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Chen J, Hou X, Yang Y, Wang C, Zhou J, Miao J, Gong F, Ge F, Chen W. Immune checkpoint inhibitors-induced diabetes mellitus (review). Endocrine 2024:10.1007/s12020-024-03942-w. [PMID: 38955861 DOI: 10.1007/s12020-024-03942-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 06/23/2024] [Indexed: 07/04/2024]
Abstract
Immune checkpoint inhibitors (ICIs) have become extensively utilized in the early-stage treatment of various cancers, offering additional therapeutic possibilities for patients with advanced cancer. However, certain patient populations are susceptible to experiencing toxic adverse effects from ICIs, such as thyrotoxicosis, rashes, among others. Specifically, ICIDM, induced by immune checkpoint inhibitors, exhibits characteristics similar to insulin-dependent diabetes mellitus (Type 1 Diabetes Mellitus, T1DM). ICIDM is characterized by a rapid onset and may coincide with severe ketoacidosis. Despite a favorable response to insulin therapy, patients typically require lifelong insulin dependence. After discussing the autoimmune adverse effects and the specifics of ICIs-induced diabetes mellitus (ICIDM), it is important to note that certain patient populations are particularly susceptible to experiencing toxic adverse effects from ICIs. Specifically, ICIDM, which is triggered by immune checkpoint inhibitors, mirrors the characteristics of insulin-dependent diabetes mellitus (Type 1 Diabetes Mellitus, T1DM). This article conducts an in-depth analysis of the literature to explore the pathogenesis, disease progression, and treatment strategies applicable to diabetes induced by immune checkpoint inhibitors (ICIDM).
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Affiliation(s)
- Jiayi Chen
- Third Department of Breast Surgery, Peking University Cancer Hospital Yunnan, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, China
| | - Xiaochen Hou
- Academy of Biomedical Engineering, Kunming Medical University, Yunnan, 650500, China
| | - Yang Yang
- Third Department of Breast Surgery, Peking University Cancer Hospital Yunnan, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, China
| | - Chenxi Wang
- Third Department of Breast Surgery, Peking University Cancer Hospital Yunnan, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, China
| | - Jie Zhou
- Third Department of Breast Surgery, Peking University Cancer Hospital Yunnan, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, China
| | - Jingge Miao
- Third Department of Breast Surgery, Peking University Cancer Hospital Yunnan, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, China
| | - Fuhong Gong
- Third Department of Breast Surgery, Peking University Cancer Hospital Yunnan, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, China
| | - Fei Ge
- Department of Breast Surgery, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650032, China.
| | - Wenlin Chen
- Third Department of Breast Surgery, Peking University Cancer Hospital Yunnan, Yunnan Cancer Hospital, The Third Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, 650118, China.
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Kotwal A, Kennedy R, Kikani N, Thosani S, Goldner W, Shariff A. Endocrinopathies Associated With Immune Checkpoint Inhibitor Use. Endocr Pract 2024; 30:584-591. [PMID: 38554775 DOI: 10.1016/j.eprac.2024.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/12/2024] [Accepted: 03/20/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE To provide a clinical approach towards immune checkpoint inhibitor (ICI)-associated endocrinopathies, their link with cancer outcomes, factors which differentiate them from other immune related adverse events, and health systems innovation to improve care for these patients. METHODS A literature search for articles pertaining to ICIs and endocrinopathies was performed and supplemented by expert opinions of the authors. RESULTS While immune related adverse events can affect almost any organ, they frequently target the endocrine glands, most commonly thyroid. Different classes of ICIs have varying frequencies of endocrinopathies related to hypophysitis, thyroiditis, diabetes mellitus, and rarely hypoadrenalism and hypoparathyroidism. ICI-associated endocrinopathies share some features with classic endocrine autoimmunity but appear to be a distinct entity. They can be challenging to diagnose and manage due to nonspecific clinical features, use of exogenous glucocorticoids, and at times rapid and severe hormone deficiency. The role of anti-inflammatory high-dose glucocorticoids is minimal, and the ICI does not usually require permanent discontinuation. ICI-associated endocrinopathies usually cause permanent hormone deficiency necessitating long-term management and patient engagement. ICI-thyroiditis has been associated with improved survival, while other endocrinopathies have not shown a significant association with outcomes in cancer patients receiving ICIs. Oncoendocrinology teams can improve the care of patients with ICI-associated endocrinopathies. CONCLUSION This narrative review provides guidance to clinicians prescribing ICIs and those managing ICI-associated endocrinopathies, and complements the frameworks provided by major scientific societies in this field.
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Affiliation(s)
- Anupam Kotwal
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska.
| | - Randol Kennedy
- Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Nupur Kikani
- Department of Endocrine Neoplasia & Hormonal Disorders, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Sonali Thosani
- Department of Endocrine Neoplasia & Hormonal Disorders, The University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Whitney Goldner
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, University of Nebraska Medical Center, Omaha, Nebraska; Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, Nebraska
| | - Afreen Shariff
- Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Duke Cancer Institute, Duke Health, Durham, North Carolina
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Garcia JA, Alcaraz D, Holgado E, Couñago F. Pembrolizumab autoimmune related diabetes: Moving forward, keep learning. World J Clin Oncol 2024; 15:576-579. [PMID: 38835848 PMCID: PMC11145962 DOI: 10.5306/wjco.v15.i5.576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/25/2024] [Accepted: 04/08/2024] [Indexed: 05/21/2024] Open
Abstract
Immune checkpoint inhibitors (and more specifically programmed cell death 1/programmed cell death ligand 1 inhibitors as Pembrolizumab) initiated a revolution in the field of melanoma and have now expanded to several tumor subtypes and in increasingly broader clinical contexts, including the adjuvant and neoadjuvant setting, with potentially curable patients and prolonged survival. The side effects related to these drugs include a wide spectrum of manifestations, with endocrinological adverse events being some of the most frequent. Pembrolizumab-induced type 1 diabetes mellitus is an infrequent but potentially serious and not clearly reversible side effect that possesses characteristic clinical features and has high morbidity and mortality, with a chronic impact on quality of life. The etiopathogenesis of this phenomenom needs to be further investigated and a collaborative effort through the involvement of oncologists and other medical specialists is necessary for the correct identification and management of patients at risk.
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Affiliation(s)
- Jose Angel Garcia
- Department of Medical Oncology, GenesisCare Spain-San Francisco de Asis University Hospital, Madrid 28002, Spain
| | - Diego Alcaraz
- Department of Medical Oncology, GenesisCare Spain-San Francisco de Asis University Hospital, Madrid 28002, Spain
| | - Esther Holgado
- Department of Chief of Medical Oncology, GenesisCare Spain-San Francisco de Asis University Hospital, Madrid 28002, Spain
| | - Felipe Couñago
- Department of Chief of Radiation Oncology, Genesiscare-San Francisco de Asis University Hospital, Madrid 28002, Spain
- Department of Chief of Radiation Oncology, GenesisCare-Vithas La Milagrosa Hospital, Madrid 28010, Spain
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Gómez-Puerta JA, Gente K, Katsumoto TR, Leipe J, Reid P, van Binsbergen WH, Suarez-Almazor ME. Mimickers of Immune Checkpoint Inhibitor-induced Inflammatory Arthritis. Rheum Dis Clin North Am 2024; 50:161-179. [PMID: 38670719 DOI: 10.1016/j.rdc.2024.01.002] [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] [Indexed: 04/28/2024]
Abstract
The differential diagnosis of inflammatory arthritis as an immune-related adverse event can be challenging as patients with cancer can present with musculoskeletal symptoms that can mimic arthritis because of localized or generalized joint pain. In addition, immune checkpoint inhibitors can exacerbate joint conditions such as crystal-induced arthritis or osteoarthritis, or induce systemic disease that can affect the joints such as sarcoidosis. This distinction is important as the treatment of these conditions can be different from that of immune-related inflammatory arthritis.
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Affiliation(s)
- José A Gómez-Puerta
- Department of Rheumatology, Hospital Clínic; University of Barcelona, Escala 11-2, Barcelona, Villarroel 170, Barcelona 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
| | - Karolina Gente
- Department of Internal Medicine V - Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Im Neuenheimer Feld 410, Heidelberg 69120, Germany
| | - Tamiko R Katsumoto
- Division of Immunology and Rheumatology, Department of Medicine, 300 Pasteur Drive Suite H305, Stanford, CA 94305, USA
| | - Jan Leipe
- Division of Rheumatology, Department of Medicine V, University Hospital Mannheim, Heidelberg University, Theodor-Kutzer-Ufer 1-3, Mannheim, Heidelberg 68167, Germany
| | - Pankti Reid
- Division of Rheumatology, Department of Medicine, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Wouter H van Binsbergen
- Department of Rheumatology & Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Center, Meibergdreef 9, 1105AZ (AMC) & De Boelelaan 1117, Amsterdam 1081 HV (VUmc), The Netherlands
| | - Maria E Suarez-Almazor
- Department of Health Services Research, MD Anderson Cancer Center, The University of Texas, 1515 Holcombe Boulevard, Houston, TX 77030, USA
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Duvalyan E, Brondfield S, Rushakoff RJ, Anderson MS, Quandt Z. Outcomes and Adverse Events in Patients with Cancer after Diagnosis of Immunotherapy-Associated Diabetes Mellitus: A Retrospective Cohort Study. Cancers (Basel) 2024; 16:1663. [PMID: 38730614 PMCID: PMC11083325 DOI: 10.3390/cancers16091663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/18/2024] [Accepted: 04/18/2024] [Indexed: 05/13/2024] Open
Abstract
Immune checkpoint inhibitor (CPI)-induced diabetes mellitus (CPI-DM) is a rare immune-related adverse event (irAE). Patients and providers fear that continuing CPIs puts patients at risk for additional irAEs and thus may discontinue therapy. Currently, there are little data to inform this decision. Therefore, this study aims to elucidate whether discontinuing CPIs after diagnosis of CPI-DM impacts the development of future irAEs and cancer outcomes such as progression and death. Patients who developed CPI-DM during cancer treatment at UCSF from 1 July 2015 to 5 July 2023 were analyzed for cancer outcomes and irAE development. Fisher's exact tests, Student t-tests, Kaplan-Meier methods, and Cox regression were used as appropriate. Of the 43 patients with CPI-DM, 20 (47%) resumed CPIs within 90 days of the irAE, 4 (9%) patients restarted after 90 days, and 19 (44%) patients never restarted. Subsequent irAEs were diagnosed in 9 of 24 (38%) who resumed CPIs and 3 of 19 (16%) who discontinued CPIs (p = 0.17). There was no significant difference in death (p = 0.74) or cancer progression (p = 0.55) between these two groups. While our single-institution study did not show worse cancer outcomes after discontinuing CPIs, many variables can impact outcomes, which our study was not adequately powered to evaluate. A nuanced approach is needed to decide whether to continue CPI treatment after a severe irAE like CPI-DM.
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Affiliation(s)
- Eva Duvalyan
- School of Medicine, University of California San Francisco, San Francisco, CA 94143, USA;
| | - Sam Brondfield
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA;
| | - Robert J. Rushakoff
- Division of Endocrinology and Metabolism, Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA; (R.J.R.); (M.S.A.)
- Diabetes Center, University of California San Francisco, San Francisco, CA 94143, USA
| | - Mark S. Anderson
- Division of Endocrinology and Metabolism, Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA; (R.J.R.); (M.S.A.)
- Diabetes Center, University of California San Francisco, San Francisco, CA 94143, USA
| | - Zoe Quandt
- Division of Endocrinology and Metabolism, Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA; (R.J.R.); (M.S.A.)
- Diabetes Center, University of California San Francisco, San Francisco, CA 94143, USA
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Wu L, Carlino MS, Brown DA, Long GV, Clifton-Bligh R, Mellor R, Moore K, Sasson SC, Menzies AM, Tsang V, Gunton JE. Checkpoint Inhibitor-Associated Autoimmune Diabetes Mellitus Is Characterized by C-peptide Loss and Pancreatic Atrophy. J Clin Endocrinol Metab 2024; 109:1301-1307. [PMID: 37997380 PMCID: PMC11031227 DOI: 10.1210/clinem/dgad685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/05/2023] [Accepted: 11/20/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE To conduct a multicenter case series characterizing the clinical characteristics at presentation and pancreatic volume changes of patients with checkpoint inhibitor-associated autoimmune diabetes (CIADM). RESEARCH DESIGN AND METHODS Electronic medical records were reviewed with 36 consecutive patients identified with CIADM, as defined by (1) previous immune checkpoint inhibitor (ICI) therapy, (2) new-onset hyperglycemia (blood glucose level ≥ 11.1 mmol/L and/or glycosylated hemoglobin ≥ 6.5%), and (3) insulin deficiency [C-peptide <0.4 nmol/L or diabetic ketoacidosis (DKA)] within 1 month of presentation. Pancreatic volume was available and measured using computed tomography volumetry for 17 patients with CIADM and 3 sets of control patients: 7 with ICI-related pancreatitis, 13 with asymptomatic ICI-related lipase elevation, and 11 ICI-treated controls for comparison. RESULTS All patients had either anti-programmed cell death protein 1 or anti-programmed cell death ligand 1 therapy. Median time from ICI commencement to CIADM diagnosis was 15 weeks. At presentation, 25 (69%) had DKA, 27 (84%) had low C-peptide, and, by 1 month, 100% had low C-peptide. Traditional type 1 diabetes autoantibodies were positive in 15/35 (43%). Lipase was elevated in 13/27 (48%) at presentation. In 4 patients with longitudinal lipase testing, elevated levels peaked 1 month prior to CIADM diagnosis. Pancreatic volume was lower pre-ICI in CIADM patients compared with controls and demonstrated a mean decline of 41% from pretreatment to 6 months post-CIADM diagnosis. CONCLUSION Pronounced biochemical and radiologic changes occur during CIADM pathogenesis. Rapid loss of C-peptide is a distinct characteristic that can be used to aid diagnosis as autoantibodies are often negative.
