L-asparaginase-induced severe necrotizing pancreatitis successfully treated with percutaneous drainage

Asparaginase-Associated Pancreatitis in Pediatric Patients with Acute Lymphoblastic Leukemia: Current Perspectives

Asparaginase therapy is a vital agent in the treatment of acute lymphoblastic leukemia (ALL), with increasing evidence of its high importance in high-risk ALL populations. However, despite the clear clinical and biological benefits of asparaginase therapy, many patients experience toxicities. A well-known treatment-limiting toxicity is asparaginase-associated pancreatitis (AAP). If severe, it necessitates discontinuation of asparaginase therapy, which can lead to a higher risk of relapse in patients with ALL. New protocols for ALL therapy have increased overall total doses of asparaginase therapy in select high-risk populations and have incorporated longer half-life formulations of pegylated asparaginase. Treatment drug monitoring has also allowed assurance of adequate levels of asparagine depletion throughout treatment. It is currently unknown if these changes will increase rates of AAP. Interestingly, important pharmacogenomics data, such as single nucleotide polymorphisms, can identify patients at the highest risk for severe AAP. The incidence of AAP in recent trials, current pharmacogenomic data that could further our understanding of the disease, and the importance of cautiously re-exposing patients to further asparaginase treatment after an initial episode of AAP are discussed.

Drug induced pancreatitis: A systematic review of case reports to determine potential drug associations

OBJECTIVE

A current assessment of case reports of possible drug-induced pancreatitis is needed. We systematically reviewed the case report literature to identify drugs with potential associations with acute pancreatitis and the burden of evidence supporting these associations.

METHODS

A protocol was developed a priori (PROSPERO CRD42017060473). We searched MEDLINE, Embase, the Cochrane Library, and additional sources to identify cases of drug-induced pancreatitis that met accepted diagnostic criteria of acute pancreatitis. Cases caused by multiple drugs or combination therapy were excluded. Established systematic review methods were used for screening and data extraction. A classification system for associated drugs was developed a priori based upon the number of cases, re-challenge, exclusion of non-drug causes of acute pancreatitis, and consistency of latency.

RESULTS

Seven-hundred and thirteen cases of potential drug-induced pancreatitis were identified, implicating 213 unique drugs. The evidence base was poor: exclusion of non-drug causes of acute pancreatitis was incomplete or poorly reported in all cases, 47% had at least one underlying condition predisposing to acute pancreatitis, and causality assessment was not conducted in 81%. Forty-five drugs (21%) were classified as having the highest level of evidence regarding their association with acute pancreatitis; causality was deemed to be probable or definite for 19 of these drugs (42%). Fifty-seven drugs (27%) had the lowest level of evidence regarding an association with acute pancreatitis, being implicated in single case reports, without exclusion of other causes of acute pancreatitis.

DISCUSSION

Much of the case report evidence upon which drug-induced pancreatitis associations are based is tenuous. A greater emphasis on exclusion of all non-drug causes of acute pancreatitis and on quality reporting would improve the evidence base. It should be recognized that reviews of case reports, are valuable scoping tools but have limited strength to establish drug-induced pancreatitis associations.

REGISTRATION

CRD42017060473.

Hypertriglyceridemia-Associated Drug-Induced Acute Pancreatitis

OBJECTIVES

The aim of our study was to investigate the cases of drug-induced acute pancreatitis (DIAP) with hypertriglyceridemia as the mechanism of injury.

METHODS

A MEDLINE search (1963-2018) of the English language literature was performed looking for all human case reports of adults (>18 years old) with hypertriglyceridemia as the mechanism of DIAP. The latest search date was February 28, 2018. Drugs were classified into probability groups based on a classification used by Badalov et al (Clin Gastroenterol Hepatol. 2007;5:648-661).

RESULTS

The search revealed a total of 76 cases in 59 published reports. A total of 25 medications were found to be implicated in DIAP secondary to hypertriglyceridemia mechanism. Most of acute pancreatitis cases were mild or moderately severe with favorable outcomes. In 3 cases involving tamoxifen, pagaspargase, and quetiapine, patient death was the outcome. Plasmapheresis was only used in 9 cases in an effort to decrease triglyceride levels.

