckMate 141, not a single agent provided any survival benefit as a second line treatment for R/M HNSCC. Areas covered: A comprehensive review of the literature was conducted on the role of nivolumab in HNSCC. Expert commentary: Nivolumab is approved by the Food and Drug Administration for the treatment of patients based on the results of CheckMate 141 showing an overall survival benefit as compared to standard care (single agent docetaxel, methotrexate, or cetuximab). Of particular interest are immune-related adverse events which should be managed according to published guidelines.
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Affiliation(s)
- Pol Specenier
- a Department of Oncology , Antwerp University Hospital , Edegem , Belgium
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32
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Zaied AA, Akturk HK, Joseph RW, Lee AS. New-onset insulin-dependent diabetes due to nivolumab. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM170174. [PMID: 29623210 PMCID: PMC5881429 DOI: 10.1530/edm-17-0174] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 03/02/2018] [Indexed: 01/05/2023] Open
Abstract
Nivolumab, a monoclonal antibody against programmed cell death-1 receptor, is increasingly used in advanced cancers. While nivolumab use enhances cancer therapy, it is associated with increased immune-related adverse events. We describe an elderly man who presented in ketoacidosis after receiving nivolumab for metastatic renal cell carcinoma. On presentation, he was hyperpneic and laboratory analyses showed hyperglycemia and anion-gapped metabolic acidosis consistent with diabetic ketoacidosis. No other precipitating factors, besides nivolumab, were identified. Pre-nivolumab blood glucose levels were normal. The patient responded to treatment with intravenous fluids, insulin and electrolyte replacement. He was diagnosed with insulin-dependent autoimmune diabetes mellitus secondary to nivolumab. Although nivolumab was stopped, he continued to require multiple insulin injection therapy till his last follow-up 7 months after presentation. Clinicians need to be alerted to the development of diabetes mellitus and diabetic ketoacidosis in patients receiving nivolumab.
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Affiliation(s)
- Ali A Zaied
- Divisions of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Halis K Akturk
- Divisions of Endocrinology, Mayo Clinic, Jacksonville, Florida, USA
| | - Richard W Joseph
- Divisions of Hematology and Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - Augustine S Lee
- Divisions of Pulmonary and Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Abstract
PURPOSE OF REVIEW Prognosis of patients with advanced melanoma is dismal with a median overall survival of about 8 months and 5-year overall survival from a diagnosis of metastatic disease of roughly 10%. However, immune checkpoint inhibitors have brought indispensable benefits to melanoma patients. Here we will review the recent clinical efficacy and adverse events of immune checkpoint inhibitors for melanoma patients. RECENT FINDINGS The immune checkpoint inhibitors increase confirmed objective response and prolong progression-free and overall survival of the afflicted patients in association with maintaining their quality of life. Although diverse immune-related adverse events occur, most of them are manageable by appropriate immunomodulating agents. Clinical efficacy of immune checkpoint inhibitors continues even after discontinuation of drugs. Compared with conventional therapeutic options, the immune checkpoint inhibitors appear to prolong the survival of patients with advanced melanoma. Further clinical trials are warranted to determine whether their combinatory use with other treatment options may augment benefits or not.
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34
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Capitao R, Bello C, Fonseca R, Saraiva C. New onset diabetes after nivolumab treatment. BMJ Case Rep 2018; 2018:bcr-2017-220999. [PMID: 29378735 DOI: 10.1136/bcr-2017-220999] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The authors describe a case of a life-threatening diabetic emergency 25 days after initiation of nivolumab (3 mg/kg) for stage 4 lung adenocarcinoma. She was admitted to the emergency department, with hyperglycaemia-related signs and symptoms, such as polyuria, polydipsia, weight loss, confusion, asthenia, dehydration, hypotension and Kussmaul respiratory pattern. Her body mass index was 21.9 kg/m2 and she did not show acanthosis nigricans. Arterial blood gas determination revealed high anion gap metabolic acidaemia and blood tests showed hyperglycaemia (1060 mg/dL), hyperketonaemia (beta-hydroxybutyrate: 6.6 mmol/dL), elevated total serum osmolality (389 mOsm/kg), low serum and urinary C-peptide and positive antiglutamic acid decarboxylase antibodies. Since nivolumab was initiated a few days before, and due to its known immune-mediated endocrine adverse events, we assumed the diagnosis of new onset immune-mediated type 1 diabetes mellitus. After prompt and adequate treatment of diabetic ketoacidosis/hyperosmolar hyperglycaemic state, she was discharged improved on multiple daily injections of insulin.
