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Choed-Amphai C, Khorana J, Sathitsamitphong L, Natesirinilkul R, Charoenkwan P. Predictive factors for L-asparaginase hypersensitivity in pediatric acute lymphoblastic leukemia. Int J Hematol 2024; 119:442-449. [PMID: 38421487 DOI: 10.1007/s12185-024-03725-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 01/18/2024] [Accepted: 01/25/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND L-Asparaginase is a crucial component of acute lymphoblastic leukemia (ALL) treatment. However, hypersensitivity is a common adverse event. This study aimed to identify risk factors for L-asparaginase hypersensitivity in childhood ALL. METHODS Children treated for ALL at Chiang Mai University Hospital, Thailand, between 2005 and 2020 were included. Demographic data, clinical characteristics, and factors related to L-asparaginase were retrospectively reviewed. RESULTS L-Asparaginase hypersensitivity was observed in 24 of 216 children with ALL (11.1%). All patients received native L-asparaginase intramuscularly, and events occurred exclusively during the post-induction phase without concurrent corticosteroid use. Univariable analysis showed that relapsed ALL, higher accumulated doses, increased exposure days, and longer interval between drug administrations were potential risk factors. In multivariable logistic regression analysis, interruption of L-asparaginase administration for ≥ 52 weeks and exposure duration of ≥ 15 days were independent risk factors, with adjusted odds ratio of 16.481 (95% CI 3.248-83.617, p = 0.001) and 4.919 (95% CI 1.138-21.263, p = 0.033), respectively. CONCLUSIONS Children with ALL who require re-exposure to L-asparaginase after 52-week interruption or who have received L-asparaginase for ≥ 15 exposure days are at risk of developing L-asparaginase hypersensitivity. Further management strategies in this setting should be evaluated.
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Affiliation(s)
- Chane Choed-Amphai
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Sriphum, Muang, Chiang Mai, 50200, Thailand.
| | - Jiraporn Khorana
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Clinical Epidemiology and Clinical Statistic, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Clinical Surgical Research Center, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Lalita Sathitsamitphong
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Sriphum, Muang, Chiang Mai, 50200, Thailand
| | - Rungrote Natesirinilkul
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Sriphum, Muang, Chiang Mai, 50200, Thailand
| | - Pimlak Charoenkwan
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Sriphum, Muang, Chiang Mai, 50200, Thailand
- Thalassemia and Hematology Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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2
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Menig S, Dinh A, Angus J, Tucker S, Leger KJ, Rushing T, Orgel E. Lack of benefit from premedication for pegylated asparaginase during pediatric acute lymphoblastic leukemia/lymphoma therapy: A side-by-side comparison. Pediatr Blood Cancer 2024; 71:e30716. [PMID: 37856184 DOI: 10.1002/pbc.30716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 09/11/2023] [Accepted: 09/28/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Pegylated l-asparaginase (PEG) is integral to treatment regimens for acute lymphoblastic leukemia (ALL) and lymphoma. Hypersensitivity reactions (HSRs) to PEG are common and can preclude continued administration. Data supporting recommendations for universal premedication (UPM) prior to PEG infusion to reduce incidence of HSRs are limited; UPM has become common practice. PROCEDURES Two free-standing children's hospitals independently implemented UPM prior to PEG infusions in 2016 and 2019, respectively. In a side-by-side retrospective analysis, incidence and severity of HSRs were analyzed pre- and postimplementation of UPM in youth ≥1 years old treated with frontline PEG-containing ALL regimens (2015-2018, 2016-2020). All HSRs were centrally reviewed within each institution to confirm and grade the HSR (Common Terminology Criteria for Adverse Events, v5). Planned analyses of subsets at potentially greater risk for HSRs included intensive PEG regimens (≥5 doses), adolescent and young adults (AYA), Hispanic/Latinx ethnicity, and obesity. RESULTS In 410 patients (by institution, n = 282 and n = 128), the overall incidence of Grade ≥ 3 HSRs was 20% (56 out of 282) and 18% (23 out of 128), respectively. No difference in incidence of Grade ≥ 3 HSRs in patients with versus without UPM was found at either institution (23 vs. 19%, p = .487 and 19 vs. 17%, p = .845). UPM also did not reduce the severity of HSRs, nor influence HSR risk within any patient subset. CONCLUSIONS UPM prior to PEG infusion did not alter incidence or severity of HSRs at either institution. HSR remains a common complication of PEG therapy, impacting the patient experience. Alternative strategies to reduce HSRs are urgently required.
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Affiliation(s)
- Sarah Menig
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
| | - Andrew Dinh
- Department of Pharmacy, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Jonathan Angus
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sarah Tucker
- Department of Pharmacy, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kasey J Leger
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Teresa Rushing
- Department of Pharmacy, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Etan Orgel
- Department of Pediatrics, University of Southern California, Los Angeles, California, USA
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles, Los Angeles, California, USA
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3
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Vagrecha A, Tao V, Corless R, Colon C, Redner A, Atlas M. A comprehensive strategy to address shortage of Erwinia asparaginase in pediatric acute lymphoblastic leukemia. Expert Rev Clin Pharmacol 2023; 16:763-769. [PMID: 37294084 DOI: 10.1080/17512433.2023.2223970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 06/05/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Pegylated form of E. coli derived asparaginase (PEG) is a crucial component of pediatric ALL therapy. Patients who develop a hypersensitivity (HSR) reaction with PEG receive an alternative form - Erwinia asparaginase (EA). However, an international shortage in 2017 had made it challenging to treat these patients. We have developed a comprehensive strategy to address this need. PATIENTS AND METHODS This is a single center, retrospective analysis. All patients receiving PEG were premedicated to reduce infusion reactions. Patients who developed HSR underwent PEG desensitization. Patients were compared to historic controls. RESULTS Fifty-six patients were treated within the study period. There was no difference in the frequency of reactions before and after the adoption of universal premedication (p = 0.78). Eight patients (14.2%) developed either ≥ Grade 2 HSR or silent inactivation and 5 patients (62.5%) successfully underwent desensitization. The remaining three patients received EA asparaginase. This intervention led to a decrease in PEG substitution, with 3 patients (5.3%) requiring EA compared to 8 patients (15.09%) in the pre-intervention period. (p = 0.11) PEG desensitization was more cost effective than EA administration. CONCLUSION PEG desensitization is a safe, cost effective, and practical alternative in children with ALL and a Grade 2 or higher HSR.
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Affiliation(s)
- Anshul Vagrecha
- Department of Pediatrics, Division of Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Vincent Tao
- Department of Pediatrics, Division of Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Rosemarie Corless
- Department of Pediatrics, Division of Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Cassandra Colon
- Department of Pediatrics, Division of Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Arlene Redner
- Department of Pediatrics, Division of Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
- Department of Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Mark Atlas
- Department of Pediatrics, Division of Hematology/Oncology and Cellular Therapy, Cohen Children's Medical Center, New Hyde Park, NY, USA
- Department of Pediatrics, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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4
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Lee A, Eldem I, Altintas B, Nguyen H, Willis D, Langley R, Shinawi M. Treatment and outcomes of symptomatic hyperammonemia following asparaginase therapy in children with acute lymphoblastic leukemia. Mol Genet Metab 2023; 139:107627. [PMID: 37327713 DOI: 10.1016/j.ymgme.2023.107627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/31/2023] [Accepted: 06/02/2023] [Indexed: 06/18/2023]
Abstract
Hyperammonemia has been reported following asparaginase administration, consistent with the mechanisms of asparaginase, which catabolizes asparagine to aspartic acid and ammonia, and secondarily converts glutamine to glutamate and ammonia. However, there are only a few reports on the treatment of these patients, which varies widely from watchful waiting to treatment with lactulose, protein restriction, sodium benzoate, and phenylbutyrate to dialysis. While many patients with reported asparaginase-induced hyperammonemia (AIH) are asymptomatic, some have severe complications and even fatal outcomes despite medical intervention. Here, we present a cohort of five pediatric patients with symptomatic AIH, which occurred after switching patients from polyethylene glycolated (PEG)- asparaginase to recombinant Crisantaspase Pseudomonas fluorescens (4 patients) or Erwinia (1 patient) asparaginase, and discuss their subsequent management, metabolic workup, and genetic testing. We developed an institutional management plan, which gradually evolved based on our local experience and previous treatment modalities. Because of the significant reduction in glutamine levels after asparaginase administration, sodium benzoate should be used as a first-line ammonia scavenger for symptomatic AIH instead of sodium phenylacetate or phenylbutyrate. This approach facilitated continuation of asparaginase doses, which is known to improve cancer outcomes. We also discuss the potential contribution of genetic modifiers to AIH. Our data highlights the need for increased awareness of symptomatic AIH, especially when an asparaginase with higher glutaminase activity is used, and its prompt management. The utility and efficacy of this management approach should be systematically investigated in a larger cohort of patients.