CONCLUSIONS

Hypertriglyceridemia-associated DIAP is a rare phenomenon, and the current systematic review provides a summary of drugs that have been implicated in this phenomenon, which allow physicians to be oriented about this adverse effect when these drugs are used.

Clinical Characteristics and Sequelae of Severe Hypertriglyceridemia in Pediatrics

OBJECTIVE

Severe hypertriglyceridemia (HTG) (i.e., plasma triglycerides [TGs] >1,000 mg/dL) in children is a rare but pernicious and understudied condition. Our objective was to evaluate the etiology, characteristics, and sequelae of severe pediatric HTG.

METHODS

This was a retrospective electronic medical record review of pediatric patients with severe HTG at a tertiary referral Children's hospital over a 17-year period.

RESULTS

There were a total of 124 patients with severe HTG. The etiology varied: hemato-oncologic (n = 48), diabetes and insulin resistance-related (n = 46), total parenteral nutrition (TPN)-related (n = 6), renal (n = 12), and miscellaneous (n = 12). There was considerable variability in the number of days for the plasma TGs to decrease to <1,000 mg/dL (147.7 ± 567.3 days) and to further decrease to <500 mg/dL (136.84 ± 230.9 days). Patients with diabetes required the longest time to improve their plasma TGs (165.8 ± 305.7 days) compared to other groups. There were 11 cases of pancreatitis, comorbid with diabetes (n = 5), hemato-oncologic conditions (n = 3), and TPN (n = 3). Sixty-seven patients (54%) had persistent HTG.

CONCLUSION

Severe HTG in pediatrics is commonly due to secondary causes. Patients with diabetes tend to have a longer course of dyslipidemia. A substantial number of patients had persistent dyslipidemia, indicating underlying genetic susceptibility to HTG that is phenotypically expressed consequent to a secondary metabolic insult.

ABBREVIATIONS

DKA = diabetic ketoacidosis; EMR = electronic medical record; GSD = glycogen storage disorder; HbA1c = hemoglobin A1c; HIV = human immunodeficiency virus; HTG = hypertriglyceridemia; ICD-9 = International Classification of Diseases-Ninth Revision; IV = intravenous; LCHAD = long-chain 3-hydroxyacyl coenzyme A dehydrogenase deficiency; LPL = lipoprotein lipase; NPO = nothing by mouth; PCOS = polycystic ovary syndrome; T1DM = type 1 diabetes mellitus; T2DM = type 2 diabetes mellitus; TG = triglyceride; TPN = total parenteral nutrition; VLDL = very-low-density lipoprotein.

Acute Pancreatitis in Pediatric Patients: Demographics, Etiology, and Diagnostic Imaging

OBJECTIVE

The objective of this article is to provide updates on acute pancreatitis in children regarding the imaging findings, causes, and complications based on a review of the current studies in the pediatrics literature. We discuss the epidemiology of acute pancreatitis, the role of imaging and imaging findings in the diagnosis of acute pancreatitis, and the causes and complications of acute pancreatitis.

CONCLUSION

The incidence of acute pancreatitis is increasing in children. Imaging plays an important role in the diagnosis of acute pancreatitis because imaging findings can be used to establish the cause of acute pancreatitis, evaluate for complications of acute pancreatitis, and possibly predict the course of the disease.

Pegaspargase Induced Hypertriglyceridemia Resulting in Severe Fatal Pancreatitis

Pegaspargase is used to treat acute lymphocytic leukemia (ALL). Pegaspargase definitely has its benefits in treating ALL; however we cannot lose sight of one of its very rare but potentially deadly complications, acute pancreatitis. Clinicians should monitor triglycerides while the patient is on treatment with Pegaspargase and suspect acute pancreatitis if the patient develops abdominal pain. If pancreatitis occurs, therapy should be stopped immediately and not reinstituted. For patients with hypertriglyceridemia without pancreatitis, discontinuation of therapy should be considered.

Investigation of protective effect of L-carnitine on L-asparaginase-induced acute pancreatic injury in male Balb/c mice

INTRODUCTION

The present analysis deals with the biochemical and histopathological effects of L-carnitine in mice with L-asparaginase (ASNase)-induced experimental acute pancreatic injury (API).