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Affiliation(s)
- Ricardo Capitao
- Department of Endocrinology, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Carlos Bello
- Department of Endocrinology, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Ricardo Fonseca
- Department of Endocrinology, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Catarina Saraiva
- Department of Endocrinology, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
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Iglesias P. Cancer immunotherapy-induced endocrinopathies: Clinical behavior and therapeutic approach. Eur J Intern Med 2018; 47:6-13. [PMID: 28826822 DOI: 10.1016/j.ejim.2017.08.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/11/2017] [Accepted: 08/16/2017] [Indexed: 12/29/2022]
Abstract
Cancer immunotherapy has proven to be effective in a wide variety of tumors. The use of immune checkpoint blocking monoclonal antibodies has become a standard treatment regimen in some of them as advanced melanoma. However, given the mechanism of action, its use may be associated with immune-related adverse events that may complicate the clinical course and prognosis of patients. Among these are autoimmune endocrine adverse effects, such as hypophysitis, hypo and hyperthyroidism, and adrenal insufficiency. This review focuses on the most relevant and new aspects related to the incidence, clinical presentation, diagnosis and treatment of these adverse effects associated with different types of immune checkpoint inhibitors in cancer immunotherapy.
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Affiliation(s)
- Pedro Iglesias
- Department of Endocrinology, Hospital Ramón y Cajal, Ctra. de Colmenar, Km 9.100, 28034 Madrid, Spain.
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36
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Gauci ML, Laly P, Vidal-Trecan T, Baroudjian B, Gottlieb J, Madjlessi-Ezra N, Da Meda L, Madelaine-Chambrin I, Bagot M, Basset-Seguin N, Pages C, Mourah S, Boudou P, Lebbé C, Gautier JF. Autoimmune diabetes induced by PD-1 inhibitor-retrospective analysis and pathogenesis: a case report and literature review. Cancer Immunol Immunother 2017; 66:1399-1410. [PMID: 28634815 PMCID: PMC11028556 DOI: 10.1007/s00262-017-2033-8] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 06/12/2017] [Indexed: 12/16/2022]
Abstract
Anti-PD-1 antibody treatment is approved in advanced melanoma and provides median overall survival over 24 months. The main treatment-related side effects are immune-related adverse events, which include rash, pruritus, vitiligo, thyroiditis, diarrhoea, hepatitis and pneumonitis. We report a case of autoimmune diabetes related to nivolumab treatment. A 73-year-old man was treated in second line with nivolumab at 3 mg/kg every two weeks for metastatic melanoma. At 6 weeks of treatment, he displayed diabetic ketoacidosis. Nivolumab was withheld 3.5 weeks and insulin therapy was initiated, enabling a normalization of glycaemia and the disappearance of symptoms. Laboratory investigations demonstrated the presence of islet cell autoantibodies, while C-peptide was undetectable. Retrospective explorations on serum banked at week 0 and 3 months before the start of nivolumab, already showed the presence of autoantibodies, but normal insulin, C-peptide secretion and glycaemia. Partial response was obtained at month 3, and nivolumab was then resumed at the same dose. The clinical context and biological investigations before, at and after nivolumab initiation suggest the autoimmune origin of this diabetes, most likely induced by anti-PD-1 antibody in a predisposed patient. The role of PD-1/PD-L1 binding is well known in the pathogenesis of type 1 diabetes. Therefore, this rare side effect can be expected in a context of anti-PD-1 treatment. Glycaemia should be monitored during PD-1/PD-L1 blockade. The presence of autoantibodies before treatment could identify individuals at risk of developing diabetes, but systematic titration may not be relevant considering the rarity of this side effect.
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Affiliation(s)
- Marie-Léa Gauci
- AP-HP Dermatology Department, Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75475, Paris Cedex 10, France.
- INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France.