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Affiliation(s)
- Linda Wu
- Westmead Institute for Medical Research, Centre for Diabetes and Endocrinology, Westmead 2145, NSW, Australia
- Department of Endocrinology, Westmead Hospital, Westmead 2145, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown 2050, NSW, Australia
- Melanoma Institute Australia, The University of Sydney, Wollstonecraft 2065, NSW, Australia
| | - Matteo Salvatore Carlino
- Faculty of Medicine and Health, The University of Sydney, Camperdown 2050, NSW, Australia
- Melanoma Institute Australia, The University of Sydney, Wollstonecraft 2065, NSW, Australia
- Department of Oncology, Westmead Hospital, Westmead 2145, NSW Australia
| | - David Alexander Brown
- Westmead Institute for Medical Research, Centre for Diabetes and Endocrinology, Westmead 2145, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown 2050, NSW, Australia
- Institute of Clinical Pathology and Medical Research, Department of Immunology, NSW Health Pathology, Westmead 2145, NSW, Australia
- Department of of Immunology, Westmead Hospital, Westmead 2145, NSW Australia
| | - Georgina Venetia Long
- Faculty of Medicine and Health, The University of Sydney, Camperdown 2050, NSW, Australia
- Department of Medical Oncology, Royal North Shore Hospital, St Leonards 2065, NSW, Australia
| | - Roderick Clifton-Bligh
- Faculty of Medicine and Health, The University of Sydney, Camperdown 2050, NSW, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards 2065, NSW, Australia
| | - Rhiannon Mellor
- Department of Oncology, Westmead Hospital, Westmead 2145, NSW Australia
| | - Krystal Moore
- Department of Radiology, Westmead Hospital, Westmead 2145, NSW Australia
| | - Sarah Christina Sasson
- Faculty of Medicine and Health, The University of Sydney, Camperdown 2050, NSW, Australia
- Department of of Immunology, Westmead Hospital, Westmead 2145, NSW Australia
| | - Alexander Maxwell Menzies
- Faculty of Medicine and Health, The University of Sydney, Camperdown 2050, NSW, Australia
- Department of Medical Oncology, Royal North Shore Hospital, St Leonards 2065, NSW, Australia
| | - Venessa Tsang
- Faculty of Medicine and Health, The University of Sydney, Camperdown 2050, NSW, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards 2065, NSW, Australia
| | - Jenny Elizabeth Gunton
- Westmead Institute for Medical Research, Centre for Diabetes and Endocrinology, Westmead 2145, NSW, Australia
- Department of Endocrinology, Westmead Hospital, Westmead 2145, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown 2050, NSW, Australia
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Mostafa EA, Abo Hashish MMA, Ismail NA, Hasanin HM, Hasanin RM, Wahby AA, Ashmawy I, Abd El Aziz SH, Wahed MMA. Assessment of vitamin D status and vitamin D receptor polymorphism in Egyptian children with Type 1 diabetes. J Genet Eng Biotechnol 2024; 22:100343. [PMID: 38494252 PMCID: PMC10980865 DOI: 10.1016/j.jgeb.2023.100343] [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: 03/19/2024]
Abstract
BACKGROUND The endocrine system of vitamin D regulates about 3 % of the human genome. Vitamin D exerts its actions via a nuclear vitamin D receptor (VDR) which in turn regulates insulin secretion from the pancreas. VDR gene polymorphisms could have an impact on how autoimmune illnesses like Type 1 diabetes mellitus (T1DM) develop. We aimed to explore the relation between T1DM and VDR gene polymorphisms in Egyptian diabetic children and their siblings. METHODS Enzyme-linked immunosorbent assay was used to quantify 25(OH) vitamin D in the study, which had 179 participants (group 1 = 85 diabetic children, group 2 = 57 siblings of the patients, group 3 = 37 healthy controls). Real-time polymerase chain reaction (RT-PCR) was used to analyze the genotyping of the VDR gene polymorphisms Apa-I (rs7975232), Fok-I (rs2228570), Taq-I (rs731236) and Bsm-I (rs1544410). RESULTS The mean serum 25(OH) vitamin D levels was significantly lower in T1DM patients (14.99 ± 9.24 ng/mL) and siblings (16.31 ± 7.96 ng/mL) compared to the controls (19.48 ± 7.42 ng/mL) (p = 0.031). The genotypes distribution of VDR Fok-I (rs2228570) and Bsm-I (rs1544410) polymorphisms showed a significant difference between patients, siblings and controls as P = 0.001 and 0.026 respectively, while the VDR ApaI and TaqI polymorphisms did not. FokI-A allele frequency was significantly lower in T1DM patients and siblings than in controls (p < 0.001). FokI-AA genotype had a statistical significant higher vitamin D levels than other genotypes with p value of 0.024. CONCLUSION Our study found that T1DM children had lower vitamin D levels, and VDR FokI and BsmI gene polymorphisms were linked to T1DM in Egyptian children. Determining the relationship between vitamin D levels and VDR polymorphisms, particularly the FokI and other genetic analyses may aid in the early diagnosis of T1DM in children.
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Affiliation(s)
- Eman A Mostafa
- Department of Pediatrics, National Research Center, Affiliation ID: 60014618, Cairo, Egypt.
| | - Maha M A Abo Hashish
- Department of Pediatrics, National Research Center, Affiliation ID: 60014618, Cairo, Egypt
| | - Nagwa Abdallah Ismail
- Department of Pediatrics, National Research Center, Affiliation ID: 60014618, Cairo, Egypt
| | - Hasanin M Hasanin
- Department of Pediatrics, National Research Center, Affiliation ID: 60014618, Cairo, Egypt
| | - Rasha M Hasanin
- Department of Pediatrics, National Research Center, Affiliation ID: 60014618, Cairo, Egypt
| | - Aliaa Ahmed Wahby
- Department of Clinical and Chemical Pathology, National Research Center, Affiliation ID: 60014618, Cairo, Egypt
| | - Ingy Ashmawy
- Department of Clinical and Chemical Pathology, National Research Center, Affiliation ID: 60014618, Cairo, Egypt
| | - Shereen Hamdy Abd El Aziz
- Department of Clinical and Chemical Pathology, National Research Center, Affiliation ID: 60014618, Cairo, Egypt
| | - Mai Magdy Abdel Wahed
- Department of Clinical and Chemical Pathology, National Research Center, Affiliation ID: 60014618, Cairo, Egypt
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Angelousi A, Ziogas DC, Siampanopoulou V, Mytareli C, Anastasopoulou A, Lyrarakis G, Gogas H. Reaching the Diagnosis of Checkpoint Inhibitor-Induced Diabetes Mellitus in Different Clinical Scenarios: A Real-World Application of Updated Diagnostic Criteria. Diseases 2024; 12:40. [PMID: 38391787 PMCID: PMC10887699 DOI: 10.3390/diseases12020040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Checkpoint inhibitor (CPI)-associated diabetes mellitus (CPI-DM) is a rare immune-related adverse event (irAE) that presents with variable clinical manifestations. Data about its pathogenesis have not yet been adequately studied. METHODS Applying the recently updated diagnostic criteria from the American Diabetes Association, we retrospectively reviewed the medical records of all CPI-treated patients referred to our endocrinological unit for managing their endocrine irAEs and analyzed the incidence of CPI-DM, its clinical characteristics, and its management. RESULTS Among the 326 CPI-treated patients with endocrine irAEs, 4 patients met the updated criteria for the diagnosis of CPI-DM, representing 1.22% of all endocrine irAEs in our cohort. These four patients presented with distinct clinical scenarios regarding the irAE onset, the underlying malignancy, the administered CPI regimen, and the type of circulating autoantibodies. CONCLUSION The variable presentation of CPI-DM and the non-standard sensitivity of the presence of the type 1 DM traditional autoantibodies highlight the need for distinct guidelines and increased awareness of its diagnosis and management.
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Affiliation(s)
- Anna Angelousi
- First Department of Internal Medicine, Unit of Endocrinology, Laikon Hospital, Center of Excellence of Endocrine Tumours (ERN), National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Dimitrios C Ziogas
- First Department of Medicine, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Vasiliki Siampanopoulou
- First Department of Internal Medicine, Unit of Endocrinology, Laikon Hospital, Center of Excellence of Endocrine Tumours (ERN), National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Chrysoula Mytareli
- First Department of Internal Medicine, Unit of Endocrinology, Laikon Hospital, Center of Excellence of Endocrine Tumours (ERN), National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Amalia Anastasopoulou
- First Department of Medicine, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - George Lyrarakis
- First Department of Medicine, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Helen Gogas
- First Department of Medicine, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
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Rogiers A, Dimitriou F, Lobon I, Harvey C, Vergara IA, Pires da Silva I, Lo SN, Scolyer RA, Carlino MS, Menzies AM, Long GV. Seasonal patterns of toxicity in melanoma patients treated with combination anti-PD-1 and anti-CTLA-4 immunotherapy. Eur J Cancer 2024; 198:113506. [PMID: 38184928 DOI: 10.1016/j.ejca.2023.113506] [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: 09/11/2023] [Revised: 12/06/2023] [Accepted: 12/19/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Immune checkpoint inhibitors are frequently associated with the development of immunotherapy-related adverse events (irAEs). The exact etiology, including the role of environmental factors, remains incompletely understood. METHODS We analyzed the records of 394 melanoma patients from three centers (northern and southern hemisphere). Patients had received at least one cycle of anti-PD-1/anti-CTLA-4 with a minimum follow-up of 3 months. We study the distribution and time to irAEs onset throughout the calendar year. RESULTS 764 irAEs were recorded; the most frequent were skin rash (35%), hepatitis (32%) and colitis (30%). The irAEs incidence was the highest in autumn and winter, and the ratio for the 'number of irAEs' per 'therapies commenced' was the highest in winter and lowest in summer (2.4 and 1.7, respectively). Season-specific patterns in the time of irAEs onset were observed for pneumonitis (shorter time to onset in autumn, p = 0.025), hepatitis (shorter time to onset in spring, p = 0.016) and sarcoid-like immune reaction (shorter time to onset in autumn, p = 0.041). Season-specific patterns for early-onset irAEs were observed for hepatitis (spring, p = 0.023) and nephritis (summer, p = 0.017). Early-onset pneumonitis was more frequent in autumn-winter (p = 0.008) and early-onset nephritis in spring-summer (p = 0.004). CONCLUSIONS Environmental factors that are associated with particular seasons may contribute to the development of certain irAEs and suggest the potential effect of environmental triggers. The identification of these factors may enhance preventive and therapeutic strategies to reduce the morbidity of irAEs.
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Affiliation(s)
- Aljosja Rogiers
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Florentia Dimitriou
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland; Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Irene Lobon
- Cancer Dynamics Laboratory, The Francis Crick Institute, London, United Kingdom
| | - Catriona Harvey
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Charles Perkin Centre, The University of Sydney, Sydney, NSW, Australia
| | - Ismael A Vergara
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Charles Perkin Centre, The University of Sydney, Sydney, NSW, Australia
| | - Ines Pires da Silva
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Westmead and Blacktown Hospitals, Sydney, New South Wales, Australia
| | - Serigne N Lo
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Richard A Scolyer
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia; Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Matteo S Carlino
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Westmead and Blacktown Hospitals, Sydney, New South Wales, Australia
| | - Alexander M Menzies
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, NSW, Australia
| | - Georgina V Long
- Melanoma Institute Australia, The University of Sydney, Sydney, New South Wales, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Medical Oncology, Royal North Shore and Mater Hospitals, Sydney, NSW, Australia.
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10
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Basek A, Jakubiak GK, Cieślar G, Stanek A. Life-Threatening Endocrinological Immune-Related Adverse Events of Immune Checkpoint Inhibitor Therapy. Cancers (Basel) 2023; 15:5786. [PMID: 38136332 PMCID: PMC10742092 DOI: 10.3390/cancers15245786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 11/29/2023] [Accepted: 12/06/2023] [Indexed: 12/24/2023] Open
Abstract
Malignant neoplasms are currently one of the leading causes of morbidity and mortality worldwide, posing a major public health challenge. However, recent advances in research in cancer biology and immunity have led to the development of immunotherapy, which is now used on an everyday basis in cancer treatment in addition to surgical treatment, classical cytostatics, and radiotherapy. The efficacy of immunotherapy has promoted the great popularity of this treatment among patients, as well as significant research interest. The increasing number of patients being treated with immunotherapy not only reassures physicians of the efficacy of this technique but also shows the wide spectrum of side effects of this therapy, which has not been considered before. Immune-related adverse events may affect many systems and organs, such as digestive, cardiovascular, respiratory, skin, or endocrine organs. Most complications have a mild or moderate course, but there are life-threatening manifestations that are essential to be aware of because if they are not properly diagnosed and treated on time, they can have fatal consequences. The purpose of this paper was to present the results of a literature review on the current state of knowledge on life-threatening endocrine side effects (such as adrenal crisis, thyroid storm, myxoedema crisis, diabetic ketoacidosis, and severe hypocalcaemia) of immune checkpoint inhibitors to provide information on symptoms, diagnostics, and management strategies.
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Affiliation(s)
- Aleksandra Basek
- Student Research Group, Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland;
| | - Grzegorz K. Jakubiak
- Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland; (G.C.); (A.S.)
| | - Grzegorz Cieślar
- Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland; (G.C.); (A.S.)
| | - Agata Stanek
- Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland; (G.C.); (A.S.)
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11
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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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12
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Ye D, Qiu M, Wu L, Li B. Clinical Features of Camrelizumab-Associated Diabetes Mellitus. Am J Ther 2023; 30:e559-e561. [PMID: 35551142 DOI: 10.1097/mjt.0000000000001493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Dong Ye
- Department of Integrated Medicine, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Moqin Qiu
- Department of Respiratory Oncology, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Lili Wu
- Department of Integrated Medicine, Guangxi Medical University Cancer Hospital, Nanning, China
| | - Bixun Li
- Department of Integrated Medicine, Guangxi Medical University Cancer Hospital, Nanning, China
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13
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Daetwyler E, Zippelius A, Danioth S, Donath MY, Gut L. Nivolumab-induced diabetes mellitus-a case report with literature review of the treatment options. Front Immunol 2023; 14:1248919. [PMID: 37965350 PMCID: PMC10640970 DOI: 10.3389/fimmu.2023.1248919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/10/2023] [Indexed: 11/16/2023] Open
Abstract
Background Immune checkpoint inhibitor (ICI) treatment has become important for treating various cancer types, including metastatic renal cell carcinoma. However, ICI treatment can lead to endocrine immune-related adverse events (irAEs) by overstimulating the patient's immune system. Here, we report a rare case of a new onset of diabetes mellitus (DM), caused by nivolumab, and we discuss the feasible treatment options with a focus on TNF antagonism. Case presentation A 50-year-old man was diagnosed with metastatic renal cell carcinoma. Due to systemic progression, a combined immunotherapy with ipilimumab and nivolumab was initiated, according to the current study protocol (SAKK 07/17). The administration of ipilimumab was stopped after 10 months, due to partial response as seen in the computer tomography (CT), and nivolumab was continued as monotherapy. Fourteen months after the start of the treatment, the patient was admitted to the emergency department with lethargy, vomiting, blurred vision, polydipsia, and polyuria. The diagnosis of DM with diabetic ketoacidosis was established, although autoantibodies to β-cells were not detectable. Intravenous fluids and insulin infusion treatment were immediately initiated with switching to a subcutaneous administration after 1 day. In addition, the patient received an infusion of the TNF inhibitor infliximab 4 days and 2 weeks after the initial diagnosis of DM. However, the C-peptide values remained low, indicating a sustained insulin deficiency, and the patient remained on basal bolus insulin treatment. Two months later, nivolumab treatment was restarted without destabilization of the diabetic situation. Conclusions In contrast to the treatment of other irAEs, the administration of corticosteroids is not recommended in ICI-induced DM. The options for further treatment are mainly based on the low numbers of case series and case reports. In our case, the administration of infliximab-in an attempt to salvage the function of β-cells-was not successful, and this is in contrast to some previous reports. This apparent discrepancy may be explained by the absence of insulin resistance in our case. There is so far no evidence for immunosuppressive treatment in this situation. Prompt recognition and immediate start of insulin treatment are most important in its management.