METHODS

A total of 32 male Balb/c mice were divided into four groups as follows. Group I (control) was injected with single saline via the intraperitoneal route. Group II received 500 mg/kg of L-carnitine daily with the injected volume of 62.5-75 μl for 25-30 g mice using a Hamilton microinjector applied for 5 days. Group III received a single 10,000 IU Escherichia coli ASNase/kg body weight dose of ASNase at a dose of 500 mg/kg. Group IV received 500 mg/kg of L-carnitine daily and a single dose of 500 mg/kg of ASNase and were decapitated on the fifth day following the injection. Blood and pancreatic tissue samples were obtained for evaluation of histopathological structure and levels of malondialdehyde (MDA), reduced glutathione (GSH), total sialic acid (TSA), glucose, amylase and triglyceride.

RESULTS

In group III, compared to group IV and group I it was determined that levels of GSH and amylase were significantly lower while levels of MDA, TSA, glucose and triglyceride were higher. Levels of GSH, MDA, TSA, glucose, triglyceride and amylase, especially in group IV, approached that of group I. As a result, L-carnitine for ASNase-induced API mice may be protective against pancreatic tissue degeneration and oxidative stress or lipid peroxidation.

Endoscopic necrosectomy in children

Acute pancreatitis in children is rarely complicated by the development of necrosis. Although endoscopic transluminal necrosectomy is evolving as the standard of care in adults, its feasibility in the pediatric population has not been established. We hereby report the first case series of children with necrotizing pancreatitis successfully treated with endoscopic therapy. We believe the use of fully covered self-expanding metallic stents in the cystgastrostomy may reduce the number of transluminal necrosectomy sessions for large necrotic collections in children.

Acute necrotizing pancreatitis in children

OBJECTIVE

To describe the etiologic factors, course, and outcome of acute necrotizing pancreatitis in children.

STUDY DESIGN

We performed a retrospective study of children with necrotizing pancreatitis diagnosed during the last 21 years at Yale-New Haven Children's Hospital. Computed tomography (CT) criteria were used to diagnose necrotizing pancreatitis and to assess severity index. Charts were reviewed to collect demographics, etiology, details of hospital stay, complications, and outcome.

RESULTS

Seven children (mean age, 11.6 years; range, 4-17.8 years) had necrotizing pancreatitis. Etiologic factors were medications, diabetes, and gallstones. All had prolonged hospitalization (9-40 days; mean, 20 days) and 5 patients required admission to the pediatric intensive care unit. During the hospital stay, patients developed complications involving the respiratory, hematologic, renal, metabolic, and circulatory systems. All patients had aggressive supportive medical therapy, and none required surgery. There were no deaths attributable to pancreatitis. Late complications after hospital discharge occurred in 5 patients and included pseudocysts, transient hyperglycemia, diabetes, and pancreatic exocrine insufficiency. The CT severity index correlated with the risk of complications.

CONCLUSIONS

A cute necrotizing pancreatitis has a variable etiology in children. CT scan is useful in the diagnosis and assessment of severity. Necrotizing pancreatitis in children is associated with severe acute and late complications and requires intensive medical therapy.

Asparaginase-associated pancreatitis in children

l-asparaginase has been an element in the treatment for acute lymphoblastic leukaemia (ALL) and non-Hodgkin lymphoma since the late 1960s and remains an essential component of their combination chemotherapy. Among the major toxicities associated with l-asparaginase therapy are pancreatitis, allergic reactions, thrombotic events, hepatotoxicity and hyperlipidaemia. Acute pancreatitis is one of the most common reasons for stopping treatment with l-asparaginase. Short-term complications of asparaginase-associated pancreatitis include development of pseudocysts and pancreatic necrosis. Long-term complications include chronic pancreatitis and diabetes. The pathophysiology of asparaginase-associated pancreatitis remains to be uncovered. Individual clinical and genetic risk factors have been identified, but they are only weak predictors of pancreatitis. This review explores the definition, possible risk factors, treatment and complications of asparaginase-associated pancreatitis.