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Affiliation(s)
- Angela Lee
- Department of Pediatrics, Division of Genetics and Genomic Medicine, Washington University School of Medicine, Saint Louis, MO, USA.
| | - Irem Eldem
- Department of Pediatrics, Division of Hematology and Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Burak Altintas
- Department of Pediatrics, Division of Genetics and Genomic Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Hoanh Nguyen
- Department of Pediatrics, Division of Genetics and Genomic Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Daniel Willis
- Department of Pediatrics, Division of Hematology and Oncology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Rachel Langley
- Department of Pharmacy, Washington University School of Medicine, Saint Louis, MO, USA
| | - Marwan Shinawi
- Department of Pediatrics, Division of Genetics and Genomic Medicine, Washington University School of Medicine, Saint Louis, MO, USA
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5
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Ishida H, Imamura T, Tatebe Y, Ishihara T, Sakaguchi K, Suenobu S, Sato A, Hashii Y, Deguchi T, Takahashi Y, Hasegawa D, Miyamura T, Iguchi A, Kato K, Saito-Moriya A, Hara J, Horibe K. Impact of asparaginase discontinuation on outcomes of children with acute lymphoblastic leukaemia receiving the Japan Association of Childhood Leukaemia Study ALL-02 protocol. Br J Haematol 2023. [PMID: 36891758 DOI: 10.1111/bjh.18745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/10/2023]
Abstract
Asparaginase is an essential drug for acute lymphoblastic leukaemia (ALL) treatment, but has several side effects, and its discontinuation often compromises patient outcomes. In the prospective Japan Association of Childhood Leukaemia Study ALL-02 protocol, two major changes were made: (1) additional chemotherapies to compensate for the reduction of treatment intensity when asparaginase was discontinued and (2) more intensive concomitant corticosteroid administration, relative to our previous ALL-97 protocol. In ALL-02 study, 1192 patients were included and L-asparaginase was discontinued for 88 (7.4%). Discontinuation due to allergy was markedly decreased relative to the ALL-97 protocol (2.3% vs 15.4%). Event-free survival (EFS) among patients with T-ALL was compromised when L-asparaginase was discontinued, as well as among patients with high-risk B-cell ALL, especially when discontinued before maintenance therapy. Moreover, multivariate analysis identified discontinuation of L-asparaginase as an independent poor prognostic factor for EFS. In the current study, additional chemotherapies failed to fully compensate for L-asparaginase discontinuation, illustrating the difficulty of replacing asparaginase with other classes of drugs, although this study was not designed to evaluate the effect of these modifications. Concomitant intensive corticosteroid treatment may help to reduce allergy to asparaginase. These results will assist in further optimization of asparaginase use.
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Affiliation(s)
- Hisashi Ishida
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Toshihiko Imamura
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Yasuhisa Tatebe
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Takashi Ishihara
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Kimiyoshi Sakaguchi
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Souichi Suenobu
- Division of General Pediatrics and Emergency Medicine, Oita University Faculty of Medicine, Yufu, Japan
| | - Atsushi Sato
- Department of Hematology/Oncology, Miyagi Children's Hospital, Sendai, Japan
| | - Yoshiko Hashii
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takao Deguchi
- Department of Pediatrics, Mie University, Tsu, Japan
| | - Yoshihiro Takahashi
- Department of Pediatrics, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Daiichiro Hasegawa
- Department of Hematology/Oncology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Takako Miyamura
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Akihiro Iguchi
- Department of Pediatrics, Hokkaido University Hospital, Sapporo, Japan
| | - Koji Kato
- Department of Hematology Oncology, Children's Medical Center, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Akiko Saito-Moriya
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Junichi Hara
- Department of Pediatric Hematology/Oncology, Osaka City General Hospital, Osaka, Japan
| | - Keizo Horibe
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
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6
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Sandley M, Angus J. Asparaginase therapy in patients with acute lymphoblastic leukemia: expert opinion on use and toxicity management. Leuk Lymphoma 2023; 64:776-787. [PMID: 36781296 DOI: 10.1080/10428194.2023.2171267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
The addition of asparaginase to acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL) treatment regimens provides significant patient benefits. Asparaginase therapies vary in origin (Escherichia coli- or Erwinia-derived) and preparation (native or pegylated), conferring distinct pharmacokinetic and immunogenic profiles. Clinical hypersensitivity reactions (HSRs) are commonly reported in patients and range from localized erythema to systemic anaphylaxis. Due to its favorable pharmacokinetic profile and reduced immunogenicity compared to native E. coli preparations, pegaspargase is the first-line asparaginase therapeutic option. Switching to an Erwinia-derived asparaginase is recommended for patients who experience HSRs or antibody-mediated inactivation to achieve the significant clinical benefit observed in patients who complete asparaginase treatment. Previous global shortages of asparaginase Erwinia chrysanthemi necessitated conversion mitigation strategies such as premedication protocols, desensitization, and asparaginase activity level monitoring. Here, we discuss the efficacy, safety, pharmacokinetics, current use, and administration of asparaginase therapies for pediatric and adolescent patients with ALL/LBL.
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Affiliation(s)
- Melissa Sandley
- Department of Pharmacy, Oregon Health and Science University, Portland, OR, USA
| | - Jonathan Angus
- Department of Pharmacy, Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, WA, USA
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7
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Lassaletta Á, Gutiérrez F. Asparaginase activity monitoring in pediatric acute lymphoblastic leukemia: A cross-sectional nationwide study in Spain. Cancer Rep (Hoboken) 2023; 6:e1729. [PMID: 36307379 PMCID: PMC9940000 DOI: 10.1002/cnr2.1729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/17/2022] [Accepted: 09/14/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND A cross-sectional nationwide study was designed to assess national compliance with international consensus/guidelines of monitoring asparaginase levels in children with acute lymphoblastic leukemia (ALL) treated with asparaginase in routine clinical practice. METHODS An ad hoc questionnaire was designed and completed by staff physicians from Hemato-Oncology Units throughout Spain. RESULTS A total of 39 physicians (64% pediatricians) with a mean (SD) age 43.5 (7.9) years and 15.3 (17.6) years of professional activity participated in the study. They accounted for 90% of hospitals in which children with ALL are treated in Spain. A total of 19 participants (48.7%) reported that asparaginase levels were routinely monitored (own center in 2 cases [10.5%], another hospital in 17 cases [89.5%]). Asparaginase was not monitored in 51.3% of the cases, mostly (80%) because unavailability of testing. When asparaginase was monitored, 68% of participants reported that this was done in all asparaginase-treated patients and 84% in all phases of the disease (induction, consolidation, re-induction, maintenance) with a time interval of 7 days for the pegylated form, 48 h for Erwinia asparaginase and 14 days for maintenance with the pegylated form. All participants reported that they modified treatment according to results of testing, with a limit of total depletion of ≥100 IU/L. Levels <100 or 20 IU/L were considered indicative of hypersensitivity by 46% of physicians. CONCLUSION There is still a gap between what is recommended and what is done in clinical practice, with more than 50% of centers not monitoring the level of asparaginase activity in pediatric ALL. Protocols for asparaginase testing in daily practice should be implemented.
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Affiliation(s)
- Álvaro Lassaletta
- Pediatric Hematology‐Oncology DepartmentHospital Infantil Universitario Niño JesúsMadridSpain
| | - Fernando Gutiérrez
- Research Department, Pharmacy DepartmentComplejo Hospitalario Universitario de CanariasSanta Cruz de TenerifeSpain
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8
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Asparaginase: How to Better Manage Toxicities in Adults. Curr Oncol Rep 2023; 25:51-61. [PMID: 36449117 DOI: 10.1007/s11912-022-01345-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2022] [Indexed: 12/02/2022]
Abstract
PURPOSE OF REVIEW This review aims to help oncologists who predominantly treat adults better understand and manage asparaginase associated toxicities and prevent unnecessary discontinuation or reluctance of its use. RECENT FINDINGS Given the data supporting the benefit of incorporating multiple doses of asparaginase in pediatric type regimens, it is prudent to promote deeper understanding of this drug, particularly its toxicities, and its use so as to optimize treatment of ALL. Although asparaginase is associated with a variety of toxicities, the vast majority are not life threatening and do not preclude repeat dosing of this important drug. Understanding the pharmacology and toxicity profile of asparaginase is critical to dosing asparaginase appropriately in order to minimize these toxicities.
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9
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Pike M, Kulkarni K, MacDonald T. Asparaginase activity monitoring and management of asparaginase hypersensitivity reactions in Canada. J Oncol Pharm Pract 2023; 29:105-111. [PMID: 34854779 DOI: 10.1177/10781552211055405] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Pegaspargase can cause anti-asparaginase antibody formation, which can decrease its effectiveness without causing any clinically apparent reaction (silent inactivation). When a patient has silent inactivation, a switch to Erwinia anti-asparaginase is warranted, but there is currently a global shortage of Erwinia. The only way to identify silent inactivation is to measure an asparaginase level. However, routine asparaginase level monitoring is not currently standard of care at all Canadian centers. This study aims to identify variations in practice regarding asparaginase level monitoring and Erwinia use. METHODS A 21-item survey was developed using OPINIO software and distributed to all Pediatric Hematology-Oncologists in Canada from February to October 2020. RESULTS Respondents represented 15 hospitals across each region of Canada (response rate = 52%). Only 39.2% of respondents reported routinely measuring asparaginase levels, yet 53% of respondents have modified therapy from pegaspargase to Erwinia in up to half of their patients. The most common reason for not measuring asparaginase levels was not knowing how to use levels clinically (25.5%). There was variation in the timing of levels and their target. CONCLUSIONS We identified substantial variation in asparaginase activity monitoring practices across Canada. Therefore, future research should aim to develop a national practice guideline on asparaginase activity monitoring.
