Abstract | November 17, 2023
Pembrolizumab is the Key to Diabetic Ketoacidosis
Learning Objectives
- Discuss how to diagnose Diabetic Ketoacidosis
- Demonstrate the different causes of Diabetic Ketoacidosis
- Describe Pembrolizumab as a possible cause of DKA
Introduction:
Pembrolizumab is a humanized monoclonal antibody that inhibits Program Cell Death Protein 1 checkpoint to enhance the anti-tumor response. This chemotherapy has multiple uses with side effects of hepatitis, pneumonitis, gastrointestinal distress, and skin reactions. Overall, the observed incidence of DKA in this class of immunotherapy was 0.7%. We present a unique case of a non-diabetic patient who was admitted with Diabetic Ketoacidosis (DKA) after recently starting Pembrolizumab.
Case Presentation:
This is an 86-year-old female with Non-Small Cell Lung Cancer (NSCLC) who started on first dose Pembrolizumab about three weeks prior to this admission. On admission, the non-diabetic patient was hypotensive, lethargic, and altered with blood sugar of 994 mg/dL. Work up revealed A1c of 6.5%, elevated creatinine of 1.89 mg/dL, lactic acidosis with level of 3.9 mmol/L, bicarbonate of 9 mmol/L, elevated beta hydroxybutyrate greater than 5 mg/dL and elevated anion gap of 36 with 2+ ketones on urinalysis. After a couple days of vasopressor and insulin drip requirement in Intensive Care Unit, the patient transferred to the floor. She was discharged on Lantus 12 units and mealtime 6 units.
Alternate causes of DKA, especially in a non-diabetic insulin-naïve patient, include infection, ischemia, pancreatitis, trauma, substance abuse, alcohol use and medication were ruled out. Hence, she was diagnosed with Pembrolizumab-induced DKA.
Final/Working Diagnosis:
Pembrolizumab-induced DKA
Conclusion:
Classically, Pembrolizumab has been known to cause effects of hepatitis, pneumonitis, gastrointestinal distress and skin reactions. In this non-diabetic patient, who was found to have DKA, work up ruled out multiple causes such as infection, ischemia, substance use, iatrogenic, lack of insulin, complication of well-known medications, pancreatitis, and trauma. Therefore, the only cause for this patient as a diagnosis of exclusion was Pembrolizumab, which she started her first dose three weeks prior to admission.
References and Resources
- Taylor SI, Blau JE, Rother KI. SGLT2 Inhibitors may predispose to ketoacidosis. J Clin Endocrinol Metab. 2015;100:2849-52. PMID: 26086329 doi:10.1210/jc.2015-1884
