2023-07-23 20:07:14
Why is this important?
PD-L1, PD-1 and CTLA-4 inhibitors are three ICI subtypes widely used in clinical practice in the treatment of certain cancers such as non-small cell lung, ovarian cancer, melanoma, pancreatic cancer. The known toxicity profile of these ICIs (alone or in combination therapy) is unique and known as immune-related adverse effects. The endocrine glands are common targets of adverse effects related to the immunity of ICIs, which can lead to T1D if the pancreas is involved. T1D induced by ICIs is rare, but irreversible, and can be life-threatening. In addition, T1D has an impact on the vital prognosis of cancer patients. The American Society of Clinical Oncology (ASCO) and the Chinese Society of Clinical Oncology (CSCO) have both published recommendations for the management of immune-related adverse events induced by ICIs, among which thyroid dysfunction (hyper- and hypothyroidism), hypophysitis, primary adrenal insufficiency and T1D are at the top.
Key points
The incidence rates of T1D induced by ICIs vary and are believed to be less than 1%. These figures would have increased sharply in parallel with the increasingly widespread use of these treatments. It depending on the HERE used. Anti-PD-1 would be more likely to induce T1D than CTLA-4 inhibitors. The risk of developing T1D increases in the event of association of ICI. These treatments can also significantly aggravate hyperglycaemia in subjects with pre-existing type 2 diabetes. The incidence rates of T1D vary considerably from one study to another, and would be significantly lower than those observed in clinical practice due to the strict criteria for admitting patients into the trials. The development of T1D induced by ICIs has mainly been observed in patients treated for melanoma (53%) and for non-small cell lung cancer (15%), without the exact reason being yet identified. The mechanism involved, although not completely elucidated, might go through the auto-activation of T lymphocytes by ICIs which would lead to the destruction of β cells, in addition to tumor cells. ICIs also interrupt the process of immunoregulation. Some genetic factors may be involved in this process, with higher PD-1 expression having been associated with increased susceptibility to autoimmune disorders, including T1D. The intestinal microbiota might also be implicated in autoimmune type adverse effects, including T1D. Other factors may increase the risk of autoimmune adverse effects of ICIs, including inflammation, age, dosage, type of ICIs, combination or sequential treatment. Patients should regularly measure their plasma glucose levels while being treated with ICIs, including before treatment initiation and at follow-up visits. C-peptide levels, electrolytes, HbA1c, urinary and serum ketones and blood gases will also be monitored. The patient must be informed before initiating treatment with ICIs of the symptoms and signs of hyperglycaemia and ketoacidosis (thirst, polyuria, abdominal pain, dehydration, polydipsia, vomiting, hyperventilation, etc.). Endocrinologists and oncologists must work together for glycemic control and the continuation of cancer treatment. Various international recommendations recommend that the therapeutic management of diabetes be done according to the grade of T1D, with suspension of treatment with ICIs from grade 3/4, together with the initiation of insulin therapy. Reversal of ketosis or ketoacidosis is essential by intravenous insulin. Fluid and electrolyte supplementation may be necessary. Insulin remains the leading treatment. High doses of corticosteroids or other immunosuppressive agents have been shown to be ineffective on the dysfunction of β cells with a view to reversing the pathophysiological process of the development of T1D induced by ICIs. And corticosteroids, which worsen blood sugar levels, are not recommended for the treatment of ICI-related T1D, which differs from other immune-related adverse effects such as colitis or hepatotoxicity.
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