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Affiliation(s)
- Meghan Pike
- Department of Pediatrics/Division of Pediatric Hematology-Oncology, Dalhousie University/IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Ketan Kulkarni
- Department of Pediatrics/Division of Pediatric Hematology-Oncology, Dalhousie University/IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Tamara MacDonald
- Department of Pharmacy, Dalhousie3682, University/IWK Health Centre, Halifax, Nova Scotia, Canada
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10
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Aldoss I, Pourhassan H, Douer D. SOHO State of the Art Updates and Next Questions | Asparaginase-Understanding and Overcoming Toxicities in Adults with ALL. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:787-794. [PMID: 36114134 DOI: 10.1016/j.clml.2022.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/11/2022] [Accepted: 08/18/2022] [Indexed: 06/15/2023]
Abstract
The adoption of pediatric-inspired regimens in young adults with newly diagnosed acute lymphoblastic leukemia (ALL) has significantly improved their survival outcomes. Pediatric-inspired regimens in ALL rely profoundly on delivering adequate dosing of non-myelosuppressive drugs of which asparaginase, a bacterial derived agent, is a key component. Asparaginase therapy is associated with a spectrum of unique toxicities that are observed more frequently in adult patients compared to children with ALL, and this observation has contributed to the reluctance of adult oncologists to administer the drug to their patients. Understanding the breadth of asparaginase toxicity and the associated risk factors may help in preventing severe manifestations and allow safer treatment for adults with ALL. In this review, we will discuss the different formulations of asparaginase and the appropriate dosing in adults with ALL. We will further discuss the frequency and risk factors for individual toxicities of asparaginase along with strategies for their prevention and management.
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Affiliation(s)
| | | | - Dan Douer
- University of Southern California, Los Angeles, CA
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11
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Poirée M, Neumann F, Thomas C, Simon P, Lunven AFR, Plantaz D, Doulet ST, Strullu M. [Prevention and management of pegaspargase associated-toxicities (excluding coagulation abnormalities). Recommendations of the French Society of Children and Adolescent Cancers (Leukemia committee)]. Bull Cancer 2022; 109:1125-1131. [PMID: 35987855 DOI: 10.1016/j.bulcan.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 06/07/2022] [Accepted: 06/12/2022] [Indexed: 02/05/2023]
Abstract
Pegaspargase (Oncaspar®), a pegylated form of native Escherichia Coli-derived L-asparaginase is an essential component chemotherapy used in the treatment of acute lymphoblastic leukemia (ALL) in pediatric and adult patients. Its particular toxicity profile requires a specific management to improve safety and tolerability and optimize treatment outcome and therefore survival. Within the framework of workshops of practice harmonization of the French Society of Children and Adolescent Cancers, diagnostic and management of the most commonly occuring toxicities (excluding coagulation abnormalities) during Pegaspargase treatment were reviewed according to the analysis of published studies.
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Affiliation(s)
- Marilyne Poirée
- CHU, service d'oncologie et hématologie pédiatrique, Nice, France.
| | - Florent Neumann
- CHU, service d'immuno hémato oncologie pédiatrique, Dijon, France
| | - Caroline Thomas
- CHU, service d'oncologie et d'immunologie pédiatrique, Nantes, France
| | - Pauline Simon
- CHRU, service d'hémato oncologie pédiatrique, Besançon, France
| | - Anne France Ray Lunven
- AP-HP, hôpital universitaire Robert-Debré, service d'hémato-immunologie pédiatrique, Paris, France
| | - Dominique Plantaz
- CHU, hôpital Couple enfant, clinique universitaire de pédiatrie, Grenoble, France
| | | | - Marion Strullu
- AP-HP, hôpital universitaire Robert-Debré, service d'hémato-immunologie pédiatrique, Paris, France
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12
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Albertsen BK, Lynggaard LS, Schmiegelow K. Asparaginase encapsulated in erythrocytes as second-line treatment in hypersensitive patients with acute lymphoblastic leukaemia. Br J Haematol 2022; 198:e84-e85. [PMID: 35917113 DOI: 10.1111/bjh.18373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 07/08/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Line Stensig Lynggaard
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
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13
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Chen CB, Chang HH, Chou SW, Yang YL, Lu MY, Jou ST, Chen HL, Ni YH, Lin DT, Chang MH, Wu JF. Acute pancreatitis in children with acute lymphoblastic leukemia correlates with L-asparaginase dose intensity. Pediatr Res 2022; 92:459-465. [PMID: 34718353 DOI: 10.1038/s41390-021-01796-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/24/2021] [Accepted: 10/06/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND L-Asparaginase (L-Asp) is an important therapeutic for childhood acute lymphoblastic leukemia (ALL). Asparaginase-associated pancreatitis (AAP) is a severe complication of L-Asp related to the dosage. We investigated the incidence of, and risk factors for, AAP in pediatric patients with ALL. METHODS From January 2002 to December 2018, pediatric patients with ALL treated at National Taiwan University Hospital were enrolled in this study. The diagnosis of AAP was based on the criteria of the Ponte di Legno Toxicity Working Group. RESULTS Of the 353 patients enrolled in this study, 14 (4.0%) developed AAP. The incidence of AAP in ALL patients was significantly higher after treatment with the 2013 protocol compared with the 2002 protocol of the Taiwan Pediatric Oncology Group (9.5% vs. 1.3%). Multivariate analysis showed that a high peak L-Asp dose intensity (>45,000 U/m2/month) and older age at diagnosis (>6.8 years) were independently predictive of AAP development. CONCLUSIONS The incidence of acute pancreatitis in childhood ALL was correlated more strongly with the peak dose intensity than with the cumulative dose of L-Asp. These results could be used to reduce the treatment-related complications of ALL. IMPACT L-Asparaginase is an important therapeutic for childhood acute lymphoblastic leukemia, and the accumulated dosage of L-asparaginase is considered as a major risk factor of asparaginase-associated pancreatitis. This article demonstrated that the incidence of pancreatitis correlates with the dose-intensity of L-asparaginase, but not the accumulated dosage. Identification of patient group with high risk of pancreatitis could lead to early diagnosis and reduce the complication. This finding could aid in developing further new protocol or therapeutic strategy design to reduce treatment-related complications and improve clinical outcomes of childhood acute lymphoblastic leukemia.
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Affiliation(s)
- Chi-Bo Chen
- Department of Pediatrics, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Hsiu-Hao Chang
- Department of Pediatrics, National Taiwan University Hospital and National Taiwa University, College of Medicine, Taipei, Taiwan.
| | - Shu-Wei Chou
- Department of Pediatrics, National Taiwan University Hospital and National Taiwa University, College of Medicine, Taipei, Taiwan
| | - Yung-Li Yang
- Department of Pediatrics, National Taiwan University Hospital and National Taiwa University, College of Medicine, Taipei, Taiwan
| | - Meng-Yao Lu
- Department of Pediatrics, National Taiwan University Hospital and National Taiwa University, College of Medicine, Taipei, Taiwan
| | - Shiann-Tarng Jou
- Department of Pediatrics, National Taiwan University Hospital and National Taiwa University, College of Medicine, Taipei, Taiwan
| | - Huey-Ling Chen
- Department of Pediatrics, National Taiwan University Hospital and National Taiwa University, College of Medicine, Taipei, Taiwan
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University Hospital and National Taiwa University, College of Medicine, Taipei, Taiwan
| | - Dong-Tsamn Lin
- Department of Pediatrics, National Taiwan University Hospital and National Taiwa University, College of Medicine, Taipei, Taiwan
| | - Mei-Hwei Chang
- Department of Pediatrics, National Taiwan University Hospital and National Taiwa University, College of Medicine, Taipei, Taiwan
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Hospital and National Taiwa University, College of Medicine, Taipei, Taiwan.
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14
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Maese L, Rau RE. Current Use of Asparaginase in Acute Lymphoblastic Leukemia/Lymphoblastic Lymphoma. Front Pediatr 2022; 10:902117. [PMID: 35844739 PMCID: PMC9279693 DOI: 10.3389/fped.2022.902117] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/06/2022] [Indexed: 01/19/2023] Open
Abstract
Pediatric Acute Lymphoblastic Leukemia (ALL) cure rates have improved exponentially over the past five decades with now over 90% of children achieving long-term survival. A direct contributor to this remarkable feat is the development and expanded understanding of combination chemotherapy. Asparaginase is the most recent addition to the ALL chemotherapy backbone and has now become a hallmark of therapy. It is generally accepted that the therapeutic effects of asparaginase is due to depletion of the essential amino acid asparagine, thus occupying a unique space within the therapeutic landscape of ALL. Pharmacokinetic and pharmacodynamic profiling have allowed a detailed and accessible insight into the biochemical effects of asparaginase resulting in regular clinical use of therapeutic drug monitoring (TDM). Asparaginase's derivation from bacteria, and in some cases conjugation with a polyethylene glycol (PEG) moiety, have contributed to a unique toxicity profile with hypersensitivity reactions being the most salient. Hypersensitivity, along with several other toxicities, has limited the use of asparaginase in some populations of ALL patients. Both TDM and toxicities have contributed to the variety of approaches to the incorporation of asparaginase into the treatment of ALL. Regardless of the approach to asparagine depletion, it has continually demonstrated to be among the most important components of ALL therapy. Despite regular use over the past 50 years, and its incorporation into the standard of care treatment for ALL, there remains much yet to be discovered and ample room for improvement within the utilization of asparaginase therapy.
