Biologics: Targets & Therapy (May 2023)
Treating Alpelisib-Induced Hyperinsulinemia in Patients with Advanced Breast Cancer – A Real-Life Experience
Abstract
Ruth Percik,1– 3 Cecilie Oedegaard Smith,3,4 Anca Leibovici,5,6 Ayelet Shai7 1Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Ramat Gan, Israel; 2Endo-Oncology Clinic, Sheba Medical Center, Ramat Gan, Israel; 3Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel; 4Oncology Institute, Sheba Medical Center, Ramat Gan, Israel; 5Oncology Department, Galilee Medical Center, Nahariya, Israel; 6Azrielly Faculty of Medicine, Bar-Ilan University, Zafed, Israel; 7Breast Cancer Unit, Division of Oncology, RAMBAM Health Care Campus, Haifa, IsraelCorrespondence: Ayelet Shai, Oncology Department, Rambam Health Care Campus, Ha’alia Hashnia 8, Haifa, 3109601, Israel, Tel +972507887731, Email [email protected]: PIK3CA activating mutations are found in 40% of advanced breast cancer and are associated with worse prognosis. PI3K blockage is associated with insulin resistance, leading to hyperglycemia and hyperinsulinemia. Alpelisib is the first PI3K inhibitor used in cancer treatment. Laboratory evidence indicated that alpelisib-induced hyperinsulinemia offsets the drug’s efficacy, but insulin levels were not tested in the clinical trials that evaluated alpelisib for breast cancer. Hyperglycemia could also interfere with anti-tumor effects of PI3K inhibitors by inducing Immune tolerance and altered mitochondrial metabolism. We have monitored insulin levels in 4 breast cancer patients with concomitant metabolic syndrome treated with alpelisib, and pre-treated patients with baseline increased insulin levels with pioglitazone, a potent insulin sensitizer, to target both hyperinsulinemia and hyperglycemia, and we report the treatment course of these patients. All patients achieved glycemic control and were able to maintain alpelisib dose intensity. Duration of response to alpelisib was longer than anticipated in this treatment setting. Insulin dynamics confirmed the efficacy of pioglitazone as a specific on-target hypoglycemic and hypo-insulinemic agent in the unique setting of PI3K blockade. Our experience suggests that targeting hyperinsulinemia in patients with is safe and feasible and results in good metabolic and oncologic outcomes.Keywords: alpelisib, hyperglycemia, insulin, pioglitazone, hyperinsulinemia, diabetes mellitus
