scholarly journals Accelerated Progression of Prediabetes to Insulin-Dependent Diabetes After 9 Cycles of Nivolumab

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A363-A363
Author(s):  
Bakr Swaid
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Abdominal Pain ◽  
Immune Checkpoint ◽  
Attention Deficit Disorder ◽  
Diabetes Management ◽  
Checkpoint Inhibitors ◽  
Brittle Diabetes ◽  
Insulin Dependent

Abstract Introduction: Diabetes mellitus have been reported in around 1% of patients receiving immune checkpoint inhibitors (ICI) resultingin immune checkpoint inhibitor induced diabetes mellitus (ICI-DM). 4 phenotypes of ICI-DM exist: acute autoimmuneinsulin-dependent diabetes, decompensation of prediabetes or type 2 diabetes, autoimmune pancreatitis, andautoimmune lipoatrophy. Clinical Case: A 52-year-old man was diagnosed with stage IIIb malignant melanoma. Two months following local excision, he wasstarted on nivolumab every 4 weeks planned for 1 year. His past medical history was significant for prediabetes,hypertension, obesity (BMI 33.27 kg/m²), primary hypogonadism, adult attention deficit disorder, obstructive sleepapnea, gastric ulcer, and gastroesophageal reflux disease. He denied tobacco use but reported semi-daily use ofmarijuana and alcohol. His baseline HbA1c was 6.0%. After the 8th cycle of nivolumab, he reported several bloodglucose readings in the 200 mg/dL range. He was thought to have progressed to type 2 diabetes and metformin wasstarted. Glipizide was added shortly thereafter due to persistent hyperglycemia. At the 9th cycle of nivolumab, hisHbA1c was 8.2%. In 1 week from this time, the patient developed abdominal pain, nausea, and persistent vomiting. Hewas found to be in DKA with blood glucose of 278 mg/dL, bicarbonate of 9.3 mmol/L, anion gap of 21, and arterial pHof 7.22. He was treated in the ICU per standard DKA care. His C-peptide was 0.5 ng/mL (reference 0.8–3.5) withconcomitant plasma glucose of 229 mg/dL. Autoantibody screening was negative including glutamic aciddecarboxylase antibody (anti-GAD), insulin antibody, insulin antigen-2 (IA-2) autoantibody, and zinc transporter 8antibody. The patient was discharged home on multiple daily injections of insulin but he struggled with diabetes carewhich proved to be of brittle nature requiring CGM use. Two months after completion of nivolumab treatment, thepatient reported epigastric abdominal pain with frequent nausea and occasional vomiting of few weeks duration. He wasdiagnosed with subacute pancreatitis based on symptoms and elevated lipase. There was no evidence of gallstones. Although immunotherapy-related pancreatitis was considered, we decided to try alcohol cessation first hoping to avoidthe need to use prednisone. Over several weeks, lipase normalized and his symptoms completely resolved. Conclusion: In this case, nivolumab resulted in progressive beta-cell failure and complete insulin dependence in a person with ahistory of prediabetes. Not all pancreatitis cases in the settings of immunotherapy use are immune-related adverseevents (irAE). Usual causes, e.g. alcohol, should still be considered. With cessation of alcohol, pancreatitis fullyresolved leading to avoidance of prednisone which would likely have worsened diabetes management in this patientwith brittle diabetes.

scholarly journals SAT-676 Pembrolizumab Induced Worsening Glycemic Control and DKA in Type 2 Diabetes Mellitus

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Sarita Goud ◽  
Yu Yu Thar
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Glycemic Control ◽  
Immune Checkpoint ◽  
Immune Checkpoint Inhibitors ◽  
Checkpoint Inhibitors ◽  
Insulin Dependent