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Affiliation(s)
- Luke Maese
- Huntsman Cancer Institute, University of Utah, Primary Children's Hospital, Salt Lake City, UT, United States
| | - Rachel E. Rau
- Department of Pediatrics, Baylor College of Medicine Texas Children's Hospital, Houston, TX, United States
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15
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ALMuhizi F, De Las Vecillas Sanchez L, Gilbert L, Copaescu AM, Isabwe GAC. Premedication Protocols to Prevent Hypersensitivity Reactions to Chemotherapy: a Literature Review. Clin Rev Allergy Immunol 2022; 62:534-547. [PMID: 35258842 DOI: 10.1007/s12016-022-08932-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2022] [Indexed: 12/19/2022]
Abstract
Hypersensitivity reactions (HSRs) to chemotherapy may prevent patients from receiving the most effective therapy. This review was undertaken to identify evidence-based preventive premedication strategies that reduce the likelihood of HSR in the first instance and improve the safety of subsequent infusions in patients who have demonstrated HSR to a certain class of chemotherapy. PubMed was searched until October 2021 using the key words: "hypersensitivity to chemotherapeutic drugs," "hypersensitivity to antineoplastic agents," "taxanes hypersensitivity," "platinum compound hypersensitivity," "premedication," "dexamethasone," "prednisone," "hydrocortisone," "antihistamine," "diphenhydramine," "cetirizine," "famotidine," "meperidine," "aspirin," "ibuprofen," and "montelukast." The search was restricted to articles published in English. A total of 73 abstracts were selected for inclusion in the review. Most premedication regimens have been derived empirically rather than determined through randomized trials. Based on the available evidence, we provide an update on likely HSR mechanisms and a practical guide for classifying systemic HSR. The evidence indicates that a combination of prevention strategies using newer antihistamines, H2 antagonists, leukotriene receptor antagonists, and corticosteroids and other interventions used judiciously reduces the occurrence and severity of HSR and improves safety.
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Affiliation(s)
- Faisal ALMuhizi
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre (MUHC), McGill University, Montreal, QC, Canada.,Division of Allergy and Clinical Immunology, Department of Internal Medicine, Security Forces Hospital Program, Riyadh, Saudi Arabia
| | | | - Lucy Gilbert
- Department of Oncology, Obstetrics and Gynecology, McGill University Health Center (MUHC), McGill University, Montreal, QC, Canada
| | - Ana M Copaescu
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre (MUHC), McGill University, Montreal, QC, Canada.,The Research Institute, McGill University Health Centre, McGill University, Montreal, QC, Canada.,Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, VIC, Australia
| | - Ghislaine A C Isabwe
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Centre (MUHC), McGill University, Montreal, QC, Canada. .,The Research Institute, McGill University Health Centre, McGill University, Montreal, QC, Canada.
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16
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Juluri KR, Siu C, Cassaday RD. Asparaginase in the Treatment of Acute Lymphoblastic Leukemia in Adults: Current Evidence and Place in Therapy. Blood Lymphat Cancer 2022; 12:55-79. [PMID: 35669980 PMCID: PMC9166408 DOI: 10.2147/blctt.s342052] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/16/2022] [Indexed: 01/19/2023] Open
Abstract
Acute lymphoblastic leukemia (ALL) is a rare hematologic malignancy resulting in the production of abnormal lymphoid precursor cells. Occurring in B-cell and T-cell subtypes, ALL is more common in children, comprising nearly 30% of pediatric malignancies, but also constitutes 1% of adult cancer diagnoses. Outcomes are age-dependent, with five-year overall survival of greater than 90% in children and less than 20% in older adults. L-asparaginase, an enzyme not found in humans, depletes serum levels of L-asparagine. As leukemic cells are unable to synthesize this amino acid, its deprivation results in cell death. The success of asparaginase-containing regimens in the treatment of pediatric ALL, and poor outcomes with conventional cytotoxic regimens in adults, have led to trials of pediatric or pediatric-inspired regimens incorporating asparaginase in the adolescent and young adult (AYA) and adult populations. Initially purified from Escherichia coli, newer formulations of asparaginase have been developed to address short half-life, high immunogenic potential, and manufacturing difficulties. Unfamiliarity with asparaginase use and management of its unique toxicities may result in treatment-decisions that negatively impact outcomes. In this review, we address the current use of asparaginase in the treatment of ALL, with an emphasis on its role in the treatment of adults, key clinical trials, recognition and management of toxicities, and ongoing directions of study.
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Affiliation(s)
- Krishna R Juluri
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Chloe Siu
- Seattle Cancer Care Alliance, Seattle, WA, USA
- Department of Pharmacy, University of Washington School of Pharmacy, Seattle, WA, USA
| | - Ryan D Cassaday
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Seattle Cancer Care Alliance, Seattle, WA, USA
- Correspondence: Ryan D Cassaday, Email
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17
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Khairullah A, Alexander TB, Wang K, Kaplan JB. Successful Erwinia asparaginase one-bag rapid desensitization process in a pediatric patient with acute lymphoblastic leukemia. Pediatr Blood Cancer 2022; 69:e29632. [PMID: 35234336 DOI: 10.1002/pbc.29632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 02/11/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Amanie Khairullah
- Department of Pharmacy, UNC Health Care, Chapel Hill, North Carolina, USA
| | - Thomas B Alexander
- Pediatric Hematology-Oncology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kathleen Wang
- Pediatric Allergy and Immunology, University of North Carolina, Chapel Hill, North Carolina, USA
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18
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Tolerability and Efficacy of a 1-Bag Pegaspargase Densensitization Protocol in Pediatric Oncology Patients. J Pediatr Hematol Oncol 2022; 44:e623-e627. [PMID: 34133383 DOI: 10.1097/mph.0000000000002241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/20/2021] [Indexed: 11/25/2022]
Abstract
Desensitization to pegaspargase has been previously attempted in patients who have a hypersensitivity reaction to pegaspargase when Erwinia asparaginase is not an available alternative because of supply issues. Often, these desensitizations have utilized a 3-bag method to complete the infusion. Retrospective chart review was utilized to evaluate the tolerability and efficacy of a 1-bag method for pegaspargase densensitization at a single center. Pegaspargase was infused over ∼3 hours with increases to the infusion rate every 15 minutes. Fifteen pediatric patients received a total of 28 pegaspargase infusions utilizing a 1-bag method. In total, 23 of the infusions were able to be successfully completed without signs of hypersensitivity reactions. In addition, 9 of the 15 patients were able to both successfully complete all infusions during the study period and have asparaginase levels within the therapeutic range 7 to 14 days after the infusion. Four of the 5 patients that did experience a hypersensitivity reaction were able to complete the infusion, however, none of these patients had acceptable asparaginase levels postinfusion. No patient required intubation or advanced life support measures secondary to anaphylaxis. Overall, the pegaspargase method described here was successful and well tolerated in a majority of patients.
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19
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Babcock KJ, Kinnunen A, Egelund T, Ng JS, Joyce MJ. Efficacy of a Standardized Premedication and Therapeutic Drug Monitoring Protocol for Pegaspargase to Prevent Hypersensitivity Reactions. J Pediatr Pharmacol Ther 2022; 27:232-236. [PMID: 35350153 DOI: 10.5863/1551-6776-27.3.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/16/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the efficacy of a standardized premedication and therapeutic drug monitoring (TDM) protocol to prevent hypersensitivity reactions from pegaspargase infusions. Pegaspargase is an essential therapeutic agent used for the treatment of acute lymphoblastic leukemia (ALL) in pediatric patients. METHODS This study was a retrospective cohort study conducted at Wolfson Children's Hospital, Jacksonville, Florida, and included pediatric ALL patients 0 to 21 years old. Patients were excluded if they had not received the appropriate premedication after protocol implementation or had received premedication before protocol implementation. Patients were separated into 2 groups: those who received premedication before pegaspargase infusion and those who did not. The primary endpoint was the incidence of documented hypersensitivity reactions. Observational data endpoints included incidence of silent inactivation and cost savings from reducing complicated drug substitutions. RESULTS A total of 38 patients (50 doses in no premedication group; 80 doses in premedication group) were evaluated. There was not a significant reduction in the incidence of hypersensitivity reactions for patients receiving premedication and TDM (5.3% vs 6.4%, p = 1.0). A trend towards patients reacting earlier with more severe reactions in the post-implementation group was observed. There were no incidences of silent inactivation. Observational cost analysis predicts potential drug cost savings of $106,550.45. CONCLUSIONS A standardized premedication protocol did not reduce the incidence of hypersensitivity reactions. Premedication to prevent hypersensitivity reactions may provide a potential drug cost savings. Further investigation is warranted to assess the efficacy of a standardized premedication and TDM protocol to prevent hypersensitivity reactions.
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Affiliation(s)
- Kyle J Babcock
- Department of Pharmacy (KJB, AK, TE, JSN), Wolfson Children's Hospital
- Baptist Health, Nemours Specialty Care Clinic, Jacksonville, FL
| | - Amy Kinnunen
- Department of Pharmacy (KJB, AK, TE, JSN), Wolfson Children's Hospital
- Baptist Health, Nemours Specialty Care Clinic, Jacksonville, FL
| | - Tosha Egelund
- Department of Pharmacy (KJB, AK, TE, JSN), Wolfson Children's Hospital
- Baptist Health, Nemours Specialty Care Clinic, Jacksonville, FL
| | - John S Ng
- Department of Pharmacy (KJB, AK, TE, JSN), Wolfson Children's Hospital
- Baptist Health, Nemours Specialty Care Clinic, Jacksonville, FL
| | - Michael J Joyce
- Department of Hematology/Oncology (MJJ), Wolfson Children's Hospital
- Baptist Health, Nemours Specialty Care Clinic, Jacksonville, FL
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20
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Clemmons A, Gandhi A, Clarke A, Jimenez S, Le T, Ajebo G. Premedications for Cancer Therapies: A Primer for the Hematology/Oncology Provider. J Adv Pract Oncol 2022; 12:810-832. [PMID: 35295545 PMCID: PMC8631343 DOI: 10.6004/jadpro.2021.12.8.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Chemotherapeutic agents and radiation therapy are associated with numerous potential adverse events (AEs). Many of these common AEs, namely chemotherapy- or radiation-induced nausea and vomiting, hypersensitivity reactions, and edema, can lead to deleterious outcomes (such as treatment nonadherence or cessation, or poor clinical outcomes) if not prevented appropriately. The occurrence and severity of these AEs can be prevented with the correct prescribing of prophylactic medications, often called "premedications." The advanced practitioner in hematology/oncology should have a good understanding of which chemotherapeutic agents are known to place patients at risk for these adverse events as well as be able to determine appropriate prophylactic medications to employ in the prevention of these adverse events. While several guidelines and literature exist regarding best practices for prophylaxis strategies, differences among guidelines and quality of data should be explored in order to accurately implement patient-specific recommendations. Herein, we review the existing literature for prophylaxis and summarize best practices.
