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Immune-mediated diabetes

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Immunotherapy is a common treatment for cancer that works by mimicking or modifying components of the person’s own immune system to boost it to work better against the cancer and also to remove barriers to the immune system attacking cancer cells. 

Sometimes cancer cells develop the ability to produce certain proteins, which means they can escape being attacked by chemotherapy treatment drugs.

Immunotherapy antibodies made in a lab can help the body to recognise and allow the immune system to attack the cancer cells. A side effect of this treatment can also cause auto-inflammation of the pancreatic β-cells which leads to their destruction just like in classic type 1 diabetes.

Clinical Features

  • Sudden β-cell failure occurring during or after immunotherapy treatment
    • Could appear anywhere from 5 days to 21 months after the start of treatment (1-21 immunotherapy cycles)
    • β-cells are destroyed faster than classical type 1 diabetes
  • High prevalence of DKA due to the sudden and quick onset
  • High prevalence of pancreatitis

Which drugs?

Immune checkpoint inhibitors (ICIs) are the drugs that can cause type 1 diabetes in some people taking them for cancer treatment. ICIs can trigger an immune mediated anti-tumour response as well as auto-inflammatory β-cell failure.

Some of these drugs include:

  • PD-1 inhibitors:
    • Nivolumab (Opdivo)
    • Pembrolizumab (Keytruda) (highest incidence of type 1 diabetes)
  • PDL1 inhibitors:
    • Atezolizumab (Tecentriq)
  • Durvalumab (Imfinzi) CTLA-4 inhibitors:
    • Ipilimumab (Yervoy) (rare incidence)

Diagnosis and treatment

If diabetes is discovered early, through routine glucose monitoring and symptom awareness, individuals more likely to escape DKA and may even retain some residual β-cell function (insulin production).

  • Regular glucose monitoring at the beginning of every immunotherapy cycle and throughout the duration of treatment, including HbA1c can help identify early changes.
  • Awareness of the symptoms of hyperglycemia and ketoacidosis and when to seek urgent medical attention if they should occur

ICIs generally cause absolute insulin deficiency so the person will need treatment the same as someone with classic type 1 diabetes – full insulin replacement.

Currently, there are no established treatment guidelines except that insulin is the treatment; OzDAFNE can be a helpful approach to diabetes management in this situation.

Emotional Health

Autoimmune diabetes is a complex chronic condition on top of another life-threatening condition, cancer.

If there is DKA at diagnosis, this is another life-threatening condition.

People may:

  • Have competing health priorities.
  • Have financial difficulties because some cancer treatments are expensive, and treatment cycles may be associated with an inability to work and the resultant loss of wages.
  • Feel angry because no one explained the risks of developing autoimmune diabetes.
  • Feel overwhelmed and/or depressed by having diabetes on top of cancer, which is probably still being treated.
  • Experience stress and anxiety if the diagnosis of ICI induced diabetes interrupts cancer treatment (possible in severe cases) for those worried about tumour growth.
  • Struggle with variable glucose levels associated with ongoing cancer treatments, especially when steroids are involved.
  • Benefit from ongoing emotional health support from a psychologist or counsellor.
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