Abstract INTRODUCTION Pembrolizumab(Keytruda) is a humanized IgG4 anti-programmed cell death-1 (PD-1) antibody serving as an immune-checkpoint inhibitor, now approved by FDA to treat several types of cancer. Although there are few reported cases of pembrolizumab induced new onset DKA in a non diabetic patients due to its autoimmune nature, its association in worsening glycemic control and DKA in pre-existing type 2 Diabetes mellitus is not well established. CASE 79 years old female with past medical hx of DM type 2 (Hba1c 7.4 was started on metformin), COPD(on chronic steroids and trilogy machine at home), recently diagnosed with poorly differentiated adenocarcinoma of the left lung, metastasis to liver, PDL 1 positive at 99%, started on palliative chemotherapy with Keytruda, 2 weeks after the third cycle of keytruda presented to the ED for AMS. Patient noted to be very dehydrated, somnolescent and tachypnea. Labs consistent with sugars > 600, potassium 6.8, Bicarb 5, Anion gap 33, beta hydroxybutyrate 11.5 (on 7/15/19 0.6), HbA1c 9.7,(On 12/15/16 7.3, 9/25/18 6.7, 1/22/19 7.4). PH 7.31, lactate 2.4. WBC count 21.5- no infectious source identified (CXR, CT brain, UA clean). Patient was admitted for DKA and treated with IV insulin and IV fluids. After medically stable patient was discharged with Insulin regimen. Within 5 days after being discharged, patient presented to ED again with DKA with PH 7.27, Bicarb 8, anion gap 22, sugars>600, beta hydroxybuterate 13.70. Patient was Rx for DKA- after a week of hospitalization was discharged to Hospice(due to metastatic cancer) and few weeks later expired.To summarize, pt with well controlled type 2 DM on metformin presented with frequent DKA 2 weeks after treatment with third cycle of keytruda leading to worsening glycemic control in-turn making patient Insulin dependent. CONCLUSION Incidence of Type 1 DM with pembrolizumab treatment is being increasingly recognized and reported, and DKA is a common initial presentation. However we need further studies to establish the mechanism of worsening glycemic control leading to Insulin dependent and DKA in patients with pre-existing type 2 diabetes. Also, physicians should counsel patients about this potential immune related adverse effect and educate them about the symptoms of hyperglycemia and DKA. REFERENCES Immune checkpoint inhibitors and type 1 diabetes mellitus: a case report and systematic review Jeroen M K de Filette1, Joeri J Pen2, Lore Decoster3, Thomas Vissers4, Bert Bravenboer1, Bart J Van der Auwera5, Frans K Gorus5, Bart O Roep6,7, Sandrine Aspeslagh3, Bart Neyns3, Brigitte Velkeniers1 and Aan V Kharagjitsingh1,2,5,8 Immune checkpoint inhibitors: an emerging cause of insulin-dependent diabetes. Anupam Kotwal1, Candace Haddox2, Matthew Block3, Yogish C Kudva1. BMJ open Diabetes and research, Vol 7, issue1.

Diabetic neuropathy: Epidemiological, pathogenetic, and clinical aspects with special emphasis on type 2 diabetes mellitus

1983 ◽  
Vol 104 (4_Suppl) ◽  
pp. S89-S94
Author(s):  
E. Matikainen ◽  
J. Juntunen
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Peripheral Neuropathy ◽  
Diabetic Control ◽  
Clinical Aspects ◽  
Type 2 Diabetics ◽  
Insulin Dependent

ABSTRACT. Peripheral neuropathy is a frequent complication of diabetes mellitus. Alterations of the peripheral nervous system in diabetics have been studied in numerous investigations. There are many factors known to participate in the development of this complication, e.g. the age of the patient, duration of the diabetes, quality of the diabetic control etc. The role of different types of diabetes in development of neuropathy is still largely unclear since investigations on this aspect are few. It seems, however, that peripheral neuropathy in type 2 (non-insulin dependent) diabetes is common but often mild. The differential diagnosis of the peripheral neuropathy in type 2 diabetics is more difficult than in type 1 (insulin dependent) diabetics, since these patients tend to be older and also may have other concomitant disorders. In this paper the clinical features and pathogenetic mechanisms of neuropathy in type 2 diabetes are briefly discussed.

scholarly journals Impact of an Advanced Practice Pharmacist Type 2 Diabetes Management Program: A Pilot Study

2019 ◽  
Vol 10 (4) ◽  
pp. 20
Author(s):  
Jelena Lewis ◽  
Tiffany Nguyen ◽  
Hana Althobaiti ◽  
Mona Alsheikh ◽  
Brad Borsari ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Diabetes Management ◽  
Drug Dose ◽  
Advanced Practice ◽  
Dose Increase ◽  
Therapeutic Decisions ◽  
The Impact

Background: The purpose of this study was to describe the impact of an Advanced Practice Pharmacist (APh) on lowering hemoglobin A1c (HbA1c) in patients with type 2 diabetes within a patient centered medical home (PCMH) and to classify the types of therapeutic decisions made by the APh. Methods: This was a retrospective study using data from electronic health records. The study evaluated a partnership between Chapman University School of Pharmacy and Providence St. Joseph Heritage Healthcare that provided diabetes management by an Advanced Practice Pharmacist in a PCMH under a collaborative practice agreement. Change in the HbA1c was the primary endpoint assessed in this study. The type of therapeutic decisions made by the APh were also evaluated. Descriptive analysis and Wilcoxon signed rank test were used to analyze data. Results: The study included 35 patients with diagnosis of type 2 diabetes mellitus managed by an APh from May 2017 to December 2017. Most of the patients were 60-79 years old (68.5%), 45.7% were female, and 45.7% were of Hispanic/Latino ethnicity. The average HbA1c was 8.8%±1.4% (range=6.0%-12.4%) and 7.5%±1.4% (range=5.5%-12.4%) at the initial and final APh visit, respectively (p<0.0001). Therapeutic decisions made by the APh included drug dose increase (35.5% of visits), drug added (16.4%), drug dose decrease (6.4%), drug switch (5.5%), and drug discontinuation (1.8%). Conclusion: The Advanced Practice Pharmacist’s interventions had a significant positive impact on lowering HbA1c in patients with type 2 diabetes mellitus in a PCMH. The most common therapeutic decisions made by the APh included drug dose increase and adding a new drug.   Article Type: Pharmacy Practice

scholarly journals Quality improvement project for improving inpatient glycaemic control in non-critically ill patients admitted on medical floor with type 2 diabetes mellitus

