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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Sasson SC, Wilkins LE, Watson RA, Jolly C, Brain O, Klenerman P, Olsson-Brown A, Fairfax BP. Identification of neutralising pembrolizumab anti-drug antibodies in patients with melanoma. Sci Rep 2021; 11:19253. [PMID: 34584157 PMCID: PMC8478874 DOI: 10.1038/s41598-021-98700-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 09/14/2021] [Indexed: 11/09/2022] Open
Abstract
Development of anti-drug antibodies (ADAs) can interfere with therapeutic monoclonal antibodies and may lead to drug neutralisation and clinical disease progression. Measurement of circulating drug levels and development of ADAs in the setting of anti-programmed cell death-1 agent pembrolizumab has not been well-studied. Enzyme-linked immunosorbent assays were used to measure pembrolizumab drug level and ADAs in 41 patients with melanoma at baseline, Time-point 1 (3 weeks) and Time-point 2 (21 weeks). Assay results were related to patient demographics and clinical outcome data at 6 months. The median pembrolizumab drug level at 3 weeks was 237 ng/μL and did not correlate with age, sex or body surface area.17/41 patients had an ADA detected at any timepoint, with the highest prevalence at Timepoint 1 (median concentration = 17 ng/μL). The presence of an ADA did not correlate with clinical progression at 6 months. 3/41 (7%) of patients displayed a falling pembrolizumab drug level and rising ADA titre between Timepoint 1 and 2 suggestive of a neutralising ADA. Pembrolizumab drug levels and ADAs can be readily measured. The rates of total and treatment-emergent ADAs may be higher in “real-word” settings than those previously reported. Larger studies are needed to determine effect of neutralising ADAs on long-term clinical outcome.
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Affiliation(s)
- S C Sasson
- Nuffield Department of Medicine, The University of Oxford, Oxford, UK.
| | - L E Wilkins
- The University of Oxford Medical School, Oxford, UK
| | - R A Watson
- MRC Weatherall Institute of Molecular Medicine, The University of Oxford, Oxford, UK
| | - C Jolly
- The Clatterbridge Cancer Centre, Liverpool, UK
| | - O Brain
- Nuffield Department of Medicine, The University of Oxford, Oxford, UK
| | - P Klenerman
- Nuffield Department of Medicine, The University of Oxford, Oxford, UK
| | | | - B P Fairfax
- MRC Weatherall Institute of Molecular Medicine, The University of Oxford, Oxford, UK
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Sasson SC, Zaunders JJ, Nahar K, Munier CML, Fairfax BP, Olsson-Brown A, Jolly C, Read SA, Ahlenstiel G, Palendira U, Scolyer RA, Carlino MS, Payne MJ, Cheung VTF, Gupta T, Klenerman P, Long GV, Brain O, Menzies AM, Kelleher AD. Mucosal-associated invariant T (MAIT) cells are activated in the gastrointestinal tissue of patients with combination ipilimumab and nivolumab therapy-related colitis in a pathology distinct from ulcerative colitis. Clin Exp Immunol 2020; 202:335-352. [PMID: 32734627 PMCID: PMC7670140 DOI: 10.1111/cei.13502] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/09/2020] [Accepted: 07/07/2020] [Indexed: 12/15/2022] Open
Abstract
The aim of this study was to investigate the pathogenesis of combination ipilimumab and nivolumab-associated colitis (IN-COL) by measuring gut-derived and peripheral blood mononuclear cell (GMNC; PBMC) profiles. We studied GMNC and PBMC from patients with IN-COL, IN-treated with no adverse-events (IN-NAE), ulcerative colitis (UC) and healthy volunteers using flow cytometry. In the gastrointestinal-derived cells we found high levels of activated CD8+ T cells and mucosal-associated invariant T (MAIT) cells in IN-COL, changes that were not evident in IN-NAE or UC. UC, but not IN-C, was associated with a high proportion of regulatory T cells (Treg ). We sought to determine if local tissue responses could be measured in peripheral blood. Peripherally, checkpoint inhibition instigated a rise in activated memory CD4+ and CD8+ T cells, regardless of colitis. Low circulating MAIT cells at baseline was associated with IN-COL patients compared with IN-NAE in one of two cohorts. UC, but not IN-COL, was associated with high levels of circulating plasmablasts. In summary, the alterations in T cell subsets measured in IN-COL-affected tissue, characterized by high levels of activated CD8+ T cells and MAIT cells and a low proportion of Treg , reflected a pathology distinct from UC. These tissue changes differed from the periphery, where T cell activation was a widespread on-treatment effect, and circulating MAIT cell count was low but not reliably predictive of colitis.