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Affiliation(s)
- Amber Clemmons
- University of Georgia College of Pharmacy, Augusta, Georgia.,Augusta University Medical Center, Augusta, Georgia
| | | | | | | | - Thuy Le
- Augusta University Medical Center, Augusta, Georgia
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21
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Burke MJ, Zalewska-Szewczyk B. Hypersensitivity reactions to asparaginase therapy in acute lymphoblastic leukemia: immunology and clinical consequences. Future Oncol 2022; 18:1285-1299. [PMID: 35107320 DOI: 10.2217/fon-2021-1288] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Asparaginase is commonly used in combination therapy of acute lymphoblastic leukemia. However, as an immunogenic protein, hypersensitivity reactions (HSRs) during asparaginase therapy are frequent, indicating the development of anti-asparaginase antibodies. These can be associated with diminished clinical effectiveness, including poorer survival. Therapeutic drug monitoring of serum asparaginase activity to confirm complete asparagine depletion is therefore crucial during asparaginase therapy. Switching to alternative types of asparaginase is recommended for patients experiencing HSRs or silent inactivation; those with HSRs or silent inactivation on Escherichia coli-derived asparaginases should switch to another preparation. However, prior global shortages of Erwinia asparaginase highlight the importance of alternative non-E. coli-derived asparaginase, including recombinant Erwinia asparaginase.
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Affiliation(s)
- Michael J Burke
- Department of Pediatrics, Division of Pediatric Hematology-Oncology-Blood & Marrow Transplantation, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Beata Zalewska-Szewczyk
- Department of Pediatrics, Oncology & Hematology, Medical University of Lodz, 91-738, Lodz, Poland
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22
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Monitoring of treatment with L-asparaginase in children with acute lymphoblastic leukaemia, with a focus on silent inactivation and its influence on the treatment outcome. Contemp Oncol (Pozn) 2022; 26:282-288. [PMID: 36816392 PMCID: PMC9933359 DOI: 10.5114/wo.2023.124972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/14/2023] [Indexed: 02/12/2023] Open
Abstract
Introduction The aim of the study was to analyse the frequency of silent inactivation and allergic reaction to asparaginase (ASP) and its impact on treatment results in patients with lymphoblastic leukaemia. Material and methods Seventy patients with acute lymphoblastic leukaemia treated with ASP were enrolled in the study. Asparaginase activity was monitored. The patients were switched to another ASP formulation after allergy or inactivation. The treatment results were analysed. Results Silent inactivation of native E. coli ASP was diagnosed in 5 patients (7%) and allergy in 34 patients (49%), and these patients were switched to pegylated ASP (PEG-ASP). Silent inactivation of PEG-ASP occurred in 8 patients (23%) and allergy in 6 patients (17%). Eight children continued therapy with Erwinase, and 4 did not switch to Erwinase after inactivation of PEG-ASP. Allergy to Erwinase occurred in 2 patients (22%); there was no inactivation. No significant differences in outcome were found between the groups of patients with and without allergy or silent inactivation of ASP. Due to regular monitoring and switching to other ASP preparations after allergy or silent inactivation, therapeutic activity was ensured in almost all patients. Conclusions Monitoring of ASP activity is crucial to recognize silent inactivation and to guarantee treatment effectiveness by switching to other ASP preparations.
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23
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Douer D, Gökbuget N, Stock W, Boissel N. Optimizing use of L-asparaginase–based treatment of adults with acute lymphoblastic leukemia. Blood Rev 2021; 53:100908. [DOI: 10.1016/j.blre.2021.100908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 01/19/2023]
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24
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Maese L, Rizzari C, Coleman R, Power A, van der Sluis I, Rau RE. Can recombinant technology address asparaginase Erwinia chrysanthemi shortages? Pediatr Blood Cancer 2021; 68:e29169. [PMID: 34105243 DOI: 10.1002/pbc.29169] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/14/2021] [Accepted: 05/20/2021] [Indexed: 11/11/2022]
Abstract
Acute lymphoblastic leukemia (ALL) is the most common childhood cancer. Bacterial L-asparaginase has played an important role in ALL treatment for several decades; however, hypersensitivity reactions to Escherichia coli-derived asparaginases often preclude their use. Inability to receive asparaginase due to hypersensitivities is associated with poor patient outcomes. Erwinia chrysanthemi-derived asparaginase (ERW) is an effective, non-cross-reactive treatment option, but is limited in supply. Consequently, alternative asparaginase preparations are needed to ensure asparaginase availability for patients with hypersensitivities. Recombinant technology can potentially address this unmet need by programming cells to produce recombinant asparaginase. JZP-458, a recombinant Erwinia asparaginase derived from a novel Pseudomonas fluorescens expression platform with no immunologic cross-reactivity to E. coli-derived asparaginases, has the same primary amino acid sequence as ERW, with comparable activity based on in vitro measurements. The efficient manufacturing of JZP-458 would provide an additional asparaginase preparation for patients with hypersensitivities.
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Affiliation(s)
- Luke Maese
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Carmelo Rizzari
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy
| | | | | | | | - Rachel E Rau
- Baylor College of Medicine, Texas Children's Cancer and Hematology Center, Houston, Texas, USA
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25
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Schmiegelow K, Rank CU, Stock W, Dworkin E, van der Sluis I. SOHO State of the Art Updates and Next Questions: Management of Asparaginase Toxicity in Adolescents and Young Adults with Acute Lymphoblastic Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:725-733. [PMID: 34511319 DOI: 10.1016/j.clml.2021.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 01/23/2023]
Abstract
A wider use of L-asparaginase in the treatment of children with acute lymphoblastic leukemia has improved cure rates during recent decades and hence led to introduction of pediatric-inspired treatment protocols for adolescents and young adults. In parallel, a range of burdensome, often severe and occasionally life-threatening toxicities have become frequent, including hypersensitivity, hepatotoxicity, hypertriglyceridemia, thromboembolism, pancreatitis, and osteonecrosis. This often leads to truncation of asparaginase therapy, which at least in the pediatric population has been clearly associated with a higher risk of leukemic relapse. Many of the asparaginase induced toxicities are far more common in older patients, but since their relapse rate is still unsatisfactory, the decision to discontinue asparaginase therapy should balance the risk of toxicity with continued asparaginase therapy against the risk of relapse in the individual patient. The underlying mechanisms of most of the asparaginase induced side effects are still unclear. In this review we address the individual toxicities, known risk factors, and their clinical management.
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Affiliation(s)
- Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet Copenhagen University Hospital, 2100 Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Cecilie Utke Rank
- Department of Hematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Wendy Stock
- Department of Medicine, University of Chicago Medicine and Comprehensive Cancer Center, Chicago, IL
| | - Emily Dworkin
- Department of Medicine, University of Chicago Medicine and Comprehensive Cancer Center, Chicago, IL
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26
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McCormick M, Lapinski J, Friehling E, Smith K. Premedication prior to PEG-asparaginase is cost-effective in pediatric patients with acute lymphoblastic leukemia. Pediatr Blood Cancer 2021; 68:e29051. [PMID: 33860989 DOI: 10.1002/pbc.29051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/23/2021] [Accepted: 03/25/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND PEG-asparaginase is critical in pediatric acute lymphoblastic leukemia (ALL) therapy but is highly immunogenic. Severe allergic reactions lead to substitution of further PEG-asparaginase with Erwinia. Erwinia is associated with more frequent dosing, increased expense, and limited availability. Premedication may reduce rates of allergic reactions. PROCEDURES This Markov model evaluated the cost-effectiveness of three strategies: premedication plus therapeutic drug monitoring (TDM), TDM alone, and no premedication or TDM. We modeled two scenarios: a standard-risk (SR) B-ALL patient receiving two asparaginase doses and a high-risk (HR) patient receiving seven asparaginase doses. The model incorporated costs of asparaginase, premedication, TDM and clinic visits, and lost parental wages associated with each additional Erwinia dose. We incorporated a five-year time horizon with a societal perspective. Outcomes were Erwinia substitutions avoided and differences in quality-adjusted life years (QALYs). Probabilistic and one-way sensitivity analyses evaluated model uncertainty. RESULTS In both scenarios, premedication was the least costly strategy. In SR and HR scenarios, premedication with monitoring resulted in 8% and 7% fewer changes to Erwinia compared with monitoring alone and 3% and 2% fewer changes compared with no premedication/monitoring, respectively. Premedication resulted in the most QALYs gained in the SR patients. Individual variation of model inputs did not change premedication/monitoring favorability for either scenario. In probabilistic sensitivity analyses, premedication/monitoring was favored in >87% of iterations in both scenarios. CONCLUSION Compared with other strategies, premedication use and asparaginase level monitoring in children with B-ALL is potentially cost-saving.
