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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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Feldman K, Aaronson K, Gu T, Ige K, Southworth E, Sanchez L, Stieglitz E. Desensitization using pegaspargase in the era of commercially available Erwinia: A single-institution report on efficacy, cost, and resource utilization. Pediatr Blood Cancer 2024; 71:e30891. [PMID: 38311802 DOI: 10.1002/pbc.30891] [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: 06/30/2023] [Revised: 12/23/2023] [Accepted: 01/15/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND Pegaspargase is a therapeutic enzyme that is utilized in treatment regimens targeting pediatric acute lymphoblastic leukemia. However, many patients experience hypersensitivity reactions, requiring discontinuation of the therapy. Historically, this necessitated switching to an alternative form of the drug, most commonly asparaginase Erwinia chrysanthemi; however, in recent years this was difficult due to drug shortages and eventually commercial discontinuation. We report here our experience performing pegaspargase desensitizations in patients with prior hypersensitivity reactions. PROCEDURE Patients with a clinical hypersensitivity reaction to pegaspargase were identified. When due for their next dose, patients were admitted to the pediatric intensive care unit, bone marrow transplant unit, or oncology unit, and underwent desensitization utilizing a rigorous premedication and multistep dilution-based protocol. Serum asparaginase activity levels were drawn after desensitization to assess for therapeutic levels of enzyme activity. RESULTS We identified 11 patients who underwent a total of 33 desensitizations to pegaspargase and calaspargase pegol-mknl. No patients experienced clinically significant hypersensitivity reactions necessitating stopping the infusion, nor administration of rescue medications. All serum asparaginase activity levels collected demonstrated enzyme activity levels above predefined therapeutic thresholds. Cost analysis revealed substantial savings when patients received asparaginase desensitization over the now commercially available asparaginase E. chrysanthemi (recombinant) rywn. CONCLUSIONS Performing desensitization to pegaspargase in the pediatric acute lymphoblastic leukemia population is feasible, safe, and effective. It is financially advantageous over available alternative approaches, and requires fewer injections and presentations to care.
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Affiliation(s)
- Kira Feldman
- San Francisco Department of Pediatrics, University of California, San Francisco, California, USA
| | - Kathryn Aaronson
- Division of Pediatric Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Tina Gu
- Department of Pharmacy, University of California, San Francisco, California, USA
| | - Kelsey Ige
- Division of Pediatric Immunology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Erica Southworth
- Division of Pediatric Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Lauren Sanchez
- Division of Pediatric Immunology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Elliot Stieglitz
- Division of Pediatric Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
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Kuhn AK, Martin C, Galardy P, McCullough K, Greenmyer J, O'Keefe M, Walter A, Thompson C, Ferdjallah A, Kalmes J, Kohorst M. Attempted desensitization to calaspargase pegol: a familiar approach to a new problem. Leuk Lymphoma 2024; 65:407-409. [PMID: 37991456 DOI: 10.1080/10428194.2023.2282950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/08/2023] [Indexed: 11/23/2023]
Affiliation(s)
- Alexis K Kuhn
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | | | - Paul Galardy
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Mayo Clinic, Rochester, MN, USA
| | | | - Jacob Greenmyer
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Mayo Clinic, Rochester, MN, USA
| | - Madeleine O'Keefe
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Mayo Clinic, Rochester, MN, USA
| | - Ashley Walter
- Department of Pharmacy, Mayo Clinic, Rochester, MN, USA
| | - Christineil Thompson
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Mayo Clinic, Rochester, MN, USA
| | - Asmaa Ferdjallah
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Mayo Clinic, Rochester, MN, USA
| | - Jessica Kalmes
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Mayo Clinic, Rochester, MN, USA
| | - Mira Kohorst
- Division of Pediatric Hematology/Oncology/Bone Marrow Transplant, Mayo Clinic, Rochester, MN, USA
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4
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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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5
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Wallace J, Garner L, Echols C, Phillips K, Kaplan, JB. Medication Desensitization: Single Intravenous Bag Method, in 3 Pediatric Patients. J Pediatr Pharmacol Ther 2023; 28:671-673. [PMID: 38025151 PMCID: PMC10681089 DOI: 10.5863/1551-6776-28.7.671] [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: 08/07/2022] [Accepted: 01/11/2023] [Indexed: 12/01/2023]
Abstract
Chemotherapies and biologic agents are known to cause hypersensitivity reactions (HSRs). It is imperative that pediatric patients receive these agents to treat their cancer or other rare condition, as oftentimes there are no available therapeutic alternatives. Successful medication desensitization has been described previously with a 12-step method using 3 intravenous (IV) infusion bags of varying concentrations. However, this 12-step process is time and resource intensive and increases the risk for medication errors. A recent study successfully used a simplified 12-step method with a single IV infusion bag for a paclitaxel desensitization. From the results of this study, our institution used this single IV infusion bag method for desensitization with 3 different medications. Two of these experiences were successful. We share those 3 experiences in this report.
