Acute-onset diabetes mellitus with ketoacidosis in a nivolumab-treated patient with hepatocellular carcinoma.

The therapy with immune checkpoint inhibitors (Programmed cell death-1 and programmed cell death-ligand-1 inhibitors) is a novel and promising approach in cancer treatment. The mode of action can cause serious adverse advents, mainly immune-related ones. The case of a 65 year old caucasian female is reported. She suffers from hepatocellular carcinoma since 2012. She underwent several surgeries, was treated with sorafenib and had transcatheter arterial chemoembolizations. As part of an individual healing trial, the patient was treated with nivolumab every 2 or 3 weeks since September 2017 and has no recurrence of the tumor ever since. Eight months after onset of the therapy she rapidly developed an insulin-dependent diabetes with ketoacidosis. She had no previous history of diabetes. She had no type 1 diabetes-related autoantibodies or a common HLA-genotype associated with a higher risk to develop type 1 diabetes mellitus. This adverse event during therapy with an immune checkpoint inhibitor is yet reported to be rare. Cases with a rapid-onset diabetes with ketoacidosis have also been reported under treatment with other immune checkpoint inhibitors. The pathomechanism is not clear yet and which patients are at an elevated risk. An increasing use of immune checkpoint inhibitor therapy can be expected. This may cause a concurrent increase of the side effect diabetes. Glucose monitoring and sensitizing the patients for this adverse event seems reasonable.