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Affiliation(s)
| | - Jillian Lapinski
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
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27
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Vrooman LM, Blonquist TM, Stevenson KE, Supko JG, Hunt SK, Cronholm SM, Koch V, Kay-Green S, Athale UH, Clavell LA, Cole PD, Harris MH, Kelly KM, Laverdiere C, Leclerc JM, Michon B, Place AE, Schorin MA, Welch JJG, Neuberg DS, Sallan SE, Silverman LB. Efficacy and Toxicity of Pegaspargase and Calaspargase Pegol in Childhood Acute Lymphoblastic Leukemia: Results of DFCI 11-001. J Clin Oncol 2021; 39:3496-3505. [PMID: 34228505 DOI: 10.1200/jco.20.03692] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
PURPOSE Dana-Farber Cancer Institute Acute Lymphoblastic Leukemia (ALL) Consortium Protocol 11-001 assessed efficacy and toxicity of calaspargase pegol (calaspargase), a novel pegylated asparaginase formulation with longer half-life, compared with the standard formulation pegaspargase. METHODS Patients age 1 to ≤ 21 years with newly diagnosed ALL or lymphoblastic lymphoma were randomly assigned to intravenous pegaspargase or calaspargase, 2,500 IU/m2/dose. Patients received one induction dose. Beginning week 7, pegaspargase was administered every 2 week for 15 doses and calaspargase every 3 week for 10 doses (30 weeks). Serum asparaginase activity (SAA) (≥ 0.1 IU/mL considered therapeutic) was assessed 4, 11, 18, and 25 days after the induction dose and before each postinduction dose. RESULTS Between 2012 and 2015, 239 eligible patients enrolled (230 ALL, nine lymphoblastic lymphoma); 120 were assigned to pegaspargase and 119 to calaspargase. After the induction dose, SAA was ≥ 0.1 IU/mL in ≥ 95% of patients on both arms 18 days after dosing. At day 25, more patients had SAA ≥ 0.1 IU/mL with calaspargase (88% v 17%; P ˂ .001). Postinduction, median nadir SAAs were similar (≥ 1.0 IU/mL) for both arms. Of 230 evaluable patients, 99% of pegaspargase and 95% of calaspargase patients achieved complete remission (P = .12), with no difference in frequency of high end-induction minimal residual disease among evaluable patients with B acute lymphoblastic leukemia (B-ALL). There were no differences in frequencies of asparaginase allergy, pancreatitis, thrombosis, or hyperbilirubinemia. With 5.3 years median follow-up, 5-year event-free survival for pegaspargase was 84.9% (SE ± 3.4%) and 88.1% (± SE 3.0%) for calaspargase (P = .65). CONCLUSION Every 3-week calaspargase had similar nadir SAA, toxicity, and survival outcomes compared with every 2-week pegaspargase. The high nadir SAA observed for both preparations suggest dosing strategies can be further optimized.
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Affiliation(s)
- Lynda M Vrooman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA.,Division of Hematology/Oncology, Boston Children's Hospital, Harvard Medical School Boston, MA
| | - Traci M Blonquist
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | | | - Jeffrey G Supko
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Sarah K Hunt
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Sarah M Cronholm
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Victoria Koch
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Samantha Kay-Green
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Uma H Athale
- Division of Pediatric Hematology/Oncology, McMaster University, Hamilton, ON, Canada
| | - Luis A Clavell
- Division of Pediatric Oncology, San Jorge Children's Hospital, San Juan, Puerto Rico
| | - Peter D Cole
- Division of Pediatric Hematology/Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Marian H Harris
- Department of Pathology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Kara M Kelly
- Department of Pediatric Oncology, Roswell Park Cancer Institute and Oishei Children's Hospital, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY
| | - Caroline Laverdiere
- Division of Hematology and Oncology, Hospital Sainte-Justine, University of Montreal, Montreal, Canada
| | - Jean-Marie Leclerc
- Division of Hematology and Oncology, Hospital Sainte-Justine, University of Montreal, Montreal, Canada
| | - Bruno Michon
- Division of Hematology-Oncology, Centre Hospitalier Universite de Quebec, Quebec City, Canada
| | - Andrew E Place
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA.,Division of Hematology/Oncology, Boston Children's Hospital, Harvard Medical School Boston, MA
| | | | - Jennifer J G Welch
- Division of Pediatric Hematology/Oncology, Hasbro Children's Hospital, Brown University Medical School, Providence, RI
| | - Donna S Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Stephen E Sallan
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA.,Division of Hematology/Oncology, Boston Children's Hospital, Harvard Medical School Boston, MA
| | - Lewis B Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA.,Division of Hematology/Oncology, Boston Children's Hospital, Harvard Medical School Boston, MA
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Riley DO, Schlefman JM, Vitzthum Von Eckstaedt V HC, Morris AL, Keng MK, El Chaer F. Pegaspargase in Practice: Minimizing Toxicity, Maximizing Benefit. Curr Hematol Malig Rep 2021; 16:314-324. [PMID: 33978914 DOI: 10.1007/s11899-021-00638-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW The incorporation of pegaspargase in chemotherapy regimens has significantly improved the prognosis of ALL in adults. However, pegaspargase use poses many challenges due to its unique toxicity profile. Here, we review pegaspargase's most clinically significant toxicities, and provide guidance for their prevention and management in order to avoid unnecessary drug discontinuation and achieve maximum clinical benefit. RECENT FINDINGS Clinically significant toxicities of pegaspargase include thrombosis, hypersensitivity and inactivation, hepatotoxicity, pancreatitis, and hypertriglyceridemia. The majority of these toxicities are temporary, nonfatal, and can be managed supportively without permanent pegaspargase discontinuation. Special attention should be paid to inactivation, which can lead to treatment failure, as well as pancreatitis, which necessitates complete cessation of asparaginase therapy. The question of how to best proceed in patients who cannot tolerate pegaspargase remains unanswered, and is an important area of future investigation. Pegaspargase is an essential component of the pediatric-inspired regimens that have improved survival in adult ALL. Although pegaspargase's toxicity profile is unique, it is also highly manageable and should not be a barrier to achieving maximum clinical benefit using this drug.
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Affiliation(s)
- David O Riley
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, 1215 Lee Street, Charlottesville, VA, 22903, USA
| | - Jenna M Schlefman
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | - Amy L Morris
- Department of Pharmacy Services, UVA Health, Charlottesville, VA, USA
| | - Michael K Keng
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, 1215 Lee Street, Charlottesville, VA, 22903, USA
| | - Firas El Chaer
- Department of Medicine, Division of Hematology and Oncology, University of Virginia School of Medicine, 1215 Lee Street, Charlottesville, VA, 22903, USA.
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Khalil A, Würthwein G, Golitsch J, Hempel G, Fobker M, Gerss J, Möricke A, Zimmermann M, Smisek P, Zucchetti M, Nath C, Attarbaschi A, Von Stackelberg A, Gökbuget N, Rizzari C, Conter V, Schrappe M, Boos J, Lanvers-Kaminsky C. Pre-existing antibodies against polyethylene glycol reduce asparaginase activities on first administration of pegylated E. coli asparaginase in children with acute lymphocytic leukemia. Haematologica 2020; 107:49-57. [PMID: 33299233 PMCID: PMC8719085 DOI: 10.3324/haematol.2020.258525] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Indexed: 11/09/2022] Open
Abstract
Antibodies against polyethylene glycol (PEG) in healthy subjects raise concerns about the efficacy of pegylated drugs. We evaluated the prevalence of antibodies against PEG among patients with acute lymphoblastic leukemia (ALL) prior to and/or immediately after their first dose of pegylated E.coli asparaginase (PEG-ASNase). Serum samples of 701 children, 673 with primary ALL, 28 with relapsed ALL, and 188 adults with primary ALL were analyzed for anti-PEG IgG and IgM. Measurements in 58 healthy infants served as reference to define cut-points for antibody-positive and -negative samples. Anti-PEG antibodies were detected in ALL patients prior the first PEG-ASNase with a prevalence of 13.9% (anti-PEG IgG) and 29.1% (anti-PEG IgM). After administration of PEG-ASNase the prevalence of anti-PEG antibodies decreased to 4.2% for anti-PEG IgG and to 4.5% for anti-PEG IgM. Pre-existing anti-PEG antibodies did not inhibit PEG-ASNase activity but significantly reduced PEGASNase activity levels in a concentration dependent manner. Although pre-existing anti-PEG antibodies did not boost, pre-existing anti-PEG IgG were significantly associated with firstexposure hypersensitivity reactions (CTCAE grade 2) (p
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Affiliation(s)
- Alaeddin Khalil
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster
| | - Gudrun Würthwein
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster
| | - Jana Golitsch
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster
| | - Georg Hempel
- Department of Pharmaceutical and Medical Chemistry, Clinical Pharmacy, University of Muenster
| | - Manfred Fobker
- Center of Laboratory Medicine, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149 Muenster
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University of Muenster
| | - Anja Möricke
- Department of Pediatrics, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel
| | - Martin Zimmermann
- Department of Pediatric Hematology and Oncology, Medical School Hannover
| | - Petr Smisek
- Department of Pediatric Hematology and Oncology, University Hospital Motol, Praha, Czech Republic
| | - Massimo Zucchetti
- Laboratory of Cancer Pharmacology, Department of Oncology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan
| | - Christa Nath
- Departments of Biochemistry and Oncology, The Children's Hospital at Westmead, Sydney Pharmacy School, University of Sydney, Sydney
| | - Andishe Attarbaschi
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna
| | - Arend Von Stackelberg
- Departments of Pediatric Oncology/Hematology and of General Pediatrics, Charité - University Medicine Berlin, Berlin
| | | | - Carmelo Rizzari
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, ASST-Monza, Monza
| | - Valentino Conter
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, ASST-Monza, Monza
| | - Martin Schrappe
- Department of Pediatrics, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel
| | - Joachim Boos
- Department of Pediatric Hematology and Oncology, University Children's Hospital Muenster
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30
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Abstract
The last decade has witnessed great advances in our understanding of the genetic and biological basis of childhood acute lymphoblastic leukemia (ALL), the development of experimental models to probe mechanisms and evaluate new therapies, and the development of more efficacious treatment stratification. Genomic analyses have revolutionized our understanding of the molecular taxonomy of ALL, and these advances have led the push to implement genome and transcriptome characterization in the clinical management of ALL to facilitate more accurate risk-stratification and, in some cases, targeted therapy. Although mutation- or pathway-directed targeted therapy (e.g., using tyrosine kinase inhibitors to treat Philadelphia chromosome [Ph]-positive and Phlike B-cell-ALL) is currently available for only a minority of children with ALL, many of the newly identified molecular alterations have led to the exploration of approaches targeting deregulated cell pathways. The efficacy of cellular or humoral immunotherapy has been demonstrated with the success of chimeric antigen receptor T-cell therapy and the bispecific engager blinatumomab in treating advanced disease. This review describes key advances in our understanding of the biology of ALL and optimal approaches to risk-stratification and therapy, and it suggests key areas for basic and clinical research.