Prevention and management of asparaginase/pegasparaginase-associated toxicities in adults and older adolescents: recommendations of an expert panel

The rapidly increasing use of pegasparaginase (pegASNase) in adults, after a half century of use of asparaginase (ASNase) in children, has prompted a need for guidelines in the management and prevention of toxicities of asparagine depletion in adults. Accordingly, an initial set of recommendations are provided herein. Major advantages of pegASNase are its 2-3-week duration of action, in contrast to less than 3 days with native ASNase, and the flexibility of intravenous or intramuscular administration of pegASNase and associated patient and physician convenience. The most frequent toxicities of both types of ASNase are hepatic and pancreatic, with pancreatitis being the most serious. Other toxicities are hypersensitivity reactions, thrombosis, nausea/vomiting, and fatigue. Whether or not the replacement of one dose of pegASNase for 6-9 doses of native ASNase can be achieved in adults with similar efficacy and acceptable toxicities to those achieved in children remains to be established.

Cell-cycle inhibition by Helicobacter pylori L-asparaginase

Helicobacter pylori (H. pylori) is a major human pathogen causing chronic gastritis, peptic ulcer, gastric cancer, and mucosa-associated lymphoid tissue lymphoma. One of the mechanisms whereby it induces damage depends on its interference with proliferation of host tissues. We here describe the discovery of a novel bacterial factor able to inhibit the cell-cycle of exposed cells, both of gastric and non-gastric origin. An integrated approach was adopted to isolate and characterise the molecule from the bacterial culture filtrate produced in a protein-free medium: size-exclusion chromatography, non-reducing gel electrophoresis, mass spectrometry, mutant analysis, recombinant protein expression and enzymatic assays. L-asparaginase was identified as the factor responsible for cell-cycle inhibition of fibroblasts and gastric cell lines. Its effect on cell-cycle was confirmed by inhibitors, a knockout strain and the action of recombinant L-asparaginase on cell lines. Interference with cell-cycle in vitro depended on cell genotype and was related to the expression levels of the concurrent enzyme asparagine synthetase. Bacterial subcellular distribution of L-asparaginase was also analysed along with its immunogenicity. H. pylori L-asparaginase is a novel antigen that functions as a cell-cycle inhibitor of fibroblasts and gastric cell lines. We give evidence supporting a role in the pathogenesis of H. pylori-related diseases and discuss its potential diagnostic application.

Acute pancreatitis in children with acute lymphoblastic leukemia treated with L-asparaginase

BACKGROUND

L-asparaginase (L-asp) is used as part of the initial treatment in children with acute lymphoblastic leukemia (ALL), inducing remission in 83% to 95% of the treated patients. Major toxicity effects reported are hypersensitivity reactions and dysfunctions of the liver and pancreas. Acute pancreatitis (AP) induced by L-asp has been noted in 2.5% to 16% of the treated patients. The purpose of this study was to determine the frequency and outcome of AP in children with ALL treated with L-asp in a tertiary care pediatric hospital.

METHODS

From January 1999 to June 2005, the charts of children with ALL admitted for L-asp treatment were reviewed. Data from children who developed AP were analyzed retrospectively. AP was defined as the presence of clinical data (nausea, vomiting, and abdominal pain), elevated pancreatic enzymes, and changes in the abdominal ultrasound and/or computed tomography (CT) scan. Clinical and biochemical data, abdominal ultrasound, and CT scan findings, complications, treatment, and outcome were analyzed retrospectively.

RESULTS

During the last 6 years, 266 ALL new cases were started on chemotherapy including L-asp, of which 18 of 266 (6.7%) developed AP. Pancreatic necrosis by CT scan was found in 10 patients, peripancreatic collections and pseudocyst formation were detected in 5 and 3 cases, respectively, and resolved by cystogastrostomy or drainage. Two patients developed chronic pancreatitis and 3 diabetes. There was no relationship between number of doses and pancreatic toxicity. None of the patient died due to pancreatic toxicity.

CONCLUSIONS

L-asp is an effective drug to treat ALL, the administration of L-asp requires the monitoring of pancreatic toxicity to detect AP and have treatment initiated as early as possible. Chronic complications after AP occur in almost one third of cases.

