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Rossignon P, Nguyen LDK, Boegner P, Ku J, Herpain A. Refractory insulin resistance and hemophagocytic lymphohistiocytosis following enfortumab vedotin treatment: A case report. Mol Clin Oncol 2024; 20:44. [PMID: 38799283 PMCID: PMC11117030 DOI: 10.3892/mco.2024.2742] [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: 01/09/2024] [Accepted: 04/08/2024] [Indexed: 05/29/2024] Open
Abstract
The increasing incidence of urothelial carcinoma, coupled with advancements in its therapeutic landscape, has resulted in improved survival rates for patients. This, in turn, has led to a growing population of patients requiring specialized oncological care, with Enfortumab vedotin (EV) emerging as a pivotal treatment for metastatic urothelial carcinoma. While EV is associated with hyperglycemia, ketoacidosis is exceedingly rare. To the best of our knowledge, the link between EV and hemophagocytic lymphohistiocytosis (HLH) has not yet been explored. A 56-year-old patient diagnosed with metastatic urothelial carcinoma underwent EV treatment as a third-line treatment after progression following treatment with cisplatin/gemcitabine and pembrolizumab. Notably, after receiving two doses of EV, the patient exhibited refractory insulin resistance, leading to ketoacidosis. Subsequently, HLH emerged, necessitating a treatment regimen involving dexamethasone and etoposide. Despite intensive efforts, the patient experienced septic shock, resulting in death. The present case report highlights refractory insulin resistance and ketoacidosis, followed by reactive HLH, in the context of EV therapy. The limited literature on these complications demonstrates the need for further research to improve the understanding of the underlying mechanisms. With growing evidence of the efficacy of EV and evolving survival rates in urothelial carcinoma, healthcare professionals must remain vigilant for potential adverse effects, ensuring early recognition and optimal patient care.
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Affiliation(s)
- Pierre Rossignon
- Department of Intensive Care, CHU Saint-Pierre, Université Libre de Bruxelles, 1000 Brussels, Belgium
| | - Le Diep Kieu Nguyen
- Department of Emergency, CHU Saint-Pierre, Université Libre de Bruxelles, 1000 Brussels, Belgium
| | - Petra Boegner
- Department of Oncology, CHU Saint-Pierre, Université Libre de Bruxelles, 1000 Brussels, Belgium
| | - Jade Ku
- Department of Hematology, CHU Saint-Pierre, Université Libre de Bruxelles, 1000 Brussels, Belgium
| | - Antoine Herpain
- Department of Intensive Care, CHU Saint-Pierre, Université Libre de Bruxelles, 1000 Brussels, Belgium
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Peeters G, Verhaegen A. Severe insulin resistance in a patient with diabetes after treatment with brentuximab vedotin. BMJ Case Rep 2024; 17:e251867. [PMID: 38569738 PMCID: PMC10989180 DOI: 10.1136/bcr-2022-251867] [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: 04/05/2024] Open
Abstract
A man in his late 60s with a history of well-controlled type 2 diabetes and hepatic cirrhosis presented to the emergency department due to uncontrollable hyperglycaemia following the initial brentuximab vedotin (BV) infusion. BV was initiated as a treatment for mycosis fungoides, a form of cutaneous T-cell lymphoma. The patient was diagnosed with severe hyperglycaemia with ketosis. Empiric treatment with amoxicillin-clavulanic acid, hydration and intravenous insulin infusion was initiated. Hyperglycaemia persisted despite receiving massive amounts of insulin and was corrected only after treatment with high-dose methylprednisolone for suspected type B insulin resistance. Extremely high and difficult-to-treat hyperglycaemia is a rare side effect of BV. Unfortunately, the patient died of upper gastrointestinal bleeding 22 days after discharge. In patients with obesity and/or diabetes mellitus, the blood glucose levels should be carefully monitored when treated with BV.
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Affiliation(s)
- Greet Peeters
- Endocrinology-Diabetology, ZNA Jan Palfijn, Merksem, Belgium
| | - Ann Verhaegen
- Endocrinology-Diabetology, ZNA Jan Palfijn, Merksem, Belgium
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Tama E, Black M, Moustafa MA, Hurtado MD. Severe Insulin Resistance in a Patient Treated With Nivolumab and Brentuximab-Vedotin for Hodgkin Lymphoma. JCEM CASE REPORTS 2023; 1:luad121. [PMID: 37942131 PMCID: PMC10629972 DOI: 10.1210/jcemcr/luad121] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Indexed: 11/10/2023]
Abstract
This is a case of a 26-year-old male patient, with relapsing Hodgkin lymphoma, treated with nivolumab and brentuximab-vedotin, who was admitted with hyperglycemia and severe insulin resistance requiring approximately 2000 units of intravenous insulin per day. He had no prior diagnosis of diabetes. He was eventually diagnosed with massive cytokine release and hemophagocytic lymphohistiocytosis that led to multi-organ failure and death. The mechanisms behind the hyperglycemia with severe insulin resistance remain unclear but are possibly related to hyperinflammation and immune dysregulation resulting from massive cytokine release. Nivolumab among other immunotherapeutic agents, brentuximab-vedotin, and lymphoid malignancies are rare but known risk factors for massive cytokine release and hemophagocytic lymphohistiocytosis.
