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Nivolumab-induced fulminant diabetic ketoacidosis followed by thyroiditis

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Title: Nivolumab-induced fulminant diabetic ketoacidosis followed by thyroiditis
Authors: Tzoulis, P
Corbett, RW
Ponnampalam, S
Baker, E
Heaton, D
Doulgeraki, T
Stebbing, J
Item 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.
Issue Date: 2-Mar-2018
Date of Acceptance: 2-Mar-2018
URI: http://hdl.handle.net/10044/1/58599
DOI: https://dx.doi.org/10.1530/EDM-18-0111
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/)
Sponsor/Funder: National Institute for Health Research
Funder's Grant Number: NIHR-RP-011-053
Publication Status: Published
Open Access location: https://www.edmcasereports.com/media//EDM18-0111.pdf
Appears in Collections:Department of Surgery and Cancer