Pancreatic panniculitis caused by L-asparaginase induced acute pancreatitis in a child with acute lymphoblastic leukemia

Panniculitis caused by L-asparaginase induced acute pancreatitis is an unusual condition. We report a case of a 7-year-old Thai boy with underlying acute lymphoblastic leukemia who developed pancreatic panniculitis caused by L-asparaginase administration. During the second week of induction chemotherapy, the patient developed acute pancreatitis with septic shock. Two weeks later he developed multiple subcutaneous nodules on the abdominal wall. Skin excisional biopsy showed the typical histopathological features of pancreatic panniculitis. Acute pancreatitis improved after 3 weeks of conservative treatment. The skin lesions resolved spontaneously within 1 month.

Effect of admission hypertriglyceridemia on the episodes of severe acute pancreatitis

AIM: To investigate the effect of admission hypertriglyceridemia (HTG) on the episodes of severe acute pancreatitis (SAP).

METHODS: One hundred and seventy-six patients with SAP were divided into HTG group (n = 45) and control group (n = 131) according to admission triglyceride (TG) ≥ 5.65 mmol/L and < 5.65 mmol/L, respectively. Demographics, etiology, underlying diseases, biochemical parameters, Ranson’ s score, acute physiology and chronic heath evaluation II (APACHE II) score, Balthazar’s computed tomography (CT) score, complications and mortality were compared. Correlation between admission TG and 24-h APACHE II score was analyzed.

RESULTS: SAP patients with HTG were younger (40.8 ± 9.3 years vs 52.6 ± 13.4 years, P < 0.05) with higher etiology rate of overeating, high-fat diet (40.0% vs 14.5%, P < 0.05) and alcohol abuse (46.7% vs 23.7%, P < 0.01), incidence rate of hypocalcemia (86.7% vs 63.4%, P < 0.01) and hypoalbuminemia (84.4% vs 60.3%, P < 0.01), 24-h APACHE II score (13.6 ± 5.7 vs 10.7 ± 4.6, P < 0.01) and admission serum glucose (17.7 ± 7.7 vs 13.4 ± 6.1, P < 0.01), complication rate of renal failure (51.1% vs 16.8%, P < 0.01), shock (37.9% vs 14.5%, P < 0.01) and infection (37.4% vs 18.3%, P < 0.01) and mortality (13.1% vs 9.1%, P < 0.01). Logistic regression analysis showed a positive correlation between admission TG and 24-h APACHE II score (r = 0 .509, P = 0.004).

CONCLUSION: The clinical features of SAP patients with HTG are largely consistent with previous studies. HTG aggravates the episodes of SAP.

Alanyl-glutamine consumption modifies the suppressive effect of L-asparaginase on lymphocyte populations in mice

Asparaginase (Elspar) is used in the treatment of acute lymphoblastic leukemia. It depletes plasma asparagine and glutamine, killing leukemic lymphoblasts but also causing immunosuppression. The objective of this work was to assess whether supplementing the diet with glutamine modifies the effect of asparaginase on normal lymphocyte populations in the spleen, thymus, and bone marrow. Mice consuming water ad libitum with or without alanyl-glutamine dipeptide (AlaGln; 0.05 mol/L) were injected once daily with 0 or 3 international units/g body weight Escherichia coli L-asparaginase for 7 d. Tissue expression of specific immune cell surface markers was analyzed by flow cytometry. Asparaginase reduced B220+ and sIgM+ cells in the bone marrow (P < 0.05) and diminished total cell numbers in thymus (-42%) and spleen (-53%) (P < 0.05). In thymus, asparaginase depleted double positive (CD4+ CD8+) and single positive (CD4+ CD8-, CD4-CD8+) thymocytes by over 40% (P < 0.05). In spleen, asparaginase reduced CD19+ B cells to 33% of controls and substantially depleted the CD4+ and CD8+ T cell populations. CD11b-expressing leukocytes were reduced by 50% (P < 0.05). Consumption of AlaGln did not lessen the effects of asparaginase in bone marrow or thymus but mitigated cellular losses in the CD4+, CD8+, and CD11b+ populations in spleen. AlaGln also blunted the increase in eukaryotic initiation factor 2 (eIF2) phosphorylation by asparaginase in spleen, whereas eIF2 phosphorylation did not change in thymus in response to asparaginase or AlaGln. In conclusion, asparaginase reduces maturing populations of normal B and T cells in thymus, bone marrow, and spleen. Oral consumption of AlaGln mitigates metabolic stress in spleen, supporting the peripheral immune system and cell-mediated immunity during asparaginase chemotherapy.