| | - Pauline Laly
- AP-HP Dermatology Department, Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75475, Paris Cedex 10, France
- INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Tiphaine Vidal-Trecan
- AP-HP Diabetology Department, Lariboisière Hospital, Paris, France
- INSERM U1138, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Barouyr Baroudjian
- AP-HP Dermatology Department, Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75475, Paris Cedex 10, France
- INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Jérémy Gottlieb
- AP-HP Dermatology Department, Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75475, Paris Cedex 10, France
- INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Nika Madjlessi-Ezra
- AP-HP Dermatology Department, Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75475, Paris Cedex 10, France
- INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Laetitia Da Meda
- AP-HP Dermatology Department, Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75475, Paris Cedex 10, France
- INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Isabelle Madelaine-Chambrin
- INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
- AP-HP Pharmacology Department, Saint-Louis Hospital, Paris, France
| | - Martine Bagot
- AP-HP Dermatology Department, Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75475, Paris Cedex 10, France
- INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Nicole Basset-Seguin
- AP-HP Dermatology Department, Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75475, Paris Cedex 10, France
- INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Cécile Pages
- AP-HP Dermatology Department, Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75475, Paris Cedex 10, France
- INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Samia Mourah
- INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
- AP-HP Pharmacogenomic Laboratory, Saint-Louis Hospital, Paris, France
| | - Philippe Boudou
- AP-HP Hormonology Department, Saint-Louis Hospital, Paris, France
- Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Céleste Lebbé
- AP-HP Dermatology Department, Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75475, Paris Cedex 10, France
- INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Jean-François Gautier
- AP-HP Diabetology Department, Lariboisière Hospital, Paris, France
- INSERM U1138, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
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Kapke J, Shaheen Z, Kilari D, Knudson P, Wong S. Immune Checkpoint Inhibitor-Associated Type 1 Diabetes Mellitus: Case Series, Review of the Literature, and Optimal Management. Case Rep Oncol 2017; 10:897-909. [PMID: 29279690 PMCID: PMC5731100 DOI: 10.1159/000480634] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 08/24/2017] [Indexed: 12/21/2022] Open
Abstract
With the introduction of immune checkpoint inhibitors into clinical practice, various autoimmune toxicities have been described. Antibodies targeting the receptor:ligand pairing of programmed death receptor-1 (PD-1) and its cognate ligand programmed death-ligand 1 (PD-L1) in rare reports have been associated with autoimmune diabetes mellitus. We report 2 cases of rapid-onset, insulin-dependent, type 1 diabetes mellitus in the setting of administration of nivolumab, a fully human monoclonal antibody to PD-1, and atezolizumab, a humanized monoclonal antibody to PD-L1. This appears to be the first report of autoimmune diabetes mellitus associated with atezolizumab. In addition, we provide a brief review of similar cases reported in the literature and a discussion of potential mechanisms for this phenomenon and propose a diagnostic and treatment algorithm.
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Affiliation(s)
- Jonathan Kapke
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Zachary Shaheen
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Deepak Kilari
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Paul Knudson
- Division of Endocrinology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stuart Wong
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Konda B, Nabhan F, Shah MH. Endocrine dysfunction following immune checkpoint inhibitor therapy. Curr Opin Endocrinol Diabetes Obes 2017; 24:337-347. [PMID: 28661915 DOI: 10.1097/med.0000000000000357] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitors (ICI) represent an important milestone in the modern era of antineoplastic therapy and have ushered optimism amongst oncologists and patients alike. These agents, however, are associated with significant potential toxicities, the importance of which cannot be overstated. The clinical presentation, diagnosis, and management strategies of immune-related endocrinopathies associated with ICI use are described in this case-based review. RECENT FINDINGS An increasing number of ICI have shown promise in the management of various malignancies in the recent years. These include cytotoxic T lymphocyte antigen-4 inhibitors, programmed cell death 1 (PD-1) antibodies, and PD-ligand 1 (PD-L1) antibodies. Several endocrinopathies, including hypophysitis, thyroid dysfunction, hyperglycemia, and primary adrenal insufficiency, have been associated with the use of these agents. Toxicities may range from mild transient laboratory abnormalities to potentially life-threatening ones, warranting immediate therapeutic intervention. Combination ICI therapies may be associated with a greater risk of endocrine dysfunction when compared with monotherapy. The clinical presentation and laboratory assessment of these patients often pose a diagnostic challenge as they may be confused by the symptoms related to their underlying malignancy or potential associated acute illnesses. SUMMARY ICI use is associated with serious endocrinopathies that may have a nonspecific initial presentation. A constant eye for these symptoms and a systematic approach to diagnosis are essential for prompt initiation of therapy and prevention of significant complications.
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Affiliation(s)
- Bhavana Konda
- aDivision of Medical Oncology, Department of Internal Medicine bDivision of Endocrinology, Diabetes, and Metabolism, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio, USA
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Chae YK, Chiec L, Mohindra N, Gentzler R, Patel J, Giles F. A case of pembrolizumab-induced type-1 diabetes mellitus and discussion of immune checkpoint inhibitor-induced type 1 diabetes. Cancer Immunol Immunother 2017; 66:25-32. [PMID: 27761609 PMCID: PMC11028603 DOI: 10.1007/s00262-016-1913-7] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 10/01/2016] [Indexed: 12/16/2022]
Abstract
Immune checkpoint inhibitors such as pembrolizumab, ipilimumab, and nivolumab, now FDA-approved for use in treating several types of cancer, have been associated with immune-related adverse effects. Specifically, the antibodies targeting the programmed-cell death-1 immune checkpoint, pembrolizumab and nivolumab, have been rarely reported to induce the development of type 1 diabetes mellitus. Here we describe a case of a patient who developed antibody-positive type 1 diabetes mellitus following treatment with pembrolizumab in combination with systemic chemotherapy for metastatic adenocarcinoma of the lung. We will also provide a brief literature review of other rarely reported cases of type 1 diabetes presenting after treatment with pembrolizumab and nivolumab, as well as discussion regarding potential mechanisms of this adverse effect and its importance as these drugs continue to become even more widespread.