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Affiliation(s)
- Eveline Daetwyler
- Department of Medical Oncology, University Hospital Basel, Basel, Switzerland
| | - Alfred Zippelius
- Department of Medical Oncology, University Hospital Basel, Basel, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Simona Danioth
- Clinic for Endocrinology, Diabetes & Metabolism, Luzern Cantonal Hospital, Luzern, Switzerland
| | - Marc Y. Donath
- Department of Biomedicine, University of Basel, Basel, Switzerland
- Clinic for Endocrinology, Diabetes & Metabolism, University Hospital Basel, Basel, Switzerland
| | - Lara Gut
- Clinic for Endocrinology, Diabetes & Metabolism, University Hospital Basel, Basel, Switzerland
- Clinic for Endocrinology & Diabetes, Medical University Clinic Baselland, Liestal, Switzerland
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14
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Collier JL, Pauken KE, Lee CA, Patterson DG, Markson SC, Conway TS, Fung ME, France JA, Mucciarone KN, Lian CG, Murphy GF, Sharpe AH. Single-cell profiling reveals unique features of diabetogenic T cells in anti-PD-1-induced type 1 diabetes mice. J Exp Med 2023; 220:e20221920. [PMID: 37432393 PMCID: PMC10336233 DOI: 10.1084/jem.20221920] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 04/28/2023] [Accepted: 06/23/2023] [Indexed: 07/12/2023] Open
Abstract
Immune-related adverse events (irAEs) are a notable complication of PD-1 cancer immunotherapy. A better understanding of how these iatrogenic diseases compare with naturally arising autoimmune diseases is needed for treatment and monitoring of irAEs. We identified differences in anti-PD-1-induced type 1 diabetes (T1D) and spontaneous T1D in non-obese diabetic (NOD) mice by performing single-cell RNA-seq and TCR-seq on T cells from the pancreas, pancreas-draining lymph node (pLN), and blood of mice with PD-1-induced T1D or spontaneous T1D. In the pancreas, anti-PD-1 resulted in expansion of terminally exhausted/effector-like CD8+ T cells, an increase in T-bethi CD4+FoxP3- T cells, and a decrease in memory CD4+FoxP3- and CD8+ T cells in contrast to spontaneous T1D. Notably, anti-PD-1 caused increased TCR sharing between the pancreas and the periphery. Moreover, T cells in the blood of anti-PD-1-treated mice expressed markers that differed from spontaneous T1D, suggesting that the blood may provide a window to monitor irAEs rather than relying exclusively on the autoimmune target organ.
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Affiliation(s)
- Jenna L. Collier
- Department of Immunology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
- Evergrande Center for Immunological Diseases, Harvard Medical School and Brigham and Women’s Hospital, Boston, MA, USA
| | - Kristen E. Pauken
- Department of Immunology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
- Evergrande Center for Immunological Diseases, Harvard Medical School and Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Dillon G. Patterson
- Department of Immunology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
- Evergrande Center for Immunological Diseases, Harvard Medical School and Brigham and Women’s Hospital, Boston, MA, USA
| | - Samuel C. Markson
- Department of Immunology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
- Evergrande Center for Immunological Diseases, Harvard Medical School and Brigham and Women’s Hospital, Boston, MA, USA
| | - Thomas S. Conway
- Department of Immunology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
- Evergrande Center for Immunological Diseases, Harvard Medical School and Brigham and Women’s Hospital, Boston, MA, USA
| | - Megan E. Fung
- Department of Immunology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
- Evergrande Center for Immunological Diseases, Harvard Medical School and Brigham and Women’s Hospital, Boston, MA, USA
| | - Joshua A. France
- Department of Immunology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
- Evergrande Center for Immunological Diseases, Harvard Medical School and Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Christine G. Lian
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, USA
| | - George F. Murphy
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Arlene H. Sharpe
- Department of Immunology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
- Evergrande Center for Immunological Diseases, Harvard Medical School and Brigham and Women’s Hospital, Boston, MA, USA
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
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15
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Gao Y, Zhong M, Gan L, Xiang C, Li L, Yan Y. Immune checkpoint inhibitor- and phosphatidylinositol-3-kinase inhibitor-related diabetes induced by antineoplastic drugs: two case reports and a literature review. Front Endocrinol (Lausanne) 2023; 14:1236946. [PMID: 37732122 PMCID: PMC10509015 DOI: 10.3389/fendo.2023.1236946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/17/2023] [Indexed: 09/22/2023] Open
Abstract
Immune checkpoint inhibitor (ICI)- and phosphatidylinositol-3-kinase inhibitor (PI3Ki)-related diabetes mellitus are common side effects of anti-tumor drug use that present mainly as hyperglycemia. Here, we present two case reports of diabetes mellitus caused by the use of tremelimumab and apalutamide, respectively, in cancer treatment, and a comprehensive, comparative review of the literature on these forms of diabetes. Case 1 presented with diabetic ketoacidosis and was diagnosed with ICI-related diabetes mellitus and treated with insulin. Case 2 was diagnosed with PI3Ki-related diabetes mellitus, and her blood glucose level returned to normal with the use of metformin and dapagliflozin. We systematically searched the PubMed database for articles on ICI- and PI3Ki-related diabetes mellitus and characterized the differences in clinical features and treatment between these two forms of diabetes.
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Affiliation(s)
- Yue Gao
- Department of Endocrinology, Xiaogan Hospital Affiliated with Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
- Medical College, Wuhan University of Science and Technology, Wuhan, China
| | - Mingyao Zhong
- Medical College, Wuhan University of Science and Technology, Wuhan, China
| | - Lulu Gan
- Medical College, Wuhan University of Science and Technology, Wuhan, China
| | - Cheng Xiang
- Department of Endocrinology, Xiaogan Hospital Affiliated with Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
| | - Ling Li
- Department of Endocrinology, Xiaogan Hospital Affiliated with Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
| | - Yimin Yan
- Department of Endocrinology, Xiaogan Hospital Affiliated with Wuhan University of Science and Technology, The Central Hospital of Xiaogan, Xiaogan, Hubei, China
- Medical College, Wuhan University of Science and Technology, Wuhan, China
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16
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Liao D, Liu C, Chen S, Liu F, Li W, Shangguan D, Shi Y. Recent advances in immune checkpoint inhibitor-induced type 1 diabetes mellitus. Int Immunopharmacol 2023; 122:110414. [PMID: 37390646 DOI: 10.1016/j.intimp.2023.110414] [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: 03/27/2023] [Revised: 05/23/2023] [Accepted: 05/29/2023] [Indexed: 07/02/2023]
Abstract
As a new group of anticancer drugs, immune checkpoint inhibitors (ICIs) have exhibited favorable antitumor efficacy in numerous malignant tumors. Anti-cytotoxic T lymphocyte associated antigen-4 (CTLA-4), anti-programmed cell death-1 (PD-1) and anti-programmed cell death ligand-1 (PD-L1) are three kinds of ICIs widely used in clinical practice. However, ICI therapy (monotherapy or combination therapy) is always accompanied by a unique toxicity profile known as immune-related adverse events (irAEs) affecting multiple organs. The endocrine glands are common targets of irAEs induced by ICIs, which cause type 1 diabetes mellitus (T1DM) when the pancreas is affected. Although the incidence rate of ICI-induced T1DM is rare, it will always lead to an irreversible impairment of β-cells and be potentially life-threatening. Hence, it is vital for endocrinologists and oncologists to obtain a comprehensive understanding of ICI-induced T1DM and its management. In our present manuscript, we have reviewed the epidemiology, pathology and mechanism, diagnosis, management, and treatments of ICI-induced T1DM.
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Affiliation(s)
- Dehua Liao
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410011, China
| | - Chaoyi Liu
- Department of Information, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410011, China
| | - Shanshan Chen
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410011, China
| | - Fen Liu
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410011, China
| | - Wei Li
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410011, China
| | - Dangang Shangguan
- Department of Pharmacy, Hunan Cancer Hospital, The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410011, China.
| | - Yingrui Shi
- Department of Radiation Oncology, Hunan Cancer Hospital/The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha 410011, China.
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17
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Kamal RS, Dean A, Dutt H, Rajeh A, Fernandes R. Hypoglycemia as first presentation of presumed immune checkpoint inhibitor-induced type 1 diabetes. Clin Case Rep 2023; 11:e7897. [PMID: 37692147 PMCID: PMC10485243 DOI: 10.1002/ccr3.7897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/17/2023] [Accepted: 08/23/2023] [Indexed: 09/12/2023] Open
Abstract
We present a case of a 60-year-old male diagnosed with metastatic clear cell renal cell carcinoma who developed hypoglycemia during induction ipilimumab and nivolumab treatment. This was diagnosed as presumed type 1 diabetes mellitus secondary to immunotherapy.
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Affiliation(s)
- Rayyan Syed Kamal
- Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
- Cancer Research Laboratory Program, Lawson Health Research InstituteLondon Health Sciences CentreLondonOntarioCanada
| | - Arleigh Dean
- Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
- Cancer Research Laboratory Program, Lawson Health Research InstituteLondon Health Sciences CentreLondonOntarioCanada
| | - Hanna Dutt
- Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
- Cancer Research Laboratory Program, Lawson Health Research InstituteLondon Health Sciences CentreLondonOntarioCanada
| | - Adnan Rajeh
- Schulich School of Medicine and DentistryWestern UniversityLondonOntarioCanada
- Department of Oncology, Division of Medical Oncology, Schulich School of Medicine & DentistryWestern UniversityLondonOntarioCanada
| | - Ricardo Fernandes
- Department of Oncology, Division of Medical Oncology, Schulich School of Medicine & DentistryWestern UniversityLondonOntarioCanada
- Cancer Research Laboratory ProgramLawson Health Research InstituteLondonOntarioCanada
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18
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Singh N, Hocking AM, Buckner JH. Immune-related adverse events after immune check point inhibitors: Understanding the intersection with autoimmunity. Immunol Rev 2023; 318:81-88. [PMID: 37493210 DOI: 10.1111/imr.13247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/28/2023] [Indexed: 07/27/2023]
Abstract
Immune checkpoint inhibitor therapies act through blockade of inhibitory molecules involved in the regulation of T cells, thus releasing tumor specific T cells to destroy their tumor targets. However, immune checkpoint inhibitors (ICI) can also lead to a breach in self-tolerance resulting in immune-related adverse events (irAEs) that include tissue-specific autoimmunity. This review addresses the question of whether the mechanisms that drive ICI-induced irAEs are shared or distinct with those driving spontaneous autoimmunity, focusing on ICI-induced diabetes, ICI-induced arthritis, and ICI-induced thyroiditis due to the wealth of knowledge about the development of autoimmunity in type 1 diabetes, rheumatoid arthritis, and Hashimoto's thyroiditis. It reviews current knowledge about role of genetics and autoantibodies in the development of ICI-induced irAEs and presents new studies utilizing single-cell omics approaches to identify T-cell signatures associated with ICI-induced irAEs. Collectively, these studies indicate that there are similarities and differences between ICI-induced irAEs and autoimmune disease and that studying them in parallel will provide important insight into the mechanisms critical for maintaining immune tolerance.
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Affiliation(s)
- Namrata Singh
- Division of Rheumatology, University of Washington, Seattle, Washington, USA
| | - Anne M Hocking
- Center for Translational Immunology, Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
| | - Jane H Buckner
- Center for Translational Immunology, Benaroya Research Institute at Virginia Mason, Seattle, Washington, USA
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19
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Marsiglio J, McPherson JP, Kovacsovics-Bankowski M, Jeter J, Vaklavas C, Swami U, Grossmann D, Erickson-Wayman A, Soares HP, Kerrigan K, Gibson B, Doherty JA, Hyngstrom J, Hardikar S, Hu-Lieskovan S. A single center case series of immune checkpoint inhibitor-induced type 1 diabetes mellitus, patterns of disease onset and long-term clinical outcome. Front Immunol 2023; 14:1229823. [PMID: 37671166 PMCID: PMC10475559 DOI: 10.3389/fimmu.2023.1229823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 08/01/2023] [Indexed: 09/07/2023] Open
Abstract
Background Type 1 diabetes mellitus (T1DM) is a rare, but serious immune-related adverse event (irAE) of immune checkpoint inhibitors (ICIs). Our goal was to characterize treatment outcomes associated with ICI-induced T1DM through analysis of clinical, immunological and proteomic data. Methods This was a single-center case series of patients with solid tumors who received ICIs and subsequently had a new diagnosis of T1DM. ICD codes and C-peptide levels were used to identify patients for chart review to confirm ICI-induced T1DM. Baseline blood specimens were studied for proteomic and immunophenotypic changes. Results Between 2011 and 2023, 18 of 3744 patients treated at Huntsman Cancer Institute with ICIs were confirmed to have ICI-induced T1DM (0.48%). Eleven of the 18 patients received anti-PD1 monotherapy, 4 received anti-PD1 plus chemotherapy or targeted therapy, and 3 received ipilimumab plus nivolumab. The mean time to onset was 218 days (range 22-418 days). Patients had sudden elevated serum glucose within 2-3 weeks prior to diagnosis. Sixteen (89%) presented with diabetic ketoacidosis. Three of 12 patients had positive T1DM-associated autoantibodies. All patients with T1DM became insulin-dependent through follow-up. At median follow-up of 21.9 months (range 8.4-82.4), no patients in the melanoma group had progressed or died from disease. In the melanoma group, best responses were 2 complete response and 2 partial response while on active treatment; none in the adjuvant group had disease recurrence. Proteomic analysis of baseline blood suggested low inflammatory (IL-6, OSMR) markers and high metabolic (GLO1, DXCR) markers in ICI-induced T1DM cohort. Conclusions Our case series demonstrates rapid onset and irreversibility of ICI-induced T1DM. Melanoma patients with ICI-induced T1DM display excellent clinical response and survival. Limited proteomic data also suggested a unique proteomic profile. Our study helps clinicians to understand the unique clinical presentation and long-term outcomes of this rare irAE for best clinical management.
