11 yrs girl child. Presented with Fever&Easy fatiguability for 15days to a pvt hospital. Bone marrow showed Acute lymphoblastic leukemia
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2 11 yrs girl child Presented with Fever&Easy fatiguability for 15days to a pvt hospital Bone marrow showed Acute lymphoblastic leukemia Referred to ICH
3 Child was started on modified BFM 2013 protocol PREINDUCTION PHASE: Inj.Dexamethasone
4 INDUCTION PHASE Inj.Vincristine Inj.Adriamycin T.Prednisolone Inj.L.Asparaginase IT Triple drugs
5 CONSOLIDATION PHASE Inj.Cytosine arabinoside Inj.cyclophosphamide IT Triple drugs
6 INTERIM MANAGEMENT T.Mercaptopurine T.Methotrexate IT methotrexate
7 REINDUCTION Inj.Vincristine Inj.Adriamycin T.Dexamethasone Inj.L.Asparaginase IT Triple drugs
8 RECONSOLIDATION PHASE Inj.Cytosine arabinoside Inj.cyclophosphamide IT Triple drugs
9 MAINTENANCE THERAPY(2 yrs) T.Mercaptopurine T.Methotrexate T.Dexamethasone Inj.Mtx Inj.vincristine
10 Sleeplessness Consolidation phase Crying spells T.Sertraline Communication difficulty T.clonazepam T.Clonazepam changed to T.Nitrazepam Still on these drugs without any specific complaints Sleeping difficulty persisted
11 Reconsolidation phase Diagnosed as Diabetes (non DKA ONSET) RBS-404 mg/dl Urinary ketones POSITIVE On probing found to have polyuria&polyphagia 15 days ABG-Normal
12 Started on sc insulin with CBG monitoring.initial HbA1c-6.1% Insulin changed to split mix regime & discharged with a dose of 0.5 U/kg/day On regular followup the dosage was adjusted according to SMBG After 8 wks the HbA1c was 3.9%&c-peptide was normal(3.2 ng/ml).hence insulin dose gradually tapered Insulin dose stopped after a total period of 12 wks.hba1c was 5% On regular followup tilldate (8 MONTHS).Euglycemic till date. Current HbA1c -4.7%(normal);c-peptide-2.07 ng/ml(normal)
13 11 yr old girl on ALL treatment Developed Diabetes(non-DKA onset) Controlled with insulin Resolved after 12 wks Not requiring insulin thereafter DRUG INDUCED DIABETES L.ASPARAGINASE HIGH DOSE STEROIDS
14 DIABETES-ETIOLOGICAL CLASSIFICATION TYPE 1 Autoimmune Idiopathic TYPE 2 OTHER SPECIFIC TYPES Genetic defects of ß-cell function Genetic defects of insulin action Disease of exocrine pancreas Endocrinopathies Drug or chemical induced Infections Uncommon forms of immune mediated diabetes other genetic syndrome some times associated with diabetes GESTATIONAL DIABETES
15 DRUGS CAUSING DIABETES WEAKLY DIABETOGENIC STRONGLY DIABETOGENIC Antihypertensive Statins Thiazides Steroids Antipsychotics Immunosuppressants Protease inhibitors ß-CELL POISONS vacor,alloxan, streptozocin ANTIBIOTICS Gatifloxacin Levofloxacin
16 L-ASPARAGINASE&DIABETES MELLITUS 1-14%(temporary) 1-2%(permanent) MECHANISM-inhibition of insulin synthesis inhibition of insulin receptor TIME OF ONSET-1 wk to 4 months DIAGNOSIS-1.Temporal relation of diabetes with the drug 2.Exclusion of other causes Concurrent administration of Doxorubicin,Vincristine & prednisolone increases the incidence of pancreatitis
17 CASE REPORT-1 vtransient DIABETES MELLITUS RELATED TO L-ASPARAGINASE THERAPY Portuguese article; JUNE yrs girl developed diabetes 4 months after starting this drug& required insulin for 12 months.the Anti-islet autoantibody were negative &there were no laboratory finding suggestive of pancreatitis.the DM related to LAsparaginase is insulopenic &transient,resolving with the suspension of the drug
18 CASE REPORT-2 v DKA WITH L-ASPARAGINASE Indian pediatrics ;SEP 2011 Rakesh,Madhumita,Astha Department of pediatrics,ipgme&r and SSK Hospital,kolkata 1st case-11 yrs male child with T-cell ALL developed DKA 7 days after starting maintenance phase the child managed as for DKA but succumbed to illness 3 days later 2nd case-12 yr male child with ALL-L2 ;diagnosed to have DKA after 2 months of maintenance phase &treated for DKA.However his glycemic control was not adequate & started on glargine along with actrapid
19 CASE REPORT-3 TRANSIENT DIABETES MELLITUS SECONDARY TO L-ASPARAGINASE THERAPY International journal of pediatric endocrinology 2013 Lalaine audrey Philippine General Hospital,Philippines 11 yrs girl child diagnosed as ALL developed hyperglycemia on day 16 of l-asparaginase &started on insulin.other investigation were normal.the child required insulin after 1 month of stopping lasparaginase to attain euglycemic state
20 CASE REPORT-4(ICH&HC) v CHEMOTHERAPHY INDUCED DKA Pediatric on call;may 2012 V Poovazhagi,S Thangavelu,S Shanthi Institute of Child Health and Hospital for Children, Egmore, Chennai 11 yr girl with ALL relapse,developed DKA on 7th day of therapy,treated as per DKA protocol &insulin was stopped after 4 wks of hyperglycemia, since she showed a good pancreatic beta cell reserve in terms of fasting and stimulated C peptide levels at 3 weeks of hyperglycemia (fasting C peptide was 1.1 pmol/ml and stimulated c peptide was 3 pmol/ml).
21 CARRY HOME MESSAGE Diabetes mellitus is common with LAsparaginase;hence periodic monitoring of blood sugar should be done in patients on chemotherapy for ALL Occurence of DKA does not warrant alteration of ALL treatment
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