Nivolumab-induced fulminant diabetic ketoacidosis followed by thyroiditis
File(s)
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Author(s)
Type
Journal Article
Abstract
Five days following the 3rd cycle of nivolumab, a monoclonal antibody, which acts as immune checkpoint inhibitor
against the programmed cell death protein-1, for metastatic lung adenocarcinoma, a 56-year-old woman presented
at the hospital critically ill. On admission, she had severe diabetic ketoacidosis (DKA), as evidenced by venous glucose
of 47
mmol/L, blood ketones of 7.5
mmol/L, pH of 6.95 and bicarbonate of 6.6
mmol/L. She has had no personal or
family history of diabetes mellitus (DM), while random venous glucose, measured 1 week prior to hospitalisation,
was 6.1
mmol/L. On admission, her HbA1c was 8.2% and anti-GAD antibodies were 12
kIU/L (0–5
kU/L), while islet cell
antibodies and serum C-peptide were undetectable. Nivolumab was recommenced without the development of other
immune-mediated phenomena until 6 months later, when she developed hypothyroidism with TSH 18
U/L and low free T4.
She remains insulin dependent and has required levothyroxine replacement, while she has maintained good radiological
and clinical response to immunotherapy. This case is notable for the rapidity of onset and profound nature of DKA at
presentation, which occurred two months following commencement of immunotherapy. Despite the association of
nivolumab with immune-mediated endocrinopathies, only a very small number of patients developing type 1 DM has
been reported to date. Patients should be closely monitored for hyperglycaemia and thyroid dysfunction prior to and
periodically during immunotherapy.
against the programmed cell death protein-1, for metastatic lung adenocarcinoma, a 56-year-old woman presented
at the hospital critically ill. On admission, she had severe diabetic ketoacidosis (DKA), as evidenced by venous glucose
of 47
mmol/L, blood ketones of 7.5
mmol/L, pH of 6.95 and bicarbonate of 6.6
mmol/L. She has had no personal or
family history of diabetes mellitus (DM), while random venous glucose, measured 1 week prior to hospitalisation,
was 6.1
mmol/L. On admission, her HbA1c was 8.2% and anti-GAD antibodies were 12
kIU/L (0–5
kU/L), while islet cell
antibodies and serum C-peptide were undetectable. Nivolumab was recommenced without the development of other
immune-mediated phenomena until 6 months later, when she developed hypothyroidism with TSH 18
U/L and low free T4.
She remains insulin dependent and has required levothyroxine replacement, while she has maintained good radiological
and clinical response to immunotherapy. This case is notable for the rapidity of onset and profound nature of DKA at
presentation, which occurred two months following commencement of immunotherapy. Despite the association of
nivolumab with immune-mediated endocrinopathies, only a very small number of patients developing type 1 DM has
been reported to date. Patients should be closely monitored for hyperglycaemia and thyroid dysfunction prior to and
periodically during immunotherapy.
Date Issued
2018-03-02
Date Acceptance
2018-03-02
Citation
Endocrinology, Diabetes and Metabolism Case Reports, 2018, EDM180111
ISSN
2052-0573
Publisher
BioScientifica
Journal / Book Title
Endocrinology, Diabetes and Metabolism Case Reports
Volume
EDM180111
Copyright Statement
© 2018 The authors. This work is licensed under a
Creative Commons
Attribution-NonCommercial-NoDerivs 3.0
Unported License (https://creativecommons.org/licenses/by-nc-nd/3.0/)
Creative Commons
Attribution-NonCommercial-NoDerivs 3.0
Unported License (https://creativecommons.org/licenses/by-nc-nd/3.0/)
Sponsor
National Institute for Health Research
Grant Number
NIHR-RP-011-053
Publication Status
Published