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Affiliation(s)
- Hiroto Inaba
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN; Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, TN.
| | - Charles G Mullighan
- Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, TN; Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN.
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31
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Burke PW, Hoelzer D, Park JH, Schmiegelow K, Douer D. Managing toxicities with asparaginase-based therapies in adult ALL: summary of an ESMO Open-Cancer Horizons roundtable discussion. ESMO Open 2020; 5:e000858. [PMID: 33037033 PMCID: PMC7549445 DOI: 10.1136/esmoopen-2020-000858] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 01/19/2023] Open
Abstract
With recent prospective clinical trials that used paediatric regimens with multiple doses of pegylated form of asparaginase (PEG asparaginase) in adults reporting significantly improved survival compared with historical data with regimens that used less asparaginase, PEG asparaginase is increasingly being used in the treatment of adult acute lymphoblastic leukaemia (ALL). However, administering asparaginase still comes with its challenges, especially in adult patients. Therefore, it is important to understand how to manage its toxicities properly. An expert group met in November 2019 in London to discuss recent data of paediatric as well as adult studies using paediatric regimens with regard to the best management of several key toxicities that can occur in adults treated with asparaginase including hepatotoxicity, pancreatitis, hypertriglyceridaemia, thrombosis and hypersensitivity. Several recommendations were made for each one of these toxicities, with the goal of safe administration of the drug and to educate clinicians when the drug can be continued despite side effects.
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Affiliation(s)
- Patrick W Burke
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
| | - Dieter Hoelzer
- Internal Medicine, Onkologikum Frankfurt, Frankfurt, Germany
| | - Jae H Park
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Juliane Marie Center, Rigshospitalet University Hospital, and Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Dan Douer
- Jane Anne Nohle Division of Hematology, University of Southern California, Los Angeles, California, USA
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32
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Baruchel A, Brown P, Rizzari C, Silverman L, van der Sluis I, Wolthers BO, Schmiegelow K. Increasing completion of asparaginase treatment in childhood acute lymphoblastic leukaemia (ALL): summary of an expert panel discussion. ESMO Open 2020; 5:e000977. [PMID: 32967920 PMCID: PMC7513670 DOI: 10.1136/esmoopen-2020-000977] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 08/10/2020] [Indexed: 02/02/2023] Open
Abstract
Insufficient exposure to asparaginase therapy is a barrier to optimal treatment and survival in childhood acute lymphoblastic leukaemia (ALL). Three important reasons for inactivity or discontinuation of asparaginase therapy are infusion related reactions (IRRs), pancreatitis and life-threatening central nervous system (CNS). For IRRs, real-time therapeutic drug monitoring (TDM) and premedication are important aspects to be considered. For pancreatitis and CNS thrombosis one key question is if patients should be re-exposed to asparaginase after their occurrence.An expert panel met during the Congress of the International Society for Paediatric Oncology in Lyon in October 2019 to discuss strategies for diminishing the impact of these three toxicities. The panel agreed that TDM is particularly useful for optimising asparaginase treatment and that when a tight pharmacological monitoring programme is established premedication could be implemented more broadly to minimise the risk of IRR. Re-exposure to asparaginase needs to be balanced against the anticipated risk of leukemic relapse. However, more prospective data are needed to give clear recommendations if to re-expose patients to asparaginase after the occurrence of severe pancreatitis and CNS thrombosis.
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Affiliation(s)
- André Baruchel
- Université de Paris, APHP, Hôpital Universitaire Robert-Debré, Paris, France.
| | - Patrick Brown
- Johns Hopkins Medicine Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | | | | | - Inge van der Sluis
- Princess Maxima Center for Pediatric Oncology, Utrecht, Utrecht, Netherlands
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34
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Gupta S, Wang C, Raetz EA, Schore R, Salzer WL, Larsen EC, Maloney KW, Mattano LA, Carroll WL, Winick NJ, Hunger SP, Loh ML, Devidas M. Impact of Asparaginase Discontinuation on Outcome in Childhood Acute Lymphoblastic Leukemia: A Report From the Children's Oncology Group. J Clin Oncol 2020; 38:1897-1905. [PMID: 32275469 DOI: 10.1200/jco.19.03024] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Asparaginase (ASNase) is an important component of acute lymphoblastic leukemia (ALL) treatment, but is often discontinued because of toxicity. Erwinia chrysanthemi ASNase (Erwinia) substitution was approved in 2011 for allergic reactions. Erwinia has, however, been intermittently unavailable because of drug supply issues. The impact of Erwinia substitution or complete ASNase discontinuation is unknown. METHODS Patients aged 1-30.99 years in frontline Children's Oncology Group trials for B-cell acute lymphoblastic leukemia between 2004 and 2011 (National Cancer Institute [NCI] standard risk [SR]: AALL0331; NCI high risk: AALL0232) were included. The number of prescribed pegaspargase (PEG-ASNase) doses varied by trial and strata. Maintenance therapy did not contain ASNase. Landmark analyses at maintenance compared disease-free survival (DFS) among those receiving all prescribed PEG-ASNase doses versus switching to Erwinia but receiving all doses versus not receiving all ASNase doses. RESULTS We included 5,195 AALL0331 and 3,001 AALL0232 patients. The cumulative incidence of PEG-ASNase discontinuation was 12.2% ± 4.6% in AALL0331 and 25.4% ± 0.8% in AALL0232. In multivariable analyses, NCI high-risk patients not receiving all prescribed ASNase doses had inferior DFS (hazard ratio [HR], 1.5; 95% CI, 1.2 to 1.9; P = .002) compared with those receiving all prescribed PEG-ASNase doses. Patients with Erwinia substitution who completed subsequent courses were not at increased risk (HR, 1.1; 95% CI, 0.7 to 1.6; P = .69). NCI SR patients who discontinued ASNase were not at elevated risk (HR, 1.2; 95% CI, 0.9 to 1.6; P = .23), except when restricted to those with slow early response, who were prescribed more ASNase because of therapy intensification (HR, 1.7; 95% CI, 1.1 to 2.7; P = .03). CONCLUSION Discontinuation of ASNase doses is associated with inferior DFS in higher-risk patients. Our results illustrate the severe consequences of Erwinia shortages.
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Affiliation(s)
- Sumit Gupta
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cindy Wang
- Department of Biostatistics, University of Florida, Gainesville, FL
| | | | | | - Wanda L Salzer
- US Army Medical Research and Materiel Command, Fort Detrick, MD
| | - Eric C Larsen
- Department of Pediatrics, Maine Children's Cancer Program, Scarborough, ME
| | | | | | - William L Carroll
- Department of Pediatrics and Perlmutter Cancer Center, New York University Langone Health, New York, NY
| | - Naomi J Winick
- University of Texas Southwestern/Simmons Cancer Center, Dallas, TX
| | - Stephen P Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mignon L Loh
- Department of Pediatrics, UCSF Benoiff Childen's Hospital and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
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35
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Losasso M, Bostrom B, Messinger Y. Retrospective cohort study monitoring PEG-asparaginase activity in acute lymphoblastic leukemia patients with and without premedication. F1000Res 2020; 8:1007. [PMID: 32089823 PMCID: PMC7001754 DOI: 10.12688/f1000research.19298.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2019] [Indexed: 11/20/2022] Open
Abstract
Background: PEG-L-asparaginase (pegaspargase) is a critical component of therapy for children and adults with acute lymphoblastic leukemia (ALL). Allergic reactions, which may occur in up to one third of patients, are the major cause for discontinuation. One study reported lower rates of allergic reactions with premedication. Besides allergy, an unknown number of patients develop silent neutralizing antibodies not associated with allergic reactions. The purpose of this retrospective cohort study was to determine the incidence of silent inactivation of pegasparaginase and compare incidence of allergic reactions with and without premedication. Methods: Using a commercial assay, asparaginase activity was monitored following pegaspargase (2500 units/m ) in newly diagnosed children and young adults with B- and T-cell ALL from February 2013 to May 2017. The incidence of allergic reactions before and after initiation of premedication in May 2015 was compared. Results: One patient out of 59 (1.7%) had silent inactivation after the second dose. No patient had silent inactivation after the first pegaspargase dose and no standard risk B-cell ALL patients, who received only two pegaspargase doses in combination with oral dexamethasone, had silent inactivation. The incidence of grade 3 or 4 allergic reactions was 3.7% per dose with premedication (methylprednisolone, acetaminophen and diphenhydramine) versus 5.2% without. The incidence per patient with premedication given for most of the doses was 8.3% versus 17% without. These values are not statistically significant. Premedication did not affect pegaspargase activity. Conclusions: Due to the low incidence of silent inactivation with intravenous pegaspargase and the unlikely event patients receiving only two doses of pegasparaginase would receive erwinase for this possible transient silent inactivation, we recommend routine monitoring of pegaspargase activity only in patients scheduled to receive more than two doses.
