An innovative hyperglycemia management protocol for patients receiving cancer therapy is provided through an urgent-care site within the UCSF Infusion Center, and can be replicated at other centers. The protocol ensures that patients promptly get the necessary treatment for acute hyperglycemia that can occur during cancer therapy.

“Many patients develop hyperglycemia or diabetes as a result of their cancer therapies, and they don’t tolerate this well,” said Zoe Quandt, MD, an adjunct assistant professor in endocrinology and diabetes who developed the protocol. “The acuity is higher and they need to start working with an endocrinologist quickly.” 

Rapid response is vital, as hyperglycemia is more complex to manage in patients with cancer and can interfere with their treatment.

Cancer therapies can elevate blood glucose

A recent article on diabetes care for patients with cancer, co-authored by Quandt, describes how several cancer therapies can elevate blood glucose. Glucocorticoid-induced diabetes mellitus and hyperglycemia are common in these patients because steroids can increase insulin resistance. Phosphoinositide 3-kinase (PI3K) inhibitors can also increase insulin resistance. “About half of the patients on PI3K inhibitors will develop hyperglycemia,” Quandt said.

Immune checkpoint inhibitors can cause immune-related adverse effects, including new-onset Type 1 diabetes in about 1% of patients. “It can happen fast.  A lot of people end up in diabetic ketoacidosis and are hospitalized if it isn’t caught very quickly,” Quandt said.

She conducted research on the autoimmune endocrinopathies that can be caused by immune checkpoint inhibitors. That work made her aware of the broader array of cancer treatments that can induce hyperglycemia and diabetes.

A new protocol and system of care

Quandt and Robert Rushakoff, MD, clinical director of the UCSF Diabetes Clinic at Mount Zion, collaborated with the UCSF Infusion Center team to develop a protocol for evaluating and treating patients experiencing hyperglycemia and to set up a cancer-specific urgent-care site within the center.

According to the protocol, the urgent-care team must first determine if the patient needs to be sent to the emergency department. If the patient can be treated on-site, the protocol lays out steps for doing so. “The protocol helps providers determine the amount of insulin and fluids to give the patient for acute resuscitation so that the patient can safely continue with therapy that day,” Quandt explained.

The protocol also calls for patient education. “We’ve piloted a ‘meds-to-chair’ program, where patients’ medications are delivered to the infusion center from the pharmacy,” Quandt said. “The staff can then teach patients how to use a glucometer and insulin pen. Nutrition counseling is provided as well.” Patients also have virtual visits with endocrinologists who determine if any additional care is needed.

“We’ve built a system that enables the infusion center urgent-care team to do the hands-on work with patients,” Quandt said. “They’re excited to offer this to their patients and help avoid emergency department referrals. This system is very unique in terms of how we're taking care of patients receiving cancer therapy.”

Potential biomarkers for endocrinopathies

Quandt is hopeful that biomarkers will be identified to help predict which patients are more likely to develop endocrinopathies from immune checkpoint inhibitors and PI3K inhibitors. “As these therapies are being used more frequently in earlier stages of cancer, we need to figure out how to provide patients with accurate risk assessment for side effects.”

Expanding access 

Quandt believes this protocol and system of on-site urgent care can be implemented in other infusion centers. “I think our work is a steppingstone,” she said. “I recently spoke with a patient advocate who told me the number of patients who don't have access to an endocrinologist in the community is incredibly high. Our goal is to build out the protocol algorithms further so that oncologists without endocrinologists to work with can implement this system and help more patients.”

 

Cancer research and treatment take place within the UCSF Helen Diller Family Comprehensive Cancer Center.

To learn more
UCSF Diabetes Clinic at Parnassus
Phone: (415) 353-2530 | Fax: (415) 353-2337
Refer a patient 

UCSF Diabetes Clinic at Mount Zion
Phone: (415) 885-3868 | Fax: (415) 885-7724
Refer a patient
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