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Affiliation(s)
- John Marsiglio
- Department of Internal Medicine, University of Utah Health, Salt Lake City, UT, United States
| | - Jordan P. McPherson
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT, United States
| | | | - Joanne Jeter
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT, United States
| | - Christos Vaklavas
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT, United States
| | - Umang Swami
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT, United States
| | - Douglas Grossmann
- Department of Dermatology, University of Utah Health, Salt Lake City, UT, United States
| | | | - Heloisa P. Soares
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT, United States
| | - Katie Kerrigan
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT, United States
| | - Berit Gibson
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT, United States
| | - Jennifer Anne Doherty
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT, United States
| | - John Hyngstrom
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT, United States
| | - Sheetal Hardikar
- Department of Population Health Sciences, University of Utah Health, Salt Lake City, UT, United States
| | - Siwen Hu-Lieskovan
- Huntsman Cancer Institute, University of Utah Health, Salt Lake City, UT, United States
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20
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Shen M, Chen D, Zhao R, Zheng X, Gu Y, Yang T, Shi Y. Real-world adherence to toxicity management guidelines for immune checkpoint inhibitor-induced diabetes mellitus. Front Endocrinol (Lausanne) 2023; 14:1213225. [PMID: 37554766 PMCID: PMC10405819 DOI: 10.3389/fendo.2023.1213225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/04/2023] [Indexed: 08/10/2023] Open
Abstract
Objective Immune checkpoint inhibitors(ICIs) have improved survival and are increasingly used for cancer. However, ICIs use may be limited by immune-related adverse events (irAEs), such as ICI-induced diabetes mellitus(ICI-DM). The objective of the present study was to characterize ICI-DM patients and real-world adherence to guidelines. Research design and methods The present study was a retrospective review of electronic records of ICI-DM patients at the First Affiliated Hospital of Nanjing Medical University between July 2018 and October 2022. Results 34.8% (8/23)patients monitored blood glucose in every treatment cycle. The proportion of patients with severe diabetic ketoacidosis(DKA) was lower in the tight glycemic monitoring group than the non-tight glycemic monitoring group (16.7% vs. 55.6%, p = 0.049). 78.3%(18/23) patients with hyperglycemia visited a non-endocrinologist first, but 95.7% of patients were then referred to an endocrinologist. Twenty patients were tested for distinguishing the etiology of hyperglycemia and 20% patients with positive glutamic acid decarboxylase antibody(GADA), 55% with C-peptide <3.33pmol/L. High screening rates for other ICI-induced endocrinopathies were observed and half of the patients with ICI-DM developed other endocrine gland irAEs, with the most common being thyroiditis. Moreover, five patients developed non-endocrine serious adverse events(SAEs). Twelve (52.2%) patients were withdrawn from ICI due to ICI-DM. The time to progression of tumor in ICI-DM patients in the continue and interruption group was longer than in the withdrawal group (333.5 ± 82.5 days vs. 183.1 ± 62.4 days, p = 0.161). Only 17.4% of ICI-DM patients were completely managed according to guidelines. Thus, the present study proposed a screening, diagnosis, and management algorithm for ICI-DM in real-world practice. Conclusion The present study reported the largest number of ICI-DM cases described in a single institute, providing insight into real-world ICI-DM management guideline adherence and highlighting the clinical challenges in ICI-DM management.
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Affiliation(s)
| | | | | | | | | | - Tao Yang
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yun Shi
- *Correspondence: Yun Shi, ; Tao Yang,
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Liu YC, Liu H, Zhao SL, Chen K, Jin P. Clinical and HLA genotype analysis of immune checkpoint inhibitor-associated diabetes mellitus: a single-center case series from China. Front Immunol 2023; 14:1164120. [PMID: 37359544 PMCID: PMC10288983 DOI: 10.3389/fimmu.2023.1164120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 05/25/2023] [Indexed: 06/28/2023] Open
Abstract
Objective To investigate the clinical characteristics and HLA genotypes of patients with immune checkpoint inhibitor-associated diabetes mellitus (ICI-DM) in China. Methods We enrolled 23 patients with ICI-DM and 51 patients with type 1 diabetes (T1D). Clinical characteristics of the patients were collected. HLA-DRB1, HLA-DQA1, and HLA-DQB1 genotyping was conducted via next-generation sequencing. Results The ICI-DM patients had a male predominance (70.6%), a mean body mass index (BMI) of 21.2 ± 3.5 kg/m2, and a mean onset of ICI-DM in 5 (IQR, 3-9) cycles after ICI therapy. Most (78.3%) ICI-DM patients were treated with anti-PD-1, 78.3% presented with diabetic ketoacidosis, and all had low C-peptide levels and received multiple insulin injections. Compared to T1D patients, ICI-DM patients were significantly older (57.2 ± 12.4 vs 34.1 ± 15.7 years) and had higher blood glucose but lower HbA1c levels (P<0.05). Only two (8.7%) ICI-DM patients were positive for islet autoantibodies, which was lower than that in T1D patients (66.7%, P<0.001). A total of 59.1% (13/22) of ICI-DM patients were heterozygous for an HLA T1D risk haplotype, and DRB1*0901-DQA1*03-DQB1*0303 (DR9) and DRB1*0405-DQA1*03-DQB1*0401 were the major susceptible haplotypes. Compared to T1D, the susceptible DR3-DQA1*0501-DQB1*0201 (DR3) and DR9 haplotypes were less frequent (17.7% vs 2.3%; P=0.011 and 34.4% vs 15.9%; P=0.025), whereas the protective haplotypes (DRB1*1101-DQA1*05-DQB1*0301 and DRB1*1202-DQA1*0601-DQB1*0301) were more frequent in ICI-DM patients (2.1% vs 13.6%; P=0.006 and 4.2% vs 15.9%; P=0.017). None of the ICI-DM patients had T1D-associated high-risk genotypes DR3/DR3, DR3/DR9, and DR9/DR9. Among the 23 ICI-DM patients, 7 (30.4%) presented with ICI-associated fulminant type 1 diabetes (IFD), and 16 (69.6%) presented with ICI-associated type 1 diabetes (IT1D). Compared to IT1D patients, IFD patients exhibited marked hyperglycemia and low C-peptide and HbA1c levels (P<0.05). Up to 66.7% (4/6) of IFD patients were heterozygous for reported fulminant type 1 diabetes susceptibility HLA haplotypes (DRB1*0405-DQB1*0401 or DRB1*0901-DQB1*0303). Conclusion ICI-DM shares similar clinical features with T1D, such as acute onset, poor islet function and insulin dependence. However, the lack of islet autoantibodies, the low frequencies of T1D susceptibility and high frequencies of protective HLA haplotypes indicate that ICI-DM represents a new model distinct from classical T1D.
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22
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Wu L, Tsang V, Menzies AM, Sasson SC, Carlino MS, Brown DA, Clifton-Bligh R, Gunton JE. Risk Factors and Characteristics of Checkpoint Inhibitor-Associated Autoimmune Diabetes Mellitus (CIADM): A Systematic Review and Delineation From Type 1 Diabetes. Diabetes Care 2023; 46:1292-1299. [PMID: 37220262 DOI: 10.2337/dc22-2202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/27/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Checkpoint inhibitor-associated autoimmune diabetes mellitus (CIADM) is a distinct form of autoimmune diabetes that is a rare complication of immune checkpoint inhibitor therapy. Data regarding CIADM are limited. PURPOSE To systematically review available evidence to identify presentation characteristics and risk factors for early or severe presentations of adult patients with CIADM. DATA SOURCES MEDLINE and PubMed databases were reviewed. STUDY SELECTION English full text articles from 2014 to April 2022 were identified with a predefined search strategy. Patients meeting diagnostic criteria for CIADM with evidence of hyperglycemia (blood glucose level >11 mmol/L or HbA1c ≥6.5%) and insulin deficiency (C-peptide <0.4 nmol/L and/or diabetic ketoacidosis [DKA]) were included for analysis. DATA EXTRACTION With the search strategy we identified 1,206 articles. From 146 articles, 278 patients were labeled with "CIADM," with 192 patients meeting our diagnostic criteria and included in analysis. DATA SYNTHESIS Mean ± SD age was 63.4 ± 12.4 years. All but one patient (99.5%) had prior exposure to either anti-PD1 or anti-PD-L1 therapy. Of the 91 patients tested (47.3%), 59.3% had susceptibility haplotypes for type 1 diabetes (T1D). Median time to CIADM onset was 12 weeks (interquartile range 6-24). DKA occurred in 69.7%, and initial C-peptide was low in 91.6%. T1D autoantibodies were present in 40.4% (73 of 179) and were significantly associated with DKA (P = 0.0009) and earlier time to CIADM onset (P = 0.02). LIMITATIONS Reporting of follow-up data, lipase, and HLA haplotyping was limited. CONCLUSIONS CIADM commonly presents in DKA. While T1D autoantibodies are only positive in 40.4%, they associate with earlier, more severe presentations.
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Affiliation(s)
- Linda Wu
- The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
| | - Venessa Tsang
- University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia Sydney, New South Wales, Australia
| | - Alexander M Menzies
- University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia Sydney, New South Wales, Australia
- Melanoma Institute Australia, Sydney, New South Wales, Australia
- Mater Hospital, Sydney, New South Wales, Australia
| | - Sarah C Sasson
- University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
- Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Sydney, New South Wales, Australia
| | - Matteo S Carlino
- University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
- Melanoma Institute Australia, Sydney, New South Wales, Australia
- Mater Hospital, Sydney, New South Wales, Australia
| | - David A Brown
- The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
- Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Sydney, New South Wales, Australia
| | - Roderick Clifton-Bligh
- University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia Sydney, New South Wales, Australia
| | - Jenny E Gunton
- The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
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23
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Gao MJ, Xu Y, Wang WB. Immune checkpoint inhibitor therapy-induced autoimmune polyendocrine syndrome type II and Crohn’s disease: A case report. World J Clin Cases 2023; 11:3267-3274. [PMID: 37274046 PMCID: PMC10237137 DOI: 10.12998/wjcc.v11.i14.3267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 02/17/2023] [Accepted: 04/06/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND The development of immune checkpoint inhibitors (ICIs) has heralded a new era in cancer treatment, enabling the possibility of long-term survival in patients with metastatic disease. Unfortunately, ICIs are increasingly implicated in the development of autoimmune diseases.
CASE SUMMARY We present a man with squamous cell carcinoma of the oropharynx on a combination of teriprizumab, docetaxel, and cisplatin therapy who developed autoimmune polyendocrine syndrome type II (APS-2) including thyroiditis and type 1 diabetes mellitus and Crohn’s disease (CD). He developed thirst, abdominal pain, and fatigue after two-week treatment with the protein 1 ligand inhibitor teriprizumab. Biochemistry confirmed APS-2 and thyrotoxicosis. He was commenced on an insulin infusion. However, his abdominal pain persisted. Follow-up surgery confirmed CD and his abdominal pain was relieved by mesalazine. He was continued on insulin and mesalazine therapy.
CONCLUSION Immunotherapy can affect all kinds of organs. When clinical symptoms cannot be explained by a single disease, clinicians should consider the possibility of multisystem damage.
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Affiliation(s)
- Mei-Juan Gao
- Department of Endocrinology, Peking University Shougang Hospital, Beijing 100041, China
| | - Yan Xu
- Department of Endocrinology, Peking University Shougang Hospital, Beijing 100041, China
| | - Wen-Bo Wang
- Department of Endocrinology, Peking University Shougang Hospital, Beijing 100041, China
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24
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Cardona Z, Sosman JA, Chandra S, Huang W. Endocrine side effects of immune checkpoint inhibitors. Front Endocrinol (Lausanne) 2023; 14:1157805. [PMID: 37251665 PMCID: PMC10210589 DOI: 10.3389/fendo.2023.1157805] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/05/2023] [Indexed: 05/31/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have increasingly been the mainstay of treatment for numerous malignancies. However, due to their association with autoimmunity, ICIs have resulted in a variety of side effects that involve multiple organs including the endocrine system. In this review article, we describe our current understanding of the autoimmune endocrinopathies as a result of the use of ICIs. We will review the epidemiology, pathophysiology, clinical presentation, diagnosis, and management of the most commonly encountered endocrinopathies, including thyroiditis, hypophysitis, Type 1 diabetes, adrenalitis, and central diabetes insipidus.
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Affiliation(s)
- Zulma Cardona
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Jeffrey A. Sosman
- Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Sunandana Chandra
- Division of Hematology and Oncology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Wenyu Huang
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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25
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Deligiorgi MV, Trafalis DT. A Concerted Vision to Advance the Knowledge of Diabetes Mellitus Related to Immune Checkpoint Inhibitors. Int J Mol Sci 2023; 24:ijms24087630. [PMID: 37108792 PMCID: PMC10146255 DOI: 10.3390/ijms24087630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/03/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
The rubric of immune-related (ir) diabetes mellitus (DM) (irDM) encompasses various hyperglycemic disorders related to immune checkpoint inhibitors (ICPis). Beyond sharing similarities with conventional DM, irDM is a distinct, yet important, entity. The present narrative review provides a comprehensive overview of the literature regarding irDM published in major databases from January 2018 until January 2023. Initially considered rare, irDM is increasingly being reported. To advance the knowledge of irDM, the present review suggests a concerted vision comprising two intertwined aspects: a scientific-centered and a patient-centered view. The scientific-centered aspect addresses the pathophysiology of irDM, integrating: (i) ICPi-induced pancreatic islet autoimmunity in genetically predisposed patients; (ii) altered gut microbiome; (iii) involvement of exocrine pancreas; (iv) immune-related acquired generalized lipodystrophy. The patient-centered aspect is both nurtured by and nurturing the four pillars of the scientific-centered aspect: awareness, diagnosis, treatment, and monitoring of irDM. The path forward is a multidisciplinary initiative towards: (i) improved characterization of the epidemiological, clinical, and immunological profile of irDM; (ii) standardization of reporting, management, and surveillance protocols for irDM leveraging global registries; (iii) patient stratification according to personalized risk for irDM; (iv) new treatments for irDM; and (v) uncoupling ICPi efficacy from immunotoxicity.