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Affiliation(s)
- S C Sasson
- Translational Gastroenterology Unit and Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - J J Zaunders
- Centre for Applied Medical Research, St Vincent's Hospital, Sydney, Australia
| | - K Nahar
- Melanoma Institute Australia and The University of Sydney, Sydney, Australia
| | - C M L Munier
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | - B P Fairfax
- Department of Oncology, Churchill Hospital, Oxford, UK.,Department of Oncology, University of Oxford, Oxford, UK.,MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - A Olsson-Brown
- The Clatterbridge Cancer Centre NHS Foundation Trust and Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - C Jolly
- The Clatterbridge Cancer Centre NHS Foundation Trust and Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - S A Read
- Westmead Institute of Medical Research, Sydney, Australia.,Western Sydney University, Sydney, Australia
| | - G Ahlenstiel
- Westmead Institute of Medical Research, Sydney, Australia.,Department of Gastroenterology, Blacktown Hospital, Sydney, Australia
| | - U Palendira
- Discipline of Infectious Diseases and Immunology, The University of Sydney, Sydney, Australia
| | - R A Scolyer
- Melanoma Institute Australia and The University of Sydney, Sydney, Australia.,Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital, Sydney, Australia
| | - M S Carlino
- Melanoma Institute Australia and The University of Sydney, Sydney, Australia.,Department of Medical Oncology, Westmead and Blacktown Hospitals, Sydney, Australia
| | - M J Payne
- Department of Oncology, Churchill Hospital, Oxford, UK
| | - V T F Cheung
- Translational Gastroenterology Unit and Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - T Gupta
- Translational Gastroenterology Unit and Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - P Klenerman
- Translational Gastroenterology Unit and Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Peter Medawar Building of Pathogen Research, University of Oxford, Oxford, UK
| | - G V Long
- Melanoma Institute Australia and The University of Sydney, Sydney, Australia.,Department of Medical Oncology, Royal North Shore Hospital and Mater Hospitals, Sydney, Australia
| | - O Brain
- Translational Gastroenterology Unit and Oxford Biomedical Research Centre, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Department of Gastroenterology, John Radcliffe Hospital, Oxford, UK
| | - A M Menzies
- Melanoma Institute Australia and The University of Sydney, Sydney, Australia.,Department of Medical Oncology, Royal North Shore Hospital and Mater Hospitals, Sydney, Australia
| | - A D Kelleher
- Centre for Applied Medical Research, St Vincent's Hospital, Sydney, Australia.,The Kirby Institute, University of New South Wales, Sydney, Australia
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Cheung VTF, Gupta T, Olsson-Brown A, Subramanian S, Sasson SC, Heseltine J, Fryer E, Collantes E, Sacco JJ, Pirmohamed M, Simmons A, Klenerman P, Tuthill M, Protheroe AS, Chitnis M, Fairfax BP, Payne MJ, Middleton MR, Brain O. Immune checkpoint inhibitor-related colitis assessment and prognosis: can IBD scoring point the way? Br J Cancer 2020; 123:207-215. [PMID: 32418993 PMCID: PMC7374736 DOI: 10.1038/s41416-020-0882-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/06/2020] [Accepted: 04/24/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICI) improve survival but cause immune-related adverse events (irAE). We sought to determine if CTCAE classification, IBD biomarkers/endoscopic/histological scores correlate with irAE colitis outcomes. METHODS A dual-centre retrospective study was performed on patients receiving ICI for melanoma, NSCLC or urothelial cancer from 2012 to 2018. Demographics, clinical data, endoscopies (reanalysed using Mayo/Ulcerative Colitis Endoscopic Index of Severity (UCEIS) scores), histology (scored with Nancy Index) and treatment outcomes were analysed. RESULTS In all, 1074 patients were analysed. Twelve percent (134) developed irAE colitis. Median patient age was 66, 59% were male. CTCAE diarrhoea grade does not correlate with steroid/ infliximab use. G3/4 colitis patients are more likely to need infliximab (p < 0.0001) but colitis grade does not correlate with steroid duration. CRP, albumin and haemoglobin do not correlate with severity. The UCEIS (p = 0.008) and Mayo (p = 0.016) scores correlate with severity/infliximab requirement. Patients with higher Nancy indices (3/4) are more likely to require infliximab (p = 0.03). CONCLUSIONS CTCAE assessment does not accurately reflect colitis severity and our data do not support its use in isolation, as this may negatively impact timely management. Our data support utilising endoscopic scoring for patients with >grade 1 CTCAE disease, and demonstrate the potential prognostic utility of objective histologic scoring.
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Affiliation(s)
- Vincent Ting Fung Cheung
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK.
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
| | - Tarun Gupta
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Anna Olsson-Brown
- The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Birkenhead, Wirral, CH63 4JY, UK
- Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool, L69 3BX, UK
| | - Sreedhar Subramanian
- Department of Gastroenterology, Royal Liverpool University Hospital, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Prescot Street, Liverpool, L7 8XP, UK
| | - Sarah Christina Sasson
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Jonathan Heseltine
- The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Birkenhead, Wirral, CH63 4JY, UK
| | - Eve Fryer
- Department of Cellular Pathology, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Elena Collantes
- Department of Cellular Pathology, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Joseph J Sacco
- The Clatterbridge Cancer Centre NHS Foundation Trust, Clatterbridge Road, Birkenhead, Wirral, CH63 4JY, UK
- Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool, L69 3BX, UK
| | - Munir Pirmohamed
- Institute of Translational Medicine, University of Liverpool, Crown Street, Liverpool, L69 3BX, UK
| | - Alison Simmons
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Paul Klenerman
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Mark Tuthill
- Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Old Road, Oxford, OX3 7LE, UK
| | - Andrew S Protheroe
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK
- Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Old Road, Oxford, OX3 7LE, UK
| | - Meenali Chitnis
- Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Old Road, Oxford, OX3 7LE, UK
| | - Benjamin Peter Fairfax
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK
- Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Old Road, Oxford, OX3 7LE, UK
| | - Miranda Jane Payne
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK
- Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Old Road, Oxford, OX3 7LE, UK
| | - Mark Ross Middleton
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK
- Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Old Road, Oxford, OX3 7LE, UK
| | - Oliver Brain
- Translational Gastroenterology Unit, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, UK
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