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Affiliation(s)
- Elif Tama
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Jacksonville, FL 32256, USA
| | - Meghan Black
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Jacksonville, FL 32256, USA
| | - Muhamad Alhaj Moustafa
- Division of Hematology and Oncology, Department of Medicine, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Maria D Hurtado
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Jacksonville, FL 32256, USA
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Quintas J, Mowatt KB, Mullally JA, Steinberg A. New-onset persistent hyperglycemia with initiation of brentuximab treatment. J Oncol Pharm Pract 2023:10781552231168951. [PMID: 37116870 DOI: 10.1177/10781552231168951] [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: 04/30/2023]
Abstract
INTRODUCTION The addition of brentuximab vedotin (BV) to adriamycin, vinblastine, and dacarbazine (AVD) has become the standard-of-care approach for advanced stage Hodgkin lymphoma (HL). This case describes a rare presentation of new-onset diabetes mellitus one month after initiation of BV + AVD therapy in a patient with HL. CASE REPORT A 41-year-old woman with pre-diabetes and obesity was started on BV + AVD for classical HL, nodular sclerosing type. Six weeks after initiating therapy, she was admitted for abdominal pain, at which time her blood glucose was noted to be 357 mg/dL. Her Hba1c was 8.1%. She required rapid acting insulin, and throughout admission, her glucose ranged from 132 to 263 mg/dL. After discharge, a fasting glucose of over 250 mg/dL deemed her ineligible to have a PET/CT performed to assess disease status. MANAGEMENT AND OUTCOME She was started on basal insulin, a DPP4-inhibitor, and a meglitinide analog. After initiation of therapy, her glucose levels were better controlled, and she was able to have her PET scan. Repeat Hba1c was 6.2% three months after initiation of glucose-lowering medications. She completed 6 cycles of BV + AVD therapy, with improving finger stick blood glucose (FSBG), and repeat Hba1c 1 month after completion of therapy was 5.2% on metformin monotherapy. DISCUSSION Reports of brentuximab-induced hyperglycemia are rare in the literature, noted in just a few studies and one case report. Our case demonstrates a need to monitor blood glucose levels carefully during the initiation of BV therapy, especially in individuals with risk factors such as obesity, pre-diabetes mellitus, or diabetes mellitus.
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Affiliation(s)
- Joseph Quintas
- Internal Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Kelley B Mowatt
- Hematology & Oncology, Westchester Medical Center, Valhalla, NY, USA
| | | | - Amir Steinberg
- Hematology & Oncology, Westchester Medical Center, Valhalla, NY, USA
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Thakkar K, Khurana S, Sun Y, Hembree TN. Diabetic Ketoacidosis and Profound Insulin Resistance From Brentuximab Vedotin. Cureus 2023; 15:e35804. [PMID: 37025732 PMCID: PMC10074015 DOI: 10.7759/cureus.35804] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 03/08/2023] Open
Abstract
Hodgkin's lymphoma is commonly treated with a combination of chemotherapy drugs including doxorubicin, bleomycin, vinblastine, and dacarbazine. Antibody-drug conjugates such as brentuximab vedotin are now being used to treat Hodgkin's lymphoma that has not responded to standard treatment. Brentuximab vedotin is a monoclonal antibody that selectively delivers a cytotoxic agent, monomethyl auristatin E, which targets cells expressing surface CD30 markers, a protein that may be found in high amounts in some cancer cells including lymphoma cells. Common adverse effects of the drug include diarrhea, nausea, anemia, and fatigue. We present a case of a patient with diabetic ketoacidosis and profound insulin resistance secondary to brentuximab. Diabetic ketoacidosis is a rare but serious adverse reaction in this growing class of antibody-drug conjugates.