2020 ◽  
Vol 9 (3) ◽  
pp. e000982
Author(s):  
Adeel Ahmad Khan ◽  
Aamir Shahzad ◽  
Samman Rose ◽  
Dabia Hamad S H Al Mohanadi ◽  
Muhammad Zahid
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Glycaemic Control ◽  
Diabetes Management ◽  
Oral Intake ◽  
Improvement Project ◽  
Type 2 Dm ◽  
Management Protocol ◽  
Patients With Diabetes

A significant number of patients admitted to the medical floor have type 2 diabetes mellitus (DM). Lack of a standardised inpatient hyperglycaemia management protocol leads to improper glycaemic control adding to morbidity in such patients. American Diabetes Association, in its 2019 guidelines, recommends initiation of a regimen consisting of basal insulin (long-acting insulin) or basal plus correctional insulin for non-critically ill hospitalised patients with poor or no oral intake. A combination of basal insulin, bolus (short-acting premeal or prandial) insulin and correctional scale insulin is recommended for inpatient hyperglycaemia management in non-critical patients with type 2 DM who have proper oral intake. Baseline data of 100 patients with diabetes admitted to Hamad General Hospital Doha, Qatar, showed that although insulin was used in the majority of patients, there was lack of uniformity in the initiation of insulin regimen. Adequate glycaemic control (7.8–10 mmol/L) was achieved in 45% of patients. Using Plan–Do–Study–Act (PDSA) model of improvement, a quality improvement project was initiated with the introduction of a standardised inpatient hyperglycaemia management protocol aiming to achieve 50% compliance to protocol and improvement in inpatient glycaemic control from baseline of 45% to 70%. Interventions for change included development of a standardised inpatient hyperglycaemia management protocol and its provision to medical trainees, teaching sessions for trainees and nurses, active involvement of medical consultants for supervision of trainees to address the fear of hypoglycaemia, regular reminders/feedbacks to trainees and nurses about glycaemic control of their patients and education about goals of diabetes management during hospitalisation for patients with diabetes. Overall, glycaemic control improved significantly with target glycaemic control of 70% achieved in 4 of the 10 PDSA cycles without an increase in the number of hypoglycaemic episodes. We conclude that development of a standardised inpatient insulin prescribing protocol, educational sessions for medical trainees and nurses about goals of diabetes management during hospitalisation, regular reminders to healthcare professionals and patient education are some of the measures that can improve glycaemic control of patients with type 2 DM during inpatient stay.

scholarly journals Modern technologies in management of diabetes

2017 ◽  
Vol 13 (2) ◽  
pp. 296-301
Author(s):  
Anbreen Iqbal ◽  
Muhammad Imran Qadir ◽  
Muhammad Asif
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Cell Transplantation ◽  
Islet Cell ◽  
Insulin Dependent Diabetes Mellitus ◽  
Dependent Diabetes Mellitus ◽  
Islet Cell Transplantation ◽  
Insulin Dependent

Diabetes is not one disease but rather is a heterogeneous group of syndromes characterized by an elevation of fasting blood glucose caused by a relative or absolute deficiency in insulin. The two main types of diabetes occur, type-1 is insulin dependent diabetes mellitus and type-2 is non insulin dependent diabetes mellitus. In type-1 body does not produce insulin and about 10% of all diabetic patients are affected. In type-2 diabetes imbalance of insulin and glucose occur and there are about 90% cases for type-2 diabetes. Gestational diabetes is also a type of diabetes and it is found mostly in women’s who are pregnant later such women’s are affected with type-2 diabetes and about 40% cases are studied. Different countries are affected at high level from diabetes. For the treatment of diabetes different techniques like insulin injection, oral vaccination, pancreas transplantation, transplantation of encapsulated islet cells, gene therapy technique and islet cell transplantation are used. All techniques have some advantages and disadvantages, but the encapsulated islet cell transplantation technique is promising with minimum complications. 

scholarly journals Safety and Mode of Action of Diabetes Medications in comparison with 5-Aminolevulinic Acid (5-ALA)

2019 ◽  
Vol 2019 ◽  
pp. 1-10 ◽  
Author(s):  
Peter R. Rehani ◽  
Hanaa Iftikhar ◽  
Motowo Nakajima ◽  
Tohru Tanaka ◽  
Zaid Jabbar ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Type 2 Diabetes ◽  
Type 2 Diabetes Mellitus ◽  
Amino Acid ◽  
Diabetes Management ◽  
Aminolevulinic Acid ◽  
Mechanisms Of Action ◽  
Mitochondrial Functions ◽  
Porphyrin Synthesis

5-Aminolevulinic acid (5-ALA) is a delta amino acid naturally present in every living cell of the human body. 5-ALA is produced in the mitochondria as the first product of the porphyrin synthesis pathway and composes heme; exogenously supplemented 5-ALA helps in upregulating mitochondrial functions. Mitochondrial dysfunction has been associated with the pathophysiology of diabetes mellitus. Thus, in this review, we evaluate the mechanisms of action and adverse effects of common medications used to treat type 2 diabetes mellitus as well as 5-ALA including its mechanism and possible use in diabetes management.

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