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Affiliation(s)
- Maria V Deligiorgi
- Department of Pharmacology-Clinical Pharmacology Unit, Faculty of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Dimitrios T Trafalis
- Department of Pharmacology-Clinical Pharmacology Unit, Faculty of Medicine, National and Kapodistrian University of Athens, 11527 Athens, Greece
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26
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Kotwal A, Perlman JE, Goldner WS, Marr A, Mammen JS. Endocrine Dysfunction From Immune Checkpoint Inhibitors: Pearls and Pitfalls in Evaluation and Management. JCO Oncol Pract 2023:OP2300023. [PMID: 37023383 DOI: 10.1200/op.23.00023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Immune checkpoint inhibitors (ICPis) have proven extremely efficacious in cancer therapy but also lead to a plethora of immune-related adverse events (irAEs). The endocrine irAEs are not only quite common but also may pose a challenge to the clinician while managing a patient with cancer treated with ICPis. The clinical features of endocrine dysfunction are usually nonspecific and may overlap with concurrent illnesses, underlying the importance of accurate hormone testing and efforts toward case-finding. The management of endocrine irAEs is unique in the focus being on hormone replacement rather than curtailing the autoimmune process. Although the management of thyroid irAEs appears straightforward, adrenal insufficiency and insulin-dependent diabetes can be life-threatening if not promptly recognized and treated. This clinical review synthesizes the studies to provide pearls and pitfalls in the evaluation and management of endocrine irAEs with specific reference to guidelines from oncologic societies.
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Affiliation(s)
- Anupam Kotwal
- Division of Diabetes, Endocrinology, and Metabolism, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Jordan E Perlman
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University Medical Center, Baltimore, MD
| | - Whitney S Goldner
- Division of Diabetes, Endocrinology, and Metabolism, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Alissa Marr
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Jennifer S Mammen
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University Medical Center, Baltimore, MD
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27
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Jeun R, Iyer PC, Best C, Lavis V, Varghese JM, Yedururi S, Brady V, Glitza Oliva IC, Dadu R, Milton DR, Brock K, Thosani S. Clinical outcomes of immune checkpoint inhibitor diabetes mellitus at a comprehensive cancer center. Immunotherapy 2023; 15:417-428. [PMID: 37013834 PMCID: PMC10088048 DOI: 10.2217/imt-2021-0316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 03/06/2023] [Indexed: 04/05/2023] Open
Abstract
Introduction: Immune checkpoint inhibitor-associated diabetes mellitus (ICI-DM) is a rare adverse event. In this study, we characterize clinical outcomes of patients with ICI-DM and evaluate survival impact of this complication on melanoma patients. Research design & methods: We conducted a retrospective review of 76 patients diagnosed with ICI-DM from April 2014 to December 2020. Results: 68% of patients presented in diabetic ketoacidosis, 16% had readmissions for hyperglycemia, and hypoglycemia occurred in 70% of patients after diagnosis. Development of ICI-DM did not impact overall survival or progression-free survival in melanoma patients. Conclusion: Development of ICI-DM is associated with long-term insulin dependence and pancreatic atrophy; the use of diabetes technology in this patient population can help improve glycemic control.
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Affiliation(s)
- Rebecca Jeun
- Department of Endocrinology, Diabetes & Metabolism, Baylor College of Medicine, Houston, TX 77030, USA
| | - Priyanka C Iyer
- Department of Endocrine Neoplasia & Hormonal Disorders, Unit 1461, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Conor Best
- Department of Endocrine Neoplasia & Hormonal Disorders, Unit 1461, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Victor Lavis
- Department of Endocrine Neoplasia & Hormonal Disorders, Unit 1461, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Jeena M Varghese
- Department of Endocrine Neoplasia & Hormonal Disorders, Unit 1461, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Sireesha Yedururi
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Veronica Brady
- Department of Endocrine Neoplasia & Hormonal Disorders, Unit 1461, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Isabella C Glitza Oliva
- Department of Melanoma Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ramona Dadu
- Department of Endocrine Neoplasia & Hormonal Disorders, Unit 1461, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Denai R Milton
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Kristy Brock
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Sonali Thosani
- Department of Endocrine Neoplasia & Hormonal Disorders, Unit 1461, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
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28
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Chan JSK, Lee S, Kong D, Lakhani I, Ng K, Dee EC, Tang P, Lee YHA, Satti DI, Wong WT, Liu T, Tse G. Risk of diabetes mellitus among users of immune checkpoint inhibitors: A population-based cohort study. Cancer Med 2023; 12:8144-8153. [PMID: 36647331 PMCID: PMC10134274 DOI: 10.1002/cam4.5616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/12/2022] [Accepted: 12/28/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) are increasingly established cancer therapeutics, but they are associated with new-onset diabetes mellitus (DM). Such risks have not been adequately quantified, and between-class and -sex differences remain unexplored. METHODS This was a prospective cohort study of cancer patients receiving any ICI in Hong Kong between 2013 and 2021. Patients with known DM were excluded. Due to few patients using other ICIs, only programmed cell death 1 inhibitors (PD-1i) and programmed death ligand 1 inhibitors (PD-L1i) were compared, alongside between-sex comparison. When comparing PD-1i against PD-L1i, patients with the use of other ICIs or both PD-1i and PD-L1 were further excluded. Inverse probability treatment weighting (IPTW) was used to minimize between-group covariate imbalances. RESULTS Altogether, 3375 patients were analyzed (65.2% males, median age 62.2 [interquartile range 53.8-69.5] years old). Over a median follow-up of 1.0 [0.4-2.4] years, new-onset DM occurred in 457 patients (13.5%), with a 3-year risk of 14.5% [95% confidence interval 13.3%, 15.8%]. IPTW achieve acceptable covariate balance between sexes, and between PD-1i (N = 622) and PD-L1i (N = 2426) users. Males had significantly higher risk of new-onset DM (hazard ratio 1.35 [1.09, 1.67], p = 0.006), while PD-1i and PD-L1i users did not have significantly different risks (hazard ratio vs PD-L1i 0.81 [0.59, 1.11], p = 0.182). These were consistent in those with at least 1 year of follow-up, and on competing risk regression. CONCLUSION Users of ICI may have a substantial risk of new-onset DM, which may be higher in males but did not differ between PD-1i and PD-L1i.
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Affiliation(s)
| | - Sharen Lee
- Cardio-Oncology Research Unit, Cardiovascular Analytics Group, Hong Kong, China
| | - Dicken Kong
- Cardio-Oncology Research Unit, Cardiovascular Analytics Group, Hong Kong, China
| | - Ishan Lakhani
- Cardio-Oncology Research Unit, Cardiovascular Analytics Group, Hong Kong, China
| | - Kenrick Ng
- Department of Medical Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Edward Christopher Dee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Pias Tang
- Cardio-Oncology Research Unit, Cardiovascular Analytics Group, Hong Kong, China
| | - Yan Hiu Athena Lee
- Cardio-Oncology Research Unit, Cardiovascular Analytics Group, Hong Kong, China
| | - Danish Iltaf Satti
- Cardio-Oncology Research Unit, Cardiovascular Analytics Group, Hong Kong, China
| | - Wing Tak Wong
- School of Life Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China.,Kent and Medway Medical School, University of Kent and Canterbury Christ Church University, Canterbury, Kent, UK.,School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
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29
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Fujita Y, Kamitani F, Yamamoto M, Fukuoka H, Hirota Y, Nishiyama N, Goda N, Okada Y, Inaba Y, Nakajima H, Kurematsu Y, Kanie K, Shichi H, Urai S, Suzuki M, Yamamoto N, Bando H, Iguchi G, Suto H, Funakoshi Y, Kiyota N, Takahashi Y, Ogawa W. Combined Hypophysitis and Type 1 Diabetes Mellitus Related to Immune Checkpoint Inhibitors. J Endocr Soc 2023; 7:bvad002. [PMID: 36694808 PMCID: PMC9856268 DOI: 10.1210/jendso/bvad002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Indexed: 01/09/2023] Open
Abstract
Context The occurrence of multiple endocrinopathies due to immune checkpoint inhibitors (ICIs) is a relatively common adverse event. However, the occurrence of a combination of hypophysitis and type 1 diabetes mellitus (T1DM) is extremely rare, and its clinical features are unclear. Objective We comparatively analyzed the clinical features of this combination and each individual ICI-induced endocrinopathy. Methods We reported 3 cases that we encountered and reviewed previously reported cases of patients with combined hypophysitis and T1DM due to ICIs. Results Anti-programmed cell death-1 (anti-PD-1) antibodies were prescribed to all 3 cases. The duration from ICI initiation to the onset of endocrine disease was 12 to 48 weeks. Several human leukocyte antigen (HLA) haplotypes that have disease susceptibility to hypophysitis were detected in all 3 patients. With the 17 previously reported cases, combined endocrinopathies were more common in men (85%). The onset age was in the 60s for both combined and single endocrinopathies. Anti-PD-1 antibodies were used in most of the cases (90%). The time from ICI initiation to the onset of endocrinopathies was 24 (8-76) weeks for hypophysitis and 32 (8-76) weeks for T1DM in patients with combined endocrinopathies, which was not significantly different from that for each single endocrinopathy. Conclusion We presented 3 cases of patients with combined endocrinopathies of hypophysitis and T1DM that may have been caused by anti-PD-1 antibodies. There was no difference in the time from ICI initiation to the onset of endocrinopathies between combined and single endocrinopathies. Further case accumulation and pathogenic investigations are required.
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Affiliation(s)
| | | | - Masaaki Yamamoto
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidenori Fukuoka
- Correspondence: Hidenori Fukuoka MD, PhD, Division of Diabetes and Endocrinology, Kobe University Hospital, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe 650-0017 Japan.
| | - Yushi Hirota
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Nobuharu Nishiyama
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
| | - Naho Goda
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
| | - Yuko Okada
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
| | - Yuiko Inaba
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan
| | - Hiroki Nakajima
- Department of Diabetes and Endocrinology, Nara Medical University, Nara, Japan
| | - Yukako Kurematsu
- Department of Diabetes and Endocrinology, Nara Medical University, Nara, Japan
| | - Keitaro Kanie
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroki Shichi
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shin Urai
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masaki Suzuki
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naoki Yamamoto
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hironori Bando
- Division of Diabetes and Endocrinology, Kobe University Hospital, Kobe, Japan,Division of Development of Advanced Therapy for Metabolic Diseases, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Genzo Iguchi
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, Kobe, Japan,Medical Center for Student Health, Kobe University, Kobe, Japan,Division of Biosignal Pathophysiology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hirotaka Suto
- Division of Medical Oncology and Hematology, Kobe University Graduate School of Medicine, Kobe, Japan,Department of Medical Oncology and Hematology, Cancer Center, Kobe University Hospital, Kobe, Japan
| | - Yohei Funakoshi
- Division of Medical Oncology and Hematology, Kobe University Graduate School of Medicine, Kobe, Japan,Department of Medical Oncology and Hematology, Cancer Center, Kobe University Hospital, Kobe, Japan
| | - Naomi Kiyota
- Division of Medical Oncology and Hematology, Kobe University Graduate School of Medicine, Kobe, Japan,Department of Medical Oncology and Hematology, Cancer Center, Kobe University Hospital, Kobe, Japan
| | - Yutaka Takahashi
- Department of Diabetes and Endocrinology, Nara Medical University, Nara, Japan
| | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Kobe University Graduate School of Medicine, Kobe, Japan
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30
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Lee M, Jeong K, Park YR, Rhee Y. Increased risk of incident diabetes after therapy with immune checkpoint inhibitor compared with conventional chemotherapy: A longitudinal trajectory analysis using a tertiary care hospital database. Metabolism 2023; 138:155311. [PMID: 36122764 DOI: 10.1016/j.metabol.2022.155311] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 09/10/2022] [Accepted: 09/13/2022] [Indexed: 12/14/2022]
Abstract
AIMS/HYPOTHESIS Immune checkpoint inhibitor (ICI) has been emerged as a promising cancer treatment. However, ICI use induces immune-related adverse events, including diabetes mellitus. We compared the risk of new-onset diabetes between patients receiving an ICI and those receiving conventional chemotherapy (CC). METHODS Using a tertiary care hospital database, we included cancer patients without a previous history of diabetes who were treated with either CC or an ICI. One-to-five nearest neighbor propensity matching was applied, and the risk of diabetes was estimated using a Cox proportional hazards model. Latent class growth modeling was performed with a trajectory approach to determine distinct clusters that followed similar glucose trajectory patterns over time. RESULTS Among 1326 subjects, 1105 received CC, and 221 received an ICI. The risk of new-onset diabetes was significantly higher in the ICI group than the CC group (adjusted hazard ratio 2.454, 95 % confidence interval 1.528-3.940; p < 0.001). The ICI group had a higher proportion of subjects in the trajectory cluster with an increasing glucose pattern than the CC group (10.4 % and 7.4 %, respectively). Within the ICI group, the subjects with an increasing glucose pattern were predominantly male and associated with enhanced lymphocytosis after ICI administration. CONCLUSIONS ICI therapy is associated with an increased risk of incident diabetes compared with CC. The glucose levels of patients treated with an ICI, especially males and those with prominent lymphocytosis after ICI treatment, need to be monitored regularly to detect ICI-associated diabetes as early as possible.
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Affiliation(s)
- Minyoung Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyeongseob Jeong
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yu Rang Park
- Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Yumie Rhee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Institute of Endocrine Research, Yonsei University College of Medicine, Seoul, Republic of Korea.