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Affiliation(s)
- Young Kwang Chae
- Developmental Therapeutics Program of the Division of Hematology/Oncology, Northwestern University, Chicago, IL, 60611, USA.
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, 60611, USA.
- Feinberg School of Medicine, Northwestern University, 645 N. Michigan Ave, Suite 1006, Chicago, IL, 60611, USA.
| | - Lauren Chiec
- Feinberg School of Medicine, Northwestern University, 645 N. Michigan Ave, Suite 1006, Chicago, IL, 60611, USA
| | - Nisha Mohindra
- Developmental Therapeutics Program of the Division of Hematology/Oncology, Northwestern University, Chicago, IL, 60611, USA
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, 60611, USA
- Feinberg School of Medicine, Northwestern University, 645 N. Michigan Ave, Suite 1006, Chicago, IL, 60611, USA
| | - Ryan Gentzler
- University of Virginia School of Medicine, Charlottesville, VA, 22908-0395, USA
| | - Jyoti Patel
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, 60611, USA
- Feinberg School of Medicine, Northwestern University, 645 N. Michigan Ave, Suite 1006, Chicago, IL, 60611, USA
- The University of Chicago Medicine, Chicago, IL, 60637, USA
| | - Francis Giles
- Developmental Therapeutics Program of the Division of Hematology/Oncology, Northwestern University, Chicago, IL, 60611, USA
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, 60611, USA
- Feinberg School of Medicine, Northwestern University, 645 N. Michigan Ave, Suite 1006, Chicago, IL, 60611, USA
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40
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Aleksova J, Lau PKH, Soldatos G, McArthur G. Glucocorticoids did not reverse type 1 diabetes mellitus secondary to pembrolizumab in a patient with metastatic melanoma. BMJ Case Rep 2016; 2016:bcr-2016-217454. [PMID: 27881588 DOI: 10.1136/bcr-2016-217454] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Immune checkpoint inhibitors offer patients with advanced melanoma substantial improvements in survival. Unlike chemotherapy, immune checkpoint inhibitors such as ipilimumab and pembrolizumab cause unique immune-related adverse events (irAEs), including the development of endocrinopathies. We report a case of a man aged 60 years who developed diabetic ketoacidosis (DKA) following the use of pembrolizumab for the treatment of metastatic melanoma. He received four cycles of ipilimumab, before proceeding to pembrolizumab. Five weeks after initiating pembrolizumab, he presented in DKA with a pH of 7.0, bicarbonate of 7 mmol/L, blood glucose of 27 mmol/L and serum ketones of 5.9 mmol/L. Antibodies to glutamic acid decarboxylase (anti-GAD) and Islet antigen 2 (IA-2) were negative and C-peptide was low at 57 pmol/L (300-2350 pmol/L). There was no personal or family history of autoimmune conditions. Standard immunosuppression for irAEs was started using prednisolone in an attempt to salvage β cell function but was unsuccessful. To the best of our knowledge, this is the first reported attempt at reversing pembrolizumab-induced type 1 diabetes using glucocorticoids.
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Affiliation(s)
| | - Peter K H Lau
- Peter MacCallum Cancer Institute, Cancer Medicine, East Melbourne, Victoria, Australia
| | - Georgia Soldatos
- Peter MacCallum Cancer Institute, Cancer Medicine, East Melbourne, Victoria, Australia.,Monash Centre for Health Research and Implementation, Melbourne, Victoria, Australia
| | - Grant McArthur
- Department of Medical Oncology, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Australia
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Abstract
INTRODUCTION The treatment of melanoma is evolving rapidly over the past few years. Areas covered: We conducted a comprehensive review of the literature on the role of nivolumab in melanoma Expert commentary: Nivolumab is approved by FDA and EMA for the treatment of patients with metastatic melanoma. Nivolumab is superior to chemotherapy and to ipilimumab in previously untreated patients and to chemotherapy in ipilimumab pre-treated patients. The addition ipilimumab to nivolumab is associated with a higher response rate and a better PFS, particularly in patients with PD-L1 negative tumors, albeit at the cost of an increase in grade 3-4 adverse event rate. Definitive survival data on this combination are pending and the selection of patients most likely to benefit from this combination and its pharmacoeconomics are to be elucidated. Prospectively validated predictive markers are lacking. Of particular interest are immune-related adverse events which should be managed according to published guidelines.
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Affiliation(s)
- Pol Specenier
- a Faculty of Medicine and Health Sciences , University of Antwerp , Antwerp , Belgium.,b Department of Medical Oncology , Antwerp University Hospital , Edegem , Belgium
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