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Affiliation(s)
- Michael Losasso
- University of St. Thomas, 2115 Summit Avenue, St. Paul, Minnesota, 55105, USA
| | - Bruce Bostrom
- Cancer and Blood Disorders, Children's Minnesota, 2525 Chicago Avenue South, Minneapolis, Minnesota, 55404, USA
| | - Yoav Messinger
- Cancer and Blood Disorders, Children's Minnesota, 2525 Chicago Avenue South, Minneapolis, Minnesota, 55404, USA
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Nadeem K, Colantonio D, Kircanski I, Naqvi A, Hitzler J, Whitlock JA, Dupuis LL. Clinical decisions following implementation of asparaginase activity monitoring in pediatric patients with acute lymphoblastic leukemia: Experience from a single-center study. Pediatr Blood Cancer 2020; 67:e28044. [PMID: 31625674 DOI: 10.1002/pbc.28044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 09/24/2019] [Accepted: 09/30/2019] [Indexed: 11/08/2022]
Abstract
We undertook this retrospective study to describe decisions made following asparaginase activity monitoring implementation at our center. Clinically apparent reactions (CARs) and asparaginase activity monitoring costs were described. Patients with acute lymphoblastic leukemia, aged <18 years who received asparaginase between April 2016 and September 2017, were included. Decisions made following receipt of asparaginase activity results were categorized as continuation, modification, premedication, or discontinuation. We included 129 patients (median age: 5.33 years) receiving 565 asparaginase doses. CARs were observed following 25 asparaginase doses (19/361 [5.3%] pegaspargase). A total of 224 asparaginase activity levels were ordered in 88 patients. Following receipt of 190 asparaginase activity results, asparaginase therapy was continued, modified, or premedicated in 188 (98.9%), 1 (0.005%), and 1 (0.005%) cases, respectively. Inadequate asparaginase activity was observed in three patients receiving Erwinia asparaginase. Asparaginase activity monitoring allowed patients with pegaspargase-associated CAR and adequate activity to continue therapy unchanged and was cost neutral.
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Affiliation(s)
- Komail Nadeem
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - David Colantonio
- Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Canada.,The Ottawa Hospital/Eastern Ontario Regional Laboratory Association, Ottawa, Canada
| | - Ida Kircanski
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Ahmed Naqvi
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Johann Hitzler
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,Developmental and Stem Cell Biology, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - James A Whitlock
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - L Lee Dupuis
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
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37
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August KJ, Farooki S, Fulbright JM, August A, Portnoy JM, Pommert L, Burke MJ, Guest EM. Desensitization to pegaspargase in children with acute lymphoblastic leukemia and lymphoblastic lymphoma. Pediatr Blood Cancer 2020; 67:e28021. [PMID: 31571395 DOI: 10.1002/pbc.28021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/08/2019] [Accepted: 09/02/2019] [Indexed: 11/11/2022]
Abstract
Hypersensitivity to pegaspargase is associated with inferior survival in pediatric patients with acute lymphoblastic leukemia and lymphoblastic lymphoma. In the past year, drug-supply shortages have led to the lack of an available alternative to pegaspargase. Rather than omit asparaginase from the treatment of acute lymphoblastic leukemia or lymphoblastic lymphoma patients with hypersensitivity to pegaspargase, we continued pegaspargase treatments for nine pediatric patients, utilizing a rapid desensitization protocol. There were no adverse events related to the pegaspargase during desensitization, and all patients who were checked had asparaginase serum levels above the threshold of 0.1 IU/mL at 7 to 14 days after pegaspargase therapy.
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Affiliation(s)
| | - Sana Farooki
- Children's Mercy Hospitals, Kansas City, Missouri
| | | | | | | | | | | | - Erin M Guest
- Children's Mercy Hospitals, Kansas City, Missouri
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Hu X, Wildman KP, Basu S, Lin PL, Rowntree C, Saha V. The cost-effectiveness of pegaspargase versus native asparaginase for first-line treatment of acute lymphoblastic leukaemia: a UK-based cost-utility analysis. HEALTH ECONOMICS REVIEW 2019; 9:40. [PMID: 31885053 PMCID: PMC6935472 DOI: 10.1186/s13561-019-0257-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 12/10/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND L-asparaginase is a key component of treatment for patients with acute lymphoblastic leukaemia (ALL) in the UK. Commonly used forms of asparaginase are native E. coli-derived asparaginase (native asparaginase) and pegaspargase in first-line combination therapy, and native Erwinia chrysanthemi-derived asparaginase (Erwinia asparaginase) as second-line treatment. The objective of this study was to evaluate the cost-effectiveness of pegaspargase versus native asparaginase in first-line combination therapy for patients with newly diagnosed ALL. A combined decision tree and health-state transition Markov cost-effectiveness model was developed to assess the relative costs and health outcomes of pegaspargase versus native asparaginase in the UK setting. RESULTS In base case analyses, first-line pegaspargase (followed by Erwinia asparaginase in cases of hypersensitivity) dominated first-line native asparaginase followed by Erwinia asparaginase; i.e. resulted in lower costs and more quality-adjusted life year gain. The favourable hypersensitivity rates and administration profile of pegaspargase led to lifetime cost savings of £4741 versus native asparaginase. Pegaspargase remained cost-effective versus all treatment strategies in all scenario analyses, including use of the 2500 IU/m2 dose, recommended for patients ≤21 years of age. CONCLUSIONS Pegaspargase, as part of multi-drug chemotherapy, is a cost-effective option for the treatment of newly diagnosed ALL. Based on this study, The National Institute for Health and Care Excellence Technology Appraisal Committee concluded that it could recommend pegaspargase as a cost-effective use of National Health Service resources in England & Wales for treating ALL in children, young people and adults with untreated, newly diagnosed disease. TRIAL REGISTRATION UKALL 2011, EudraCT number 2010-020924-22; UKALL 2003, EudraCT number 2007-004013-34; UKALL14, EudraCT number 2009-012717-22.
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Affiliation(s)
- Xingdi Hu
- GHEOR Analytics, Shire, Cambridge, MA USA
| | - Kingsley P. Wildman
- Medical Affairs for Oncology, UK & Ireland, Servier Laboratories Ltd, Stoke Poges, UK
| | - Subham Basu
- Medical Affairs Oncology, UK & Republic of Ireland, Shire Pharmaceuticals Ltd, London, UK
| | | | | | - Vaskar Saha
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, The Oglesby Cancer Research Building, 555 Wilmslow Road, Manchester, M20 4GJ UK
- Tata Translational Cancer Research Centre, Tata Medical Center, Kolkata, India
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Losasso M, Bostrom B, Messinger Y. Retrospective cohort study monitoring PEG-asparaginase activity in acute lymphoblastic leukemia patients with and without premedication. F1000Res 2019; 8:1007. [PMID: 32089823 PMCID: PMC7001754 DOI: 10.12688/f1000research.19298.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2019] [Indexed: 10/20/2023] Open
Abstract
Background: PEG-L-asparaginase (pegaspargase) is a critical component of therapy for children and adults with acute lymphoblastic leukemia (ALL). Allergic reactions, which may occur in up to one third of patients, are the major cause for discontinuation. One study reported lower rates of allergic reactions with premedication. Besides allergy, an unknown number of patients develop silent neutralizing antibodies not associated with allergic reactions. The purpose of this retrospective cohort study was to determine the incidence of silent inactivation of pegasparaginase and compare incidence of allergic reactions with and without premedication. Methods: Using a commercial assay, asparaginase activity was monitored following pegaspargase (2500 units/m 2) in newly diagnosed children and young adults with B- and T-cell ALL from February 2013 to May 2017. The incidence of allergic reactions before and after initiation of premedication in May 2015 was compared. Results: One patient out of 59 (1.7%) had silent inactivation after the second dose. No patient had silent inactivation after the first pegaspargase dose and no standard risk B-cell ALL patients, who received only two pegaspargase doses in combination with oral dexamethasone, had silent inactivation. The incidence of grade 3 or 4 allergic reactions was 3.7% per dose with premedication (methylprednisolone, acetaminophen and diphenhydramine) versus 5.2% without. The incidence per patient with premedication given for most of the doses was 8.3% versus 17% without. These values are not statistically significant. Premedication did not affect pegaspargase activity. Conclusions: Due to the low incidence of silent inactivation with intravenous pegaspargase and the unlikely event patients receiving only two doses of pegasparaginase would receive erwinase for this possible transient silent inactivation, we recommend routine monitoring of pegaspargase activity only in patients scheduled to receive more than two doses.
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Affiliation(s)
- Michael Losasso
- University of St. Thomas, 2115 Summit Avenue, St. Paul, Minnesota, 55105, USA
| | - Bruce Bostrom
- Cancer and Blood Disorders, Children's Minnesota, 2525 Chicago Avenue South, Minneapolis, Minnesota, 55404, USA
| | - Yoav Messinger
- Cancer and Blood Disorders, Children's Minnesota, 2525 Chicago Avenue South, Minneapolis, Minnesota, 55404, USA
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