Surgical Complications of Childhood Tumors

Most childhood tumors will first present to a physician; some tumors will present in an atypical manner and may mimic a surgical condition. The diagnosis may be missed if the surgeon is not aware of the possibility of cancer. A very great number of rare presentations of childhood cancer have been described in the literature. It is important that the surgeon who is not experienced in the management of childhood cancer is aware that an apparently benign condition could be a manifestation of an underlying malignancy [71, 83] (Table 22.1).

Octreotide prevents L-asparaginase-induced pancreatic injury in rats

OBJECTIVE

L-asparaginase (ASNase) is one of the most effective chemotherapeutic means for inducing remission in acute lymphoblastic leukemia. However, because of unknown risk factors, severe pancreatitis sometimes occurs in patients receiving ASNase. We assessed the effect of ASNase on pancreatic acinar cells and then investigated the preventive effects of octreotide against ASNase-induced pancreatic injury in rats.

MATERIALS AND METHODS

Rats received intraperitoneal injections of an Escherichia coli ASNase solution (200, 500, or 1000 IU/kg) or normal saline as a control every 24 hours for 5 days. Octreotide (3 microg/kg) was injected subcutaneously with ASNase (1000 IU/kg) every 8 hours for 5 days. Rats were sacrificed 24 hours after the last injection of ASNase or normal saline.

RESULTS

Only the rats given 1000 IU/kg ASNase had significantly increased levels of pancreatic amylase (1962 +/- 152 vs 2179 +/- 84 IU/L, p < 0.01), trypsin (27.3 +/- 3.6 vs 41.1 +/- 22.8 IU/L, p < 0.05), and pancreatic secretory trypsin inhibitor (0.03 +/- 0.09 vs 0.27 +/- 0.10 ng/mL, p < 0.01) as compared to the control group. In addition, the acinar cells showed histological damage; however, octreotide injection provided protection against histological damage and the pancreatic enzymes remained within normal limits.

CONCLUSIONS

Although ASNase by itself did not cause pancreatitis, it did cause increased levels of pancreatic enzymes and histological damage to the pancreas associated with pancreatic injury or pre-pancreatitis. Prior treatment with octreotide prevented the development of ASNase-induced pancreatic injury.

Predicting asparaginase-associated pancreatitis

BACKGROUND

Pancreatitis is a well-known, but little-understood complication of asparaginase. There is no predictor of who will develop asparaginase-associated pancreatitis (AAP). To better define this population, we present a retrospective analysis regarding AAP and provide a review of the relevant literature.

METHODS

We systematically reviewed medical records of 254 asparaginase recipients during a 5-year period. Pancreatitis was defined and graded according to CTCAE v3.0.

RESULTS

Pancreatitis was diagnosed in 48 (19%) patients. Thirty-three (13%) patients were identified as having AAP. Twelve cases occurred after Escherichia coli asparaginase and 20 followed PEG-asparaginase. Pancreatitis was independent of the individual or cumulative asparaginase dose. The interval to pancreatitis diagnosis was longer for PEG-asparaginase than E. coli asparaginase (P = 0.02). AAP was seen more frequently in patients receiving prednisone (P = 0.02) and daunomycin (P = 0.006) while less frequent with dexamethasone (P = 0.04). Other chemotherapy agents appeared to have no association with AAP. As observed by others, those with pancreatitis were older (P = 0.001), but the significance of this remains uncertain.

CONCLUSIONS

This study emphasizes our inability to predict who will develop pancreatic toxicity from asparaginase and suggests that those at risk might have an unidentified genetic predisposition.