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31
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Spagnolo CC, Giuffrida G, Cannavò S, Franchina T, Silvestris N, Ruggeri RM, Santarpia M. Management of Endocrine and Metabolic Toxicities of Immune-Checkpoint Inhibitors: From Clinical Studies to a Real-Life Scenario. Cancers (Basel) 2022; 15:cancers15010246. [PMID: 36612243 PMCID: PMC9818218 DOI: 10.3390/cancers15010246] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/22/2022] [Accepted: 12/24/2022] [Indexed: 01/03/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have revolutionized the therapeutic landscape of solid tumors. However, although ICIs are better tolerated than conventional chemotherapy, their use is associated with a peculiar toxicity profile, related to the enhancement of the immune response, affecting several organs. Among immune-related adverse events (irAEs), up to 10% involve the endocrine system. Most of them are represented by thyroid disorders (hypothyroidism and hyperthyroidism), mainly correlated to the use of anti-PD-1 and/or anti-PD-L1 agents. Less common endocrine irAEs include hypophysitis, adrenalitis, and metabolic irAEs. A deeper understanding of endocrine toxicities is a critical goal for both oncologists and endocrinologists. A strict collaboration between these specialists is mandatory for early recognition and proper treatment of these patients. In this review we will provide a comprehensive overview of endocrine and metabolic adverse events of ICIs, with particular interest in the pathogenesis, predisposing factors and clinical presentation of these irAEs, and their impact on clinical outcomes of patients. Furthermore, we will summarize the most recent studies and recommendations on the clinical approach to immune-related endocrinopathies with the purpose to optimize the diagnostic algorithm, and to help both oncologists and endocrinologists to improve the therapeutic management of these unique types of irAEs, in a real-life scenario.
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Affiliation(s)
- Calogera Claudia Spagnolo
- Medical Oncology Unit, Department of Human Pathology “G.Barresi”, University of Messina, 98125 Messina, Italy
| | - Giuseppe Giuffrida
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV, University of Messina, 98125 Messina, Italy
| | - Salvatore Cannavò
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV, University of Messina, 98125 Messina, Italy
| | - Tindara Franchina
- Medical Oncology Unit, Department of Human Pathology “G.Barresi”, University of Messina, 98125 Messina, Italy
| | - Nicola Silvestris
- Medical Oncology Unit, Department of Human Pathology “G.Barresi”, University of Messina, 98125 Messina, Italy
| | - Rosaria Maddalena Ruggeri
- Endocrinology Unit, Department of Human Pathology of Adulthood and Childhood DETEV, University of Messina, 98125 Messina, Italy
| | - Mariacarmela Santarpia
- Medical Oncology Unit, Department of Human Pathology “G.Barresi”, University of Messina, 98125 Messina, Italy
- Correspondence:
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32
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Wright JJ, Johnson DB. APPROACH TO THE PATIENT WITH IMMUNE CHECKPOINT INHIBITOR-ASSOCIATED ENDOCRINE DYSFUNCTION. J Clin Endocrinol Metab 2022; 108:1514-1525. [PMID: 36481794 PMCID: PMC10188314 DOI: 10.1210/clinem/dgac689] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
Immune checkpoint inhibitors (ICI) are cancer therapies that are approved in at least 19 different cancers. They function by stimulating immune cell responses against cancer, and their toxicities comprise a host of autoinflammatory syndromes that may impact any organ system. Endocrine toxicities occur in as high as 25-50% of ICI recipients, depending on the treatment regimen used. These toxicities vary in severity from mild, asymptomatic cases of subclinical hypothyroidism to severe, fatal cases of adrenal crisis, thyroid dysfunction, or diabetic ketoacidosis. Thus, timely recognition and treatment is critical. Herein, we present clinical cases of ICI-induced thyroid dysfunction, hypophysitis, and insulin-dependent diabetes mellitus. We use these cases to discuss the screening, diagnosis, and management of ICI-associated endocrine dysfunction.
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Affiliation(s)
- Jordan J Wright
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Douglas B Johnson
- Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
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33
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Husebye ES, Castinetti F, Criseno S, Curigliano G, Decallonne B, Fleseriu M, Higham CE, Lupi I, Paschou SA, Toth M, van der Kooij M, Dekkers OM. Endocrine-related adverse conditions in patients receiving immune checkpoint inhibition: an ESE clinical practice guideline. Eur J Endocrinol 2022; 187:G1-G21. [PMID: 36149449 PMCID: PMC9641795 DOI: 10.1530/eje-22-0689] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022]
Abstract
Immune checkpoint inhibitors (ICI) have revolutionized cancer treatment but are associated with significant autoimmune endocrinopathies that pose both diagnostic and treatment challenges. The aim of this guideline is to provide clinicians with the best possible evidence-based recommendations for treatment and follow-up of patients with ICI-induced endocrine side-effects based on the Grading of Recommendations Assessment, Development, and Evaluation system. As these drugs have been used for a relatively short time, large systematic investigations are scarce. A systematic approach to diagnosis, treatment, and follow-up is needed, including baseline tests of endocrine function before each treatment cycle. We conclude that there is no clear evidence for the benefit of high-dose glucocorticoids to treat endocrine toxicities with the possible exceptions of severe thyroid eye disease and hypophysitis affecting the visual apparatus. With the exception of thyroiditis, most endocrine dysfunctions appear to be permanent regardless of ICI discontinuation. Thus, the development of endocrinopathies does not dictate a need to stop ICI treatment.
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Affiliation(s)
- Eystein S Husebye
- Department of Clinical Science and K.G. Jebsen Center of Autoimmune Diseases, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Correspondence should be addressed to E S Husebye;
| | - Frederik Castinetti
- Aix Marseille Univ, INSERM U1251, Marseille Medical genetics, Department of Endocrinology, Assistance Publique-Hopitaux de Marseille, 13005 Marseille, France
| | - Sherwin Criseno
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Giuseppe Curigliano
- Department of Oncology and Hematology, University of Milan, European Institute of Oncology, IRCCS, Milan, Italy
| | | | - Maria Fleseriu
- Pituitary Center, Department of Medicine and Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Claire E Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, University of Manchester, Manchester, UK
| | - Isabella Lupi
- Endocrine Unit, Pisa University Hospital, Pisa, Italy
| | - Stavroula A Paschou
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Miklos Toth
- Department of Internal Medicine and Oncology, ENETS Center of Excellence, Faculty of Medicine, Semmelweis University, Budapest, Hungary
| | | | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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Qiu J, Luo S, Yin W, Guo K, Xiang Y, Li X, Liu Z, Zhou Z. Characterization of immune checkpoint inhibitor-associated fulminant type 1 diabetes associated with autoantibody status and ethnic origin. Front Immunol 2022; 13:968798. [PMID: 36451831 PMCID: PMC9702060 DOI: 10.3389/fimmu.2022.968798] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/07/2022] [Indexed: 12/05/2023] Open
Abstract
OBJECTIVE Fulminant type 1 diabetes may uniquely occur as a fatal adverse event during immune checkpoint inhibitor (ICI) therapy. We investigated the clinical and immunological characteristics of ICI-associated fulminant type 1 diabetes (IFD). RESEARCH DESIGN AND METHODS We enrolled 80 patients with IFD (77 cases from the literature), 56 patients with ICI-associated type 1 diabetes (IT1D) (55 cases from the literature), 45 patients with traditional fulminant type 1 diabetes (TFD), and 43 patients with acute-onset type 1 diabetes for comprehensive analysis including islet autoantibodies and subgroup analysis based on ethnic origin. RESULTS Patients with IFD accounted for 58.8% (80/136) of patients with ICI-related diabetes. IFD had a more rapid onset than IT1D after ICI therapy (90.5 days vs. 120 days, p <0.05). The onset time and number of infusions after ICI therapy initiation were lower in the antibody-positive IFD group than that in the antibody-negative IFD group (both p <0.001). IFD had a more rapid onset and more serious among Caucasians than that among Asians (p <0.01, p <0.05, respectively), and the prevalence of islet autoantibody positivity in the Caucasian IFD were prominently higher than those in the Asian IFD (p <0.05). Onset age and plasma glucose levels were significantly higher in the IFD group than those in the TFD and acute-onset type 1 diabetes groups. HbA1c levels were slightly higher in patients with IFD than those with TFD. CONCLUSIONS IFD is relatively common in Caucasian population where TFD is very rare or almost absent. IFD occurrence is significantly related to islet autoantibody status and ethnic origin.
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Affiliation(s)
- Junlin Qiu
- Department of Metabolism and Endocrinology, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Shuoming Luo
- Department of Metabolism and Endocrinology, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Wenfeng Yin
- Department of Metabolism and Endocrinology, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Keyu Guo
- Department of Metabolism and Endocrinology, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Yufei Xiang
- Department of Metabolism and Endocrinology, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Xia Li
- Department of Metabolism and Endocrinology, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Zhenqi Liu
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville, VA, United States
| | - Zhiguang Zhou
- Department of Metabolism and Endocrinology, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital of Central South University, Changsha, China
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Phang CA, Kumar S, Rohl P. Acute presentation of immunotherapy-related diabetes mellitus without ketoacidosis, low C-peptide or elevated HbA1c. Endocrinol Diabetes Metab Case Rep 2022; 2022:22-0291. [PMID: 36448841 PMCID: PMC9716361 DOI: 10.1530/edm-22-0291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/11/2022] [Indexed: 11/07/2023] Open
Abstract
Summary The rapid rise in the use of immune checkpoint inhibitors as systemic cancer therapy has seen the emergence of immunotherapy-induced diabetes, a severe irreversible immunotherapy-related adverse event. Affected patients typically present with diabetic ketoacidosis (DKA) and low C-peptide consistent with insulin deficiency secondary to autoimmune β-cell destruction. We present the unusual case of a 61-year-old female with metastatic ampullary duodenal adenocarcinoma with primary tumour adjacent to the pancreatic head. She was commenced on immunotherapy after conventional systemic chemotherapy. Acute-onset hyperglycaemia was detected after 7 weeks on weekly blood glucose monitoring, with no glucocorticoid use or prior history of diabetes. On presentation, there was no evidence of DKA, and her glycated haemoglobin level was within the normal non-diabetic range at 5.3%, reflecting the acuity of her presentation. Initial serum C-peptide was preserved; however, it became undetectable a few weeks later, confirming insulin deficiency. We describe a case of atypical presentation of immunotherapy-induced diabetes, review the existing literature on this emerging clinical entity and discuss the differential diagnosis for new-onset diabetes mellitus in patients with metastatic cancer. Learning points Regular proactive glycaemic monitoring in patients receiving immunotherapy, particularly antibodies against programmed death ligand 1 and PD1, can facilitate very early detection of immunotherapy-induced diabetes, prompting insulin commencement and avoiding life-threatening presentations of diabetic ketoacidosis. Glycated haemoglobin can be within the normal range in patients diagnosed acutely with immunotherapy-induced diabetes. Serum C-peptide can be preserved initially in patients diagnosed with immunotherapy-induced diabetes but is likely to become undetectable during their illness. New-onset diabetes in patients with metastatic cancer carries a broad differential diagnosis.
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Affiliation(s)
- Cun An Phang
- Cun An PHANG Medical Student, University of New South Wales, Sydney, Australia
| | - Shejil Kumar
- Shejil KUMAR Endocrinology Advanced Trainee, St George Hospital, Sydney, Australia
| | - Peter Rohl
- Peter ROHL Staff Specialist in Endocrinology, St George Hospital, Sydney, Australia
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Perdigoto AL, Deng S, Du KC, Kuchroo M, Burkhardt DB, Tong A, Israel G, Robert ME, Weisberg SP, Kirkiles-Smith N, Stamatouli AM, Kluger HM, Quandt Z, Young A, Yang ML, Mamula MJ, Pober JS, Anderson MS, Krishnaswamy S, Herold KC. Immune cells and their inflammatory mediators modify β cells and cause checkpoint inhibitor-induced diabetes. JCI Insight 2022; 7:e156330. [PMID: 35925682 PMCID: PMC9536276 DOI: 10.1172/jci.insight.156330] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 07/28/2022] [Indexed: 11/17/2022] Open
Abstract
Checkpoint inhibitors (CPIs) targeting programmed death 1 (PD-1)/programmed death ligand 1 (PD-L1) and cytotoxic T lymphocyte antigen 4 (CTLA-4) have revolutionized cancer treatment but can trigger autoimmune complications, including CPI-induced diabetes mellitus (CPI-DM), which occurs preferentially with PD-1 blockade. We found evidence of pancreatic inflammation in patients with CPI-DM with shrinkage of pancreases, increased pancreatic enzymes, and in a case from a patient who died with CPI-DM, peri-islet lymphocytic infiltration. In the NOD mouse model, anti-PD-L1 but not anti-CTLA-4 induced diabetes rapidly. RNA sequencing revealed that cytolytic IFN-γ+CD8+ T cells infiltrated islets with anti-PD-L1. Changes in β cells were predominantly driven by IFN-γ and TNF-α and included induction of a potentially novel β cell population with transcriptional changes suggesting dedifferentiation. IFN-γ increased checkpoint ligand expression and activated apoptosis pathways in human β cells in vitro. Treatment with anti-IFN-γ and anti-TNF-α prevented CPI-DM in anti-PD-L1-treated NOD mice. CPIs targeting the PD-1/PD-L1 pathway resulted in transcriptional changes in β cells and immune infiltrates that may lead to the development of diabetes. Inhibition of inflammatory cytokines can prevent CPI-DM, suggesting a strategy for clinical application to prevent this complication.
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Affiliation(s)
| | | | | | | | | | | | - Gary Israel
- Department of Radiology and Biomedical Imaging, and
| | - Marie E. Robert
- Department of Pathology, Yale University, New Haven, Connecticut, USA
| | - Stuart P. Weisberg
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | | | - Angeliki M. Stamatouli
- Division of Endocrinology, Diabetes, and Metabolism, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | | | - Zoe Quandt
- Department of Medicine and
- Diabetes Center, University of California, San Francisco, San Francisco, California, USA
| | - Arabella Young
- Diabetes Center, University of California, San Francisco, San Francisco, California, USA
- Huntsman Cancer Institute, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | | | | | - Mark S. Anderson
- Department of Medicine and
- Diabetes Center, University of California, San Francisco, San Francisco, California, USA
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Hino C, Nishino K, Pham B, Jeon WJ, Nguyen M, Cao H. Nivolumab plus ipilimumab induced endocrinopathy and acute interstitial nephritis in metastatic sarcomatoid renal-cell carcinoma: A case report and review of literature. Front Immunol 2022; 13:993622. [PMID: 36052087 PMCID: PMC9425087 DOI: 10.3389/fimmu.2022.993622] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 07/28/2022] [Indexed: 11/13/2022] Open
Abstract
The prognosis of sarcomatoid renal cell carcinoma has changed dramatically with the emergence of immune checkpoint inhibitors. Notably the use of nivolumab and ipilimumab combination therapy has demonstrated promising durable therapeutic response for patients with treatment-naïve sarcomatoid renal-cell carcinoma. We present a case of 45-year-old man with a history of metastatic sarcomatoid renal cell carcinoma treated with nivolumab plus ipilimumab who developed type 1 diabetes mellitus, adrenal insufficiency, thyroiditis/hypothyroidism, and acute interstitial nephritis as a result of immunotherapy.