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Affiliation(s)
- Jordan Wallace
- Department of Pharmacy (JW, LG, CE, KP, JBK), University of North Carolina Medical Center, Chapel Hill, NC
| | - Lauren Garner
- Department of Pharmacy (JW, LG, CE, KP, JBK), University of North Carolina Medical Center, Chapel Hill, NC
| | - Carmen Echols
- Department of Pharmacy (JW, LG, CE, KP, JBK), University of North Carolina Medical Center, Chapel Hill, NC
| | - Kynlon Phillips
- Department of Pharmacy (JW, LG, CE, KP, JBK), University of North Carolina Medical Center, Chapel Hill, NC
| | - Jenna Bognaski Kaplan,
- Department of Pharmacy (JW, LG, CE, KP, JBK), University of North Carolina Medical Center, Chapel Hill, NC
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6
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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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7
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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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8
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Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J, Khan DA, Golden DBK, Shaker M, Stukus DR, Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunol 2022; 150:1333-1393. [PMID: 36122788 DOI: 10.1016/j.jaci.2022.08.028] [Citation(s) in RCA: 131] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/18/2022] [Accepted: 08/30/2022] [Indexed: 12/14/2022]
Affiliation(s)
- David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Aleena Banerji
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Kimberly G Blumenthal
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Roland Solensky
- Corvallis Clinic, Oregon State University/Oregon Health Science University College of Pharmacy, Corvallis, Ore
| | - Andrew A White
- Department of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, Calif
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Derek K Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St Joe's Hamilton, Hamilton, Ontario, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Matthew J Greenhawt
- Food Challenge and Research Unit Section of Allergy and Immunology, Children's Hospital Colorado University of Colorado School of Medicine, Aurora, Colo
| | - Caroline C Horner
- Department of Pediatrics, Division of Allergy Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Dennis Ledford
- Division of Allergy and Immunology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla; James A. Haley Veterans Affairs Hospital, Tampa, Fla
| | - Jay A Lieberman
- Division of Allergy and Immunology, The University of Tennessee Health Science Center, Memphis, Tenn
| | - John Oppenheimer
- Division of Allergy, Rutgers New Jersey Medical School, Rutgers, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; The Ohio State University College of Medicine, Columbus, Ohio
| | - Dana Wallace
- Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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9
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Cecconello DK, Rechenmacher C, Silva KADS, Scherer FF, Prates TDB, Marques RF, Daudt LE, Michalowski MB. Follow our path with asparaginase activity: one technique, but different uses in clinical practice. Exp Hematol Oncol 2022; 11:86. [PMCID: PMC9635150 DOI: 10.1186/s40164-022-00351-5] [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: 06/29/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Acute lymphoblastic leukemia is the most common childhood malignancy. One of the drugs used in the treatment is Asparaginase, and monitoring of its activity levels enables better outcomes. Since 2018, our laboratory has been working to establish a regular analysis of activity. This implementation allowed to qualify care by detecting silent inactivation and also establishing desensitization as a safe way to overcome the lack of Erwinia. We were able to monitor children aged 0 to 18 years who were being treated with PEG-ASNase. The activity was assessed on days 7 (90 samples) and 14 (52 samples) after ASNase infusions. 142 samples were analyzed. 95.7% reached an adequate activity level (≥ 0.1 IU/mL). Patients treated with ASNase can develop allergic reactions. With the activity monitoring, is possible to circumvent situations like these and implement desensitization protocols for patients who had clinical hypersensitivity without inactivation. Desensitization induces temporary unresponsiveness to drug antigens, allowing the patients to proceed with the prescribed chemotherapy. We have received samples from four patients being treated with different desensitization protocols. Patients tolerated the protocols well. Only one had a grade 2 reaction during the infusion and activity < 0.1 IU/mL, which resulted in the switch to Erwinia. The dose adaptation is a possible and more recent use of ASNase monitoring and we were able to confirm the feasibility of PEG-ASNase desensitization protocols.
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Affiliation(s)
- Daiane Keller Cecconello
- grid.8532.c0000 0001 2200 7498Post Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Translational Pediatrics Laboratory, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Ciliana Rechenmacher
- grid.8532.c0000 0001 2200 7498Post Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Translational Pediatrics Laboratory, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Klerize Anecely de Souza Silva
- grid.8532.c0000 0001 2200 7498Post Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS Brazil
| | - Fernanda Fetter Scherer
- grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Thomas Dal Bem Prates
- grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Rebeca Ferreira Marques
- grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Liane Esteves Daudt
- grid.8532.c0000 0001 2200 7498Post Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Translational Pediatrics Laboratory, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Mariana Bohns Michalowski
- grid.8532.c0000 0001 2200 7498Post Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Translational Pediatrics Laboratory, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
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10
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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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11
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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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12
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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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13
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Esenboga S, Akarsu A, Ocak M, Gur Cetinkaya P, Sahiner UM, Sekerel BE, Soyer O. Safety and efficacy of rapid drug desensitization in children. Pediatr Allergy Immunol 2022; 33:e13759. [PMID: 35338724 DOI: 10.1111/pai.13759] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/15/2022] [Accepted: 02/16/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Any drug taken at the recommended dosage may cause hypersensitivity reactions (DHR