Drug-induced acute pancreatitis: an evidence-based review

The diagnosis of drug-induced acute pancreatitis often is difficult to establish. Although some medications have been shown to cause acute pancreatitis with a large body of evidence, including rechallenge, some medications have been attributed as a cause of acute pancreatitis merely by a single published case report in which the investigators found no other cause. In addition, some medications reported to have caused acute pancreatitis have obvious patterns of presentation, including the time from initiation to the development of disease (latency). There also appear to be patterns in the severity of disease. After reviewing the literature, we have classified drugs that have been reported to cause acute pancreatitis based on the published weight of evidence for each agent and the pattern of clinical presentation. Based on our analysis of the level of evidence, 4 classes of drugs could be identified. Class I drugs include medications in which at least 1 case report described a recurrence of acute pancreatitis with a rechallenge with the drug. Class II drugs include drugs in which there is a consistent latency in 75% or more of the reported cases. Class III drugs include drugs that had 2 or more case reports published, but neither a rechallenge nor a consistent latency period. Class IV drugs were similar to class III drugs, but only 1 case report had been published. Our analysis allows an evidence-based approach when suspecting a drug as causing acute pancreatitis.

Use of L-asparaginase in childhood ALL

Owing to the high efficacy of L-asparaginase in the treatment of acute lymphatic leukaemia the enzyme was introduced into the chemotherapy schedules for remission induction of this disease shortly after results of large-scale clinical trials had become available. Since asparaginase monotherapy was associated with a high response rate but short remission duration, the enzyme is currently employed within the framework of combination chemotherapy schedules which achieve treatment response in about 90% and long-term remissions in the majority of patients. Recently initiated clinical trials have still confirmed the eminent value of asparaginase in the combination chemotherapy of acute lymphatic leukaemia and of some subtypes of non-Hodgkin lymphoma, and its important role as an essential component of multimodal treatment protocols. Despite the unique mechanism of action of this cytotoxic substance which shows relative selectivity with regard to the metabolism of malignant cells, some patients experience toxic effects during asparaginase therapy. Immunological reactions toward the foreign protein include enzyme inactivation without any clinical manifestations as well as anaphylactic shock. Severe functional disorders of organ systems result from the impaired homeostasis of the amino acids asparagine and glutamine. The changes affecting the proteins of the coagulation system have considerable clinical impact as they may induce bleeding as well as thromboembolic events and may be associated with life-threatening complications when the central nervous system is involved. Risk factors predisposing to thromboembolic complications are hereditary resistance against activated protein C and any other hereditary thrombophilia. Other organ systems potentially affected by relevant functional disorders are the central nervous system, the liver, and the pancreas, with patients who have a history of pancreatic disorders carrying an especially high risk of developing pancreatitis. Studies on the mechanisms of action and the occurrence of resistance phenomena have shown that a treatment response may only be expected if the malignant cells are unable to increase their asparagine synthetase activity to an extent providing enough asparagine to the cell; one may thus conclude that the enzyme-induced asparagine depletion of the serum constitutes the decisive cytotoxic mechanism. Independent of the asparagine depletion related cytotoxicity however, there are other mechanisms of clinical relevance like induction of apoptosis. Besides this, further influences on signal transduction cannot be excluded. Only few publications have dealt with the question of minimum trough activities to be ensured before each subsequent asparaginase dose in order to maintain uninterrupted asparagine depletion under treatment, and answers to this problem are not definitive. Clinical studies using enzymes from E. coli strains indicate that a trough activity of 100 U/l will suffice for complete asparagine depletion of the fluid body compartments with the preparations studied. These findings have been transferred to enzymes from other E. coli strains as well as those isolated from Erwinia chrysanthemi and to the PEG-conjugated E. coli asparaginases. It might be desirable to countercheck the results for confirmation or correction. The dosage and administration schedule of the various enzyme preparations required for complete asparagine depletion over a period of time have been insufficiently defined. While pharmacokinetic studies showed clinically relevant differences in biological activity and activity half-lives for enzymes from different biological sources, the findings of recently published clinical trials indicate that the therapeutic efficacy is affected when different asparaginase preparations are given by identical therapy schedules. (ABSTRACT TRUNCATED)