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Affiliation(s)
- Christopher Hino
- Department of Internal Medicine, Department of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Kevin Nishino
- Department of Internal Medicine, Department of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Bryan Pham
- Department of Internal Medicine, Department of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Won Jin Jeon
- Department of Internal Medicine, Department of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Michael Nguyen
- Department of Oncology/Hematology, Department of Medicine, Loma Linda University, Loma Linda, CA, United States
| | - Huynh Cao
- Department of Oncology/Hematology, Department of Medicine, Loma Linda University, Loma Linda, CA, United States
- *Correspondence: Huynh Cao,
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Lin C, Li X, Qiu Y, Chen Z, Liu J. PD-1 inhibitor-associated type 1 diabetes: A case report and systematic review. Front Public Health 2022; 10:885001. [PMID: 35991054 PMCID: PMC9389003 DOI: 10.3389/fpubh.2022.885001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 07/22/2022] [Indexed: 12/01/2022] Open
Abstract
Objective This study aimed to summarize the clinical characteristics of programmed death receptor 1 (PD-1) inhibitor-associated type 1 diabetes so as to improve the ability of clinicians to correctly diagnose and treat it. Methods We reported a case of a 70-year-old woman with gastric cancer who developed hyperosmolar hyperglycemic coma during camrelizumab (a PD-1 inhibitor) treatment and was diagnosed with PD-1 inhibitor-associated type 1 diabetes. We conducted a systematic review of 74 case reports of type 1 diabetes associated with PD-1 inhibitor therapy published before June 2022. Results The patient developed type 1 diabetes with hyperosmolar hyperglycemic coma after receiving camrelizumab chemotherapy for 6 months (9 cycles). We searched 69 English articles comprising 75 patients, all of whom had been treated with a PD-1 inhibitor (nivolumab or pembrolizumab) and progressed to diabetes after an average of 6.11 (1–28) cycles. Nivolumab combined with ipilimumab (a cytotoxic T lymphocyte-associated protein 4 inhibitor) had the shortest onset (4.47 cycles on average). A total of 76% (57/75) of patients developed diabetic ketoacidosis (DKA) at onset, and 50.67% (38/75) of patients had C-peptide <0.1 ng/mL. Most of the patients were tested for insulin autoantibodies, with a positive rate of 33.33% (23/69); of these, 86.96% (20/23) were tested for glutamate decarboxylase antibody and 46.67% (35/75) were tested for human leukocyte antigen (HLA). HLA-DR4 was the most common type. Conclusions The progression of type 1 diabetes induced by PD-1 inhibitors is relatively rapid. Islet failure often occurs when detected, seriously endangering patients' lives. Patients treated with PD-1 inhibitors should closely monitor their plasma glucose level during treatment to detect, diagnose, and treat diabetes on time.
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39
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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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Kawada-Horitani E, Kita S, Okita T, Nakamura Y, Nishida H, Honma Y, Fukuda S, Tsugawa-Shimizu Y, Kozawa J, Sakaue T, Kawachi Y, Fujishima Y, Nishizawa H, Azuma M, Maeda N, Shimomura I. Human adipose-derived mesenchymal stem cells prevent type 1 diabetes induced by immune checkpoint blockade. Diabetologia 2022; 65:1185-1197. [PMID: 35511238 PMCID: PMC9174328 DOI: 10.1007/s00125-022-05708-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 02/08/2022] [Indexed: 11/21/2022]
Abstract
AIMS/HYPOTHESIS Immunomodulators blocking cytotoxic T-lymphocyte-associated protein 4 (CTLA-4) and programmed cell death protein 1 (PD-1) or programmed death-ligand 1 (PD-L1) have improved the treatment of a broad spectrum of cancers. These immune checkpoint inhibitors (ICIs) reactivate the immune system against tumour cells but can also trigger autoimmune side effects, including type 1 diabetes. Mesenchymal stem cell (MSC) therapy is the most prevalent cell therapy, with tissue-regenerating, anti-fibrosis and immunomodulatory functions provided by the secretome of the cells. Here, we examined whether systemic MSC treatment could prevent the development of type 1 diabetes in a NOD mouse model. METHODS The purified PD-L1 monoclonal antibody was administered to induce diabetes in male NOD mice which normally do not develop diabetes. Human adipose-derived MSCs were administered by tail vein injections. T cells, macrophages and monocyte-derived macrophages expressing C-X-C motif chemokine ligand 9 (CXCL9) in pancreatic sections of NOD mice and a cancer patient who developed diabetes following the ICI treatments were analysed by immunofluorescence. Tissue localisation of the injected MSCs, plasma exosome levels and plasma cytokine profiles were also investigated. RESULTS PD-1/PD-L1 blockade induced diabetes in 16 of 25 (64%) NOD mice which received anti-PD-L1 mAb without hMSCs [MSC(-)], whereas MSC administration decreased the incidence to four of 21 (19%) NOD mice which received anti-PD-L1 mAb and hMSCs [MSC(+)]. The PD-1/PD-L1 blockade significantly increased the area of CD3-positive T cells (6.2-fold) and macrophage-2 (Mac-2) antigen (2.5-fold)- and CXCL9 (40.3-fold)-positive macrophages in the islets. MSCs significantly reduced T cell (45%) and CXCL9-positive macrophage (67%) accumulation in the islets and the occurrence of diabetes. The insulin content (1.9-fold) and islet beta cell area (2.7-fold) were also improved by MSCs. T cells and CXCL9-positive macrophages infiltrated into the intricate gaps between the beta cells in the islets by PD-1/PD-L1 blockade. Such immune cell infiltration was largely prevented by MSCs. The most striking difference was observed in the CXCL9-positive macrophages, which normally did not reside in the beta cell region in the islets but abundantly accumulated in this area after PD-1/PD-L1 blockade and were prevented by MSCs. The CXCL9-positive macrophages were also observed in the islets of a cancer patient who developed diabetes following the administration of ICIs but few CXCL9-positive macrophages were observed in a control patient. Mechanistically, the injected MSCs accumulated in the lung but not in the pancreas and strongly increased plasma exosome levels and changed plasma cytokine profiles. CONCLUSIONS/INTERPRETATION Our results suggest that MSCs can prevent the incidence of diabetes associated with immune checkpoint cancer therapy and may be worth further consideration for new adjuvant cell therapy.
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Affiliation(s)
- Emi Kawada-Horitani
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Shunbun Kita
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan.
- Department of Adipose Management, Graduate School of Medicine, Osaka University, Osaka, Japan.
| | - Tomonori Okita
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yuto Nakamura
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | | | | | - Shiro Fukuda
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yuri Tsugawa-Shimizu
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Junji Kozawa
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
- Department of Diabetes Care Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Takaaki Sakaue
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yusuke Kawachi
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Yuya Fujishima
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Hitoshi Nishizawa
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Miyuki Azuma
- Department of Molecular Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Norikazu Maeda
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
- Department of Metabolism and Atherosclerosis, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Iichiro Shimomura
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
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Labadzhyan A, Wentzel K, Hamid O, Chow K, Kim S, Piro L, Melmed S. Endocrine Autoantibodies Determine Immune Checkpoint Inhibitor-induced Endocrinopathy: A Prospective Study. J Clin Endocrinol Metab 2022; 107:1976-1982. [PMID: 35303106 PMCID: PMC9202695 DOI: 10.1210/clinem/dgac161] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Indexed: 12/18/2022]
Abstract
CONTEXT Incidence and awareness of endocrine-related adverse events (ERAE) associated with use of immune checkpoint inhibitors (ICI) has grown with increased ICI use, yet mechanisms for ERAE prediction, surveillance, and development are not well established. OBJECTIVE We prospectively evaluated the impact of endocrine autoimmunity on ERAE development and overall survival (OS). METHODS Adults ≥ 18 years of age prescribed ICI treatment for advanced or metastatic solid tumors and no known active/past endocrine disorders were eligible for enrollment. Thyroid, adrenal, and pancreatic antibodies as well as hormone levels were assessed prior to ICI treatment and at 8 to 9 weeks and 36 weeks after treatment for ERAE in relation to presence and changes in endocrine-specific antibodies, hormone levels, and OS. RESULTS Sixty patients were enrolled and ERAE were detected in 14 (23.3%), with a median onset of 52 days (IQR, 38.5-71.5) after first ICI dose. Hypothyroidism occurred in 12 (20%) patients, and 2 (3.33%) patients developed hypophysitis. Diabetes and primary adrenal insufficiency were not observed. Antibodies were detected in 14 patients (11 at baseline, 3 developed during follow-up) and their presence was significantly associated with ERAE (R2 59.3%, P < 0.001). Thyroid peroxidase antibody (20%) and thyroid-stimulating immunoglobulin (3.3%) were most common, and anti-GAD was present in 1 patient. The presence of ERAE was associated with a more favorable OS (P = 0.001). CONCLUSION Endocrine-specific autoantibodies play an important role in ERAE pathogenesis and may serve as predictive markers for early identification and treatment of ICI-induced endocrinopathies.
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Affiliation(s)
- Artak Labadzhyan
- Correspondence: Artak Labadzhyan, MD, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, Suite A6600, Los Angeles, CA 90048, USA.
| | - Kristopher Wentzel
- The Angeles Clinic and Research Institute, A Cedars-Sinai Affiliate, Los Angeles, CA, USA
| | - Omid Hamid
- The Angeles Clinic and Research Institute, A Cedars-Sinai Affiliate, Los Angeles, CA, USA
| | - Kamlynn Chow
- The Angeles Clinic and Research Institute, A Cedars-Sinai Affiliate, Los Angeles, CA, USA
| | - Sungjin Kim
- Biostatistics and Bioinformatics Core, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Lawrence Piro
- The Angeles Clinic and Research Institute, A Cedars-Sinai Affiliate, Los Angeles, CA, USA
| | - Shlomo Melmed
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Diabetes mellitus associated to treatment with inmunitary checkpoint inhibitors. Med Clin (Barc) 2022; 159:e19-e20. [PMID: 35659419 DOI: 10.1016/j.medcli.2022.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/03/2022] [Accepted: 02/08/2022] [Indexed: 11/21/2022]
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Chen X, Affinati AH, Lee Y, Turcu AF, Henry NL, Schiopu E, Qin A, Othus M, Clauw D, Ramnath N, Zhao L. Immune Checkpoint Inhibitors and Risk of Type 1 Diabetes. Diabetes Care 2022; 45:1170-1176. [PMID: 35238899 PMCID: PMC9174959 DOI: 10.2337/dc21-2213] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 02/05/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Type 1 diabetes mellitus (T1DM) is a rare, irreversible immune-related adverse event reported in patients receiving treatment with immune checkpoint inhibitors (ICI). However, clinical risk factors for ICI-induced T1DM (ICI-T1DM) and its impact on survival in patients remain unknown. RESEARCH DESIGN AND METHODS We used Optum's Clinformatics Data Mart database for assessment of the incidence and characteristics of T1DM in a large de-identified cohort of patients treated with ICI between 2017 and 2020. We applied Fine-Gray and cause-specific hazard models to study associations between patient/treatment characteristics and ICI-T1DM and applied the Cox model with ICI-T1DM as a time-varying covariate to assess the impact of ICI-T1DM on survival. RESULTS ICI-T1DM was observed in 261 of 30,337 (0.86%) patients. Dual use of antibodies to cytotoxic T lymphocyte antigen 4 (CTLA-4) and programmed cell death 1 (PD-1) or programmed cell death ligand 1 (PD-L1) was associated with increasing risk of ICI-T1DM (hazard ratio [HR] 1.62; 95% CI 1.15-2.26) vs. anti-PD-L1 or anti-PD-1 alone. Younger age (HR 1.19 for every 5-year decrease; 95% CI 1.13-1.25) and preexisting non-T1DM diabetes (HR 4.48; 95% CI 3.45-5.83) were also associated with higher risk of ICI-T1DM. Conversely, prior use of immunosuppressive medications (HR 0.57; 95% CI 0.34-0.95) was associated with lower incidence of ICI-T1DM, but part of its protective effect may be due to the increased mortality rate. Development of ICI-T1DM does not seem to significantly impact patient survival. CONCLUSIONS The risk of ICI-T1DM is associated with the type of ICI therapy, patient age, and preexisting non-T1DM diabetes. These data may help guide risk assessment and screening practices for patients during ICI therapy.
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Affiliation(s)
- Xuan Chen
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Alison H. Affinati
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI
| | - Yungchun Lee
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Adina F. Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI
| | - Norah Lynn Henry
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Elena Schiopu
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Angel Qin
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Megan Othus
- Biostatistics and Biomathematics Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Ann Arbor, MI
| | - Dan Clauw
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Nithya Ramnath
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI
| | - Lili Zhao
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
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Johnson DB, Nebhan CA, Moslehi JJ, Balko JM. Immune-checkpoint inhibitors: long-term implications of toxicity. Nat Rev Clin Oncol 2022; 19:254-267. [PMID: 35082367 PMCID: PMC8790946 DOI: 10.1038/s41571-022-00600-w] [Citation(s) in RCA: 387] [Impact Index Per Article: 193.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 12/15/2022]
Abstract
The development of immune-checkpoint inhibitors (ICIs) has heralded a new era in cancer treatment, enabling the possibility of long-term survival in patients with metastatic disease, and providing new therapeutic indications in earlier-stage settings. As such, characterizing the long-term implications of receiving ICIs has grown in importance. An abundance of evidence exists describing the acute clinical toxicities of these agents, although chronic effects have not been as well catalogued. Nonetheless, emerging evidence indicates that persistent toxicities might be more common than initially suggested. While generally low-grade, these chronic sequelae can affect the endocrine, rheumatological, pulmonary, neurological and other organ systems. Fatal toxicities also comprise a diverse set of clinical manifestations and can occur in 0.4-1.2% of patients. This risk is a particularly relevant consideration in light of the possibility of long-term survival. Finally, the effects of immune-checkpoint blockade on a diverse range of immune processes, including atherosclerosis, heart failure, neuroinflammation, obesity and hypertension, have not been characterized but remain an important area of research with potential relevance to cancer survivors. In this Review, we describe the current evidence for chronic immune toxicities and the long-term implications of these effects for patients receiving ICIs.
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Affiliation(s)
- Douglas B Johnson
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA.
| | - Caroline A Nebhan
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA
| | - Javid J Moslehi
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Justin M Balko
- Department of Medicine, Vanderbilt University Medical Center and Vanderbilt Ingram Cancer Center, Nashville, TN, USA
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Wing JR, Kimball A, Rengarajan M. Case 6-2022: A 68-Year-Old Man with Fatigue, Weight Loss, and Hyperglycemia. N Engl J Med 2022; 386:781-787. [PMID: 35196431 DOI: 10.1056/nejmcpc2115848] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Jonathan R Wing
- From the Department of Medicine, Massachusetts General Hospital, and the Department of Medicine, Harvard Medical School - both in Boston
| | - Allison Kimball
- From the Department of Medicine, Massachusetts General Hospital, and the Department of Medicine, Harvard Medical School - both in Boston
| | - Michelle Rengarajan
- From the Department of Medicine, Massachusetts General Hospital, and the Department of Medicine, Harvard Medical School - both in Boston
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Inaba H, Kaido Y, Ito S, Hirobata T, Inoue G, Sugita T, Yamamoto Y, Jinnin M, Kimura H, Kobayashi T, Iwama S, Arima H, Matsuoka T. Human Leukocyte Antigens and Biomarkers in Type 1 Diabetes Mellitus Induced by Immune-Checkpoint Inhibitors. Endocrinol Metab (Seoul) 2022; 37:84-95. [PMID: 35255603 PMCID: PMC8901959 DOI: 10.3803/enm.2021.1282] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/27/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Type 1 diabetes mellitus induced by immune-checkpoint inhibitors (ICI-T1DM) is a rare critical entity. However, the etiology of ICI-T1DM remains unclear. METHODS In order to elucidate risk factors for ICI-T1DM, we evaluated the clinical course and immunological status of patients with ICI-T1DM who had been diagnosed during 2016 to 2021. RESULTS Seven of 871 (0.8%, six men and one woman) patients developed ICI-T1DM. We revealed that the allele frequencies of human leukocyte antigen (HLA)-DPA1*02:02 and DPB1*05:01 were significantly higher in the patients with ICI-T1DM In comparison to the controls who received ICI (11/14 vs. 10/26, P=0.022; 11/14 vs. 7/26, P=0.0027, respectively). HLA-DRB1*04:05, which has been found to be a T1DM susceptibility allele in Asians, was also observed as a high-risk allele for ICI-T1DM. The significance of the HLA-DPB1*05:01 and DRB1*04:05 alleles was confirmed by an analysis of four additional patients. The absolute/relative neutrophil count, neutrophils-lymphocyte ratio, and neutrophil-eosinophil ratio increased, and the absolute lymphocyte count and absolute/relative eosinophil count decreased at the onset as compared with 6 weeks before. In two patients, alterations in cytokines and chemokines were found at the onset. CONCLUSION Novel high-risk HLA alleles and haplotypes were identified in ICI-T1DM, and peripheral blood factors may be utilized as biomarkers.
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Affiliation(s)
- Hidefumi Inaba
- Department of Diabetes and Endocrinology, Japanese Red Cross Wakayama Medical Center, Wakayama,
Japan
- The First Department of Medicine, Wakayama Medical University, Wakayama,
Japan
| | - Yosuke Kaido
- Department of Diabetes and Endocrinology, Japanese Red Cross Wakayama Medical Center, Wakayama,
Japan
| | - Saya Ito
- Department of Diabetes and Endocrinology, Japanese Red Cross Wakayama Medical Center, Wakayama,
Japan
| | - Tomonao Hirobata
- Department of Diabetes and Endocrinology, Japanese Red Cross Wakayama Medical Center, Wakayama,
Japan
| | - Gen Inoue
- Department of Diabetes and Endocrinology, Japanese Red Cross Wakayama Medical Center, Wakayama,
Japan
| | - Takakazu Sugita
- Department of Respiratory Medicine, Japanese Red Cross Wakayama Medical Center, Wakayama,
Japan
| | - Yuki Yamamoto
- Department of Dermatology, Wakayama Medical University, Wakayama,
Japan
| | - Masatoshi Jinnin
- Department of Dermatology, Wakayama Medical University, Wakayama,
Japan
| | - Hiroaki Kimura
- Department of Pharmaceutical Health Sciences, Kyushu University of Health and Welfare, Nobeoka,
Japan
| | - Tomoko Kobayashi
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya,
Japan
| | - Shintaro Iwama
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya,
Japan
| | - Hiroshi Arima
- Department of Endocrinology and Diabetes, Nagoya University Graduate School of Medicine, Nagoya,
Japan
| | - Takaaki Matsuoka
- The First Department of Medicine, Wakayama Medical University, Wakayama,
Japan
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Zand Irani A, Almuwais A, Gibbons H. Immune checkpoint inhibitor-induced diabetes mellitus with pembrolizumab. BMJ Case Rep 2022; 15:15/1/e245846. [PMID: 35039353 PMCID: PMC8768469 DOI: 10.1136/bcr-2021-245846] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
An 81-year-old woman with a background of metastatic melanoma on pembrolizumab with no history of diabetes was brought into the emergency department with polyuria, polydipsia and weight loss. The initial assessment was consistent with severe diabetic ketoacidosis (DKA) and prerenal acute kidney injury with no clinical evidence of infection. The patient was treated with fluid resuscitation and an insulin infusion and eventually transitioned to a basal-bolus insulin regime, which was continued after discharge. Diabetes autoantibody screen returned negative, and she was diagnosed with immune checkpoint inhibitor–induced diabetes mellitus (ICI-induced DM) due to pembrolizumab. The patient has clinically improved and pembrolizumab was continued. The aim of this report is to highlight the importance of recognising ICI-induced DM as a rare immune-related adverse event in patients receiving programmed cell death protein 1/programmed cell death protein-ligand 1 inhibitor therapy and provide clinicians with insight into immune checkpoint endocrinopathies with an emphasis on diabetes and DKA.
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Affiliation(s)
- Anis Zand Irani
- Endocrinology, Gympie Hospital, Gympie, Queensland, Australia
| | - Ahmed Almuwais
- Medicine, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Holly Gibbons
- Medicine, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
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Rodríguez de Vera-Gómez P, Piñar-Gutiérrez A, Guerrero-Vázquez R, Bellido V, Morales-Portillo C, Sancho-Márquez MP, Espejo-García P, Gros-Herguido N, López-Gallardo G, Martínez-Brocca MA, Soto-Moreno A. Flash Glucose Monitoring and Diabetes Mellitus Induced by Immune Checkpoint Inhibitors: An Approach to Clinical Practice. J Diabetes Res 2022; 2022:4508633. [PMID: 36387939 PMCID: PMC9652069 DOI: 10.1155/2022/4508633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/01/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES The aim of this study is to investigate in depth diabetes mellitus associated with immune checkpoint inhibitors (DM-ICIs) by analysing a case series. We also evaluated the clinical impact of flash glucose monitoring (FGM) systems in the management of this entity. METHODS We conducted an observational cohort study of DM-ICIs diagnosed in two hospitals in Seville (Spain). Patients with a new diagnosis of diabetes mellitus (DM) or with sudden worsening of preexisting DM after starting treatment with ICIs, with a random 5 hour-postprandial C-peptide value of <0.6 nmol/L and without possibility of subsequent withdrawal of insulin treatment, were included. RESULTS A total of 7 cases were identified, mostly males (n = 6; 85.7%), with a mean age of 64.9 years. The mean glycated hemoglobin (HbA1c) upon diagnosis was 8.1%, with diabetic ketoacidosis (DKA) observed in 6 cases (85.7%). Subcutaneous flash glucose monitoring (FGM) systems were used in six cases, with a mean follow-up period of 42.7 weeks. During the first 90 days of use, mean average glucose was 167.5 mg/dL, with a coefficient of variation (CV) of 34.6%. The mean time in the range 70-180 mg/dL (TIR) was 59.7%, with a mean time above range (TAR) 181-250 mg/dL of 27.8% and a mean TAR > 250 mg/dL of 10.2%. The mean time below range (TBR) 54-69 mg/dL was 2%, while the mean TBR < 54 mg/dL was 0.3%. The mean glucose management indicator (GMI) was 7.3%. No significant differences were observed in FGM values for the following 90 days of follow-up. A progressive improvement in all parameters of glycaemic control was observed between the first month of FGM use and the sixth month of FGM use. Of note, there was a decrease in mean CV (40.6% to 34.1%, p = 0.25), mean TAR 181-250 (30.3% to 26%, p = 0.49), mean TAR > 250 mg/dL (16.3% to 7.7%, p = 0.09), mean TBR 54-69 mg/dL (5.2% to 2%, p = 0.16), and mean TBR < 54 mg/dL (1.8% to 0.2%, p = 0.31), along with an increase in mean values of TIR 70-180 mg/dL (46.5% to 60.5%, p = 0.09). The lack of statistical significance in the differences observed in the mean FGM values over the follow-up period may be related to the small sample size. CONCLUSION DM-ICI is recognised by a state of sudden-onset insulinopenia, often associated with DKA. The use of FGM systems may be a valid option for the effective management of DM-ICIs and for the prevention of severe hyperglycaemic and hypoglycaemic episodes in this condition.
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Affiliation(s)
| | - Ana Piñar-Gutiérrez
- Endocrinology and Nutrition Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Raquel Guerrero-Vázquez
- Endocrinology and Nutrition Department, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Virginia Bellido
- Endocrinology and Nutrition Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | | | | | - Noelia Gros-Herguido
- Endocrinology and Nutrition Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Gema López-Gallardo
- Endocrinology and Nutrition Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - Alfonso Soto-Moreno
- Endocrinology and Nutrition Department, Hospital Universitario Virgen del Rocío, Seville, Spain
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Ding JT, Yang KP, Lin KL, Cao YK, Zou F. Mechanisms and therapeutic strategies of immune checkpoint molecules and regulators in type 1 diabetes. Front Endocrinol (Lausanne) 2022; 13:1090842. [PMID: 36704045 PMCID: PMC9871554 DOI: 10.3389/fendo.2022.1090842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 12/22/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Considered a significant risk to health and survival, type 1 diabetes (T1D) is a heterogeneous autoimmune disease characterized by hyperglycemia caused by an absolute deficiency of insulin, which is mainly due to the immune-mediated destruction of pancreatic beta cells. SCOPE OF REVIEW In recent years, the role of immune checkpoints in the treatment of cancer has been increasingly recognized, but unfortunately, little attention has been paid to the significant role they play both in the development of secondary diabetes with immune checkpoint inhibitors and the treatment of T1D, such as cytotoxic T-lymphocyte antigen 4(CTLA-4), programmed cell death protein-1(PD-1), lymphocyte activation gene-3(LAG-3), programmed death ligand-1(PD-L1), and T-cell immunoglobulin mucin protein-3(TIM-3). Here, this review summarizes recent research on the role and mechanisms of diverse immune checkpoint molecules in mediating the development of T1D and their potential and theoretical basis for the prevention and treatment of diabetes. MAJOR CONCLUSIONS Immune checkpoint inhibitors related diabetes, similar to T1D, are severe endocrine toxicity induced with immune checkpoint inhibitors. Interestingly, numerous treatment measures show excellent efficacy for T1D via regulating diverse immune checkpoint molecules, including co-inhibitory and co-stimulatory molecules. Thus, targeting immune checkpoint molecules may exhibit potential for T1D treatment and improve clinical outcomes.
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Affiliation(s)
- Jia-Tong Ding
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- The Second Clinical Medicine School, Nanchang University, Nanchang, China
| | - Kang-Ping Yang
- The Second Clinical Medicine School, Nanchang University, Nanchang, China
| | - Kong-Lan Lin
- The Second Clinical Medicine School, Nanchang University, Nanchang, China
| | - Yu-Ke Cao
- School of Ophthalmology & Optometry, Nanchang University, Nanchang, China
| | - Fang Zou
- Department of Endocrinology and Metabolism, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- *Correspondence: Fang Zou,
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Kotwal A, Cheung YMM, Cromwell G, Drincic A, Leblebjian H, Quandt Z, Rushakoff RJ, McDonnell ME. Patient-Centered Diabetes Care of Cancer Patients. Curr Diab Rep 2021; 21:62. [PMID: 34902069 DOI: 10.1007/s11892-021-01435-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW There is a bidirectional relationship between cancer and diabetes, with one condition influencing the prognosis of the other. Multiple cancer therapies cause diabetes including well-established medications such as glucocorticoids and novel cancer therapies such as immune checkpoint inhibitors (CPIs) and phosphoinositide 3-kinase (PI3K) inhibitors. RECENT FINDINGS The nature and severity of diabetes caused by each therapy differ, with some predominantly mediated by insulin resistance, such as PI3K inhibitors and glucocorticoids, while others by insulin deficiency, such as CPIs. Studies have demonstrated diabetes from CPIs to be more rapidly progressing than conventional type 1 diabetes. There remains a scarcity of published guidance for the screening, diagnosis, and management of hyperglycemia and diabetes from these therapies. The need for such guidance is critical because diabetes management in the cancer patient is complex, individualized, and requires inter-disciplinary care. In the present narrative review, we synthesize and summarize the most relevant literature pertaining to diabetes and hyperglycemia in the setting of these cancer therapies and provide an updated patient-centered framework for their evaluation and management.
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Affiliation(s)
- Anupam Kotwal
- Division of Diabetes, Endocrinology and Metabolism, University of Nebraska Medical Center, Omaha, NE, USA
| | - Yee-Ming M Cheung
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Grace Cromwell
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Andjela Drincic
- Division of Diabetes, Endocrinology and Metabolism, University of Nebraska Medical Center, Omaha, NE, USA
| | - Houry Leblebjian
- Department of Pharmacy, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Zoe Quandt
- Division of Endocrinology and Metabolism, University of California, San Francisco, CA, USA
| | - Robert J Rushakoff
- Division of Endocrinology and Metabolism, University of California, San Francisco, CA, USA
| | - Marie E McDonnell
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, 221 Longwood Avenue, Boston, MA, 02115, USA.
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