Diabetes due to immune checkpoint inhibitors: American Society of Clinical Oncology guideline
| Situation | Action |
|---|---|
| Screening and workup | Screening glucose at baseline and with each treatment cycle while on therapy and at follow-up visits for at least 6 months Monitor symptoms for hyperglycemia Other laboratory tests include urine or serum ketones (or both), anion gap on a metabolic panel, anti-glutamic acid decarboxylase antibody, anti-islet cell antibodies, C-peptide |
| Asymptomatic or mild symptoms (grade 1), or type 2 diabetes with fasting glucose < 160 mg/dL and no new evidence of ketoacidosis or pancreatic autoimmunity | Can continue immune checkpoint inhibitor with close clinical follow-up Refer to primary care physician for diabetes management |
| Moderate symptoms (grade 2), or type 2 diabetes with fasting glucose > 160–250 mg/dL and no new evidence of ketoacidosis or pancreatic autoimmunity | May hold immune checkpoint inhibitor until glucose control is obtained Urgent endocrine consultation for any patient with new-onset checkpoint inhibitor-associated diabetes Initiate insulin Refer to emergency department if unable to initiate therapy or if urgent outpatient specialist evaluation is unavailable |
| Severe symptoms (grade 3 or 4), or worsening glucose, glucose > 500 mg/dL, ketoacidosis, or other metabolic abnormality | Hold immune checkpoint inhibitor until glucose control is obtained to levels and symptoms similar to grade 1 Admit for diabetic ketoacidosis, volume and electrolyte resuscitation, and insulin initiation Endocrine consultation recommended for all patients Insulin therapy appropriate for all patients |
Adapted from reference 49.