With the introduction of immune checkpoint inhibitors into clinical practice, various autoimmune toxicities have been described. Antibodies targeting the receptor:ligand pairing of programmed death receptor-1 (PD-1) and its cognate ligand programmed death-ligand 1 (PD-L1) in rare reports have been associated with autoimmune diabetes mellitus. We report 2 cases of rapid-onset, insulin-dependent, type 1 diabetes mellitus in the setting of administration of nivolumab, a fully human monoclonal antibody to PD-1, and atezolizumab, a humanized monoclonal antibody to PD-L1. This appears to be the first report of autoimmune diabetes mellitus associated with atezolizumab. In addition, we provide a brief review of similar cases reported in the literature and a discussion of potential mechanisms for this phenomenon and propose a diagnostic and treatment algorithm.

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former cohort suggests that prolonged ibrutinib exposure increases the propensity for AF over time, or that these patients were at a higher risk of developing AF due to advancing age and exposure to other AF related morbidities such as hypertension, prolonged disease exposure, and effects of prior therapeutics. Cardiac amyloidosis is highly associated with arrhythmias and may have contributed to AF in one patient. The findings nonetheless continue to support an increased risk of AF for WM patients on ibrutinib therapy. The causal mechanism for ibrutinib related AF remains under investigation, though inhibition of cardiac PI3K-Akt signaling has been hypothesized [6].Despite the increased risk of ibrutinib associated AF, the overall efficacy and safety data of this agent in WM continues to supports its use. Many adverse events common to other WM therapies are absent with ibrutinib, including uninvolved immunoglobulin depletion, peripheral neuropathy, myelosuppression, disease transformation, and increased risk of secondary cancers, including treatment related myelodysplasia and acute myeloid leukemia [1]. Moreover, a prior history of AF does not appear to prohibit treatment with ibrutinib, as 11 of 12 patients (92%) with an AF event continued on ibrutinib following cardiology intervention. A baseline electrocardiogram appears warranted as to screen for arrhythmias prior to ibrutinib initiation. In summary, a higher incidence of AF is associated with the use of ibrutinib in WM patients than previously reported, with a shorter time to AF event observed in patients with versus without a prior history of AF. Nearly all patients who developed AF were able to continue ibrutinib following cardiological intervention and/or ibrutinib dose reduction.

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