Risk Assessment of Hyperglycaemia Induced by Steroid Use for Immunotherapy Toxicity in Non-Small Cell Lung Cancer (NSCLC) Patients

Islam Elkonaissi, May Low, Charlotte Milner-Watts, Emma Foreman, Mohammed Kabir, Jaishree Bhosle, Mary O’Brien

Introduction

Immune checkpoint inhibitors (ICPis) are associated with an immune-related spectrum of side effects. High dose and prolonged courses of steroids are the mainstay of management which can precipitate hyperglycaemia. Poor glycaemic control has been linked with poor cancer prognosis and reduced quality of  life in observational studies.

Aim

To determine if the risk assessment of hyperglycaemia induced by steroid use for ICPis toxicity in NSCLC is completed according to Trust clinical practice and the Joint British Diabetes Societies (JBDS) guidelines.

Method

Using electronic data records, a retrospective evaluation of NSCLC patients receiving ICPis was conducted from May 2018 to Jan 2019. All patients who received steroids for the management of immune-related adverse events were included. Clinical trials were excluded. 

To meet the target of adequate risk assessment in 90% of patients, with 95% CI of (80 – 100%), this would require a sample size of patients with immunotherapy toxicity requiring steroid management of n=35 (expected to obtain from n=100 population).

Results

  • 125 NSCLC patients  were treated with ICPis  from May 2018  to Jan 2019.
  • 36/125 patients (29%; CI: 22-37%) received steroids  for immunotherapy-related toxicities. This proportion is in accordance with clinical practice and published literature
  • 18/36 patients experienced a new grade 1 hyperglycaemia which may have required an intervention.
  • HbA1c was measured alongside  a baseline glucose  level (never in isolation) in only 22%. 
  • There was no risk assessment carried out using the JBDS assessment criteria to identify  patients at higher risk.
  • The level of laboratory glucose measurements shows that hyperglycaemia is taken into consideration in clinic reviews.

Discussion

This is a baseline audit. 

Findings highlight that current practice requires improvement and draws attention to this area. A major factor to consider is awareness of guidelines in light of the substantial increase in the complexity of management of NSCLC in recent years.

Limitations

Data was retrospectively collected.

Recommendations

  • Share findings with relevant teams
  • Develop a local diabetes risk assessment tool for this cohort 
  • Improve efforts in education and communication 
  • Re-audit in 12 months’ time.

 

Glucose levels must be monitored in patients receiving steroids for immunotherapy-related toxicity