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Köksalan D, Sözen M, Selek A, Gezer E, Cantürk Z, Çetinarslan B. Brentuximab vedotin-associated diabetic ketoacidosis: a case report. Int J Diabetes Dev Ctries 2023; 43:120-124. [PMID: 35875342 PMCID: PMC9287688 DOI: 10.1007/s13410-022-01116-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 06/29/2022] [Indexed: 11/08/2022] Open
Abstract
Background Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM). It is characterized by hyperglycemia, metabolic acidosis, and ketonemia. Fortunately, drug-induced hyperglycemias are usually mild and not life-threatening. However, rarely some cases may present with ketoacidosis. In this case report, we aimed to present a brentuximab vedotin (BV) associated with DKA. Case presentation A 23-year-old Caucasian man presented with abdominal pain, nausea, and vomiting for 1-2 weeks. The patient had a previous diagnosis of Hodgkin's lymphoma and primer hypothyroidism. He is using levothyroxine 150 μg per day and received BV treatment for Hodgkin lymphoma (HL) 10 days ago. No steroid treatment was administered for premedication before BV. Except for obesity, all system examinations are normal. There were no signs of any infection. Laboratory data revealed hyperglycemia, metabolic acidosis, and ketonemia. The patient was admitted to the service with a diagnosis of DKA. After the patient was admitted to our clinic, insulin treatment and hydration started immediately. Despite the insulin infusion reaching 1700 units per day, the patient's diabetic ketoacidosis extended to 1 week. Anti-insulin, anti-glutamic acid decarboxylase, and islet cell autoantibodies were negative, which were checked to exclude type 1 DM. Fasting C-peptide was 28 ng/mL (normal range, 0.9-7.1 ng/mL). With all these, the diabetic ketoacidosis status of the patient was evaluated as a BV side effect. Conclusion This patient is a rare case of BV-associated DKA. It is very important to know this relationship since BV treatment has turned into a standard treatment for relapsed Hodgkin lymphoma. Our case highlights that this diagnosis should be kept in mind as a complication of each dose of BV administration.
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Affiliation(s)
- Damla Köksalan
- Department of Endocrinology and Metabolism, Kocaeli University Faculty of Medicine, 41000 Kocaeli, Turkey
| | - Mehmet Sözen
- Department of Endocrinology and Metabolism, Kocaeli University Faculty of Medicine, 41000 Kocaeli, Turkey
| | - Alev Selek
- Department of Endocrinology and Metabolism, Kocaeli University Faculty of Medicine, 41000 Kocaeli, Turkey
| | - Emre Gezer
- Department of Endocrinology and Metabolism, Kocaeli University Faculty of Medicine, 41000 Kocaeli, Turkey
| | - Zeynep Cantürk
- Department of Endocrinology and Metabolism, Kocaeli University Faculty of Medicine, 41000 Kocaeli, Turkey
| | - Berrin Çetinarslan
- Department of Endocrinology and Metabolism, Kocaeli University Faculty of Medicine, 41000 Kocaeli, Turkey
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Rausch C, Bacher U, Rabaglio M, Vorburger C, Klingenberg A, Banz Y, Daskalakis M, Pabst T. Combining BeEAM with Brentuximab Vedotin for High-Dose Therapy in CD30 Positive Lymphomas before Autologous Transplantation-A Phase I Study. J Clin Med 2022; 11:5378. [PMID: 36143025 PMCID: PMC9503567 DOI: 10.3390/jcm11185378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/31/2022] [Accepted: 09/07/2022] [Indexed: 11/24/2022] Open
Abstract
The prognosis for patients with CD30+ lymphomas (Hodgkin lymphoma and various T-cell lymphomas) relapsing after autologous stem cell transplantation (ASCT) is critical. Brentuximab vedotin (BV), an ADC targeting CD30, is an obvious candidate for inclusion into high-dose chemotherapy (HDCT) regimens to improve outcomes. This single center phase I trial investigated 12 patients with CD30+ lymphoma (AITL: n = 5; relapsed HL: n = 7; median of two previous treatment lines) undergoing ASCT. In a 3 + 3 dose escalation design, 12 patients received a single BV dose at three dose levels (DL) (0.9/1.2/1.8 mg/kg b.w.) prior to standard BeEAM. All patients were treated as planned; no dose limiting toxicities (DLTs) occurred at DL 1 and 2. At DL 3, one DLT (paralytic ileus, fully recovering) occurred. Grade III febrile neutropenia occurred in one patient, and two others had septic complications, all fully recovering. Median hospitalization was 23 days. Hematologic recovery was normal. Six of twelve (50%) patients achieved CR. PFS and OS at 1 year were 67% (n = 8/12) and 83% (n = 10/12), respectively. The addition of brentuximab to standard BeEAM HDCT seems to be safe. We observed a CR rate of 75% post-ASCT in a highly pretreated population. The efficacy of this novel HDCT combination with BV at a 1.8 mg/kg dose level needs to be explored in larger studies.
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Affiliation(s)
- Christian Rausch
- Department of Medical Oncology, Inselspital, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
- Medical Department III—Hematology and Oncology, Campus Grosshadern, Ludwig Maximilian’s University Munich, 81377 Munich, Germany
| | - Ulrike Bacher
- Department of Hematology, Inselspital, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
| | - Manuela Rabaglio
- Department of Medical Oncology, Inselspital, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
| | - Corinne Vorburger
- Department of Medical Oncology, Inselspital, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
| | - Anke Klingenberg
- Department of Medical Oncology, Inselspital, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
| | - Yara Banz
- Institute of Pathology, University of Bern, 3008 Bern, Switzerland
| | - Michael Daskalakis
- Department of Hematology, Inselspital, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, University Hospital Bern, University of Bern, 3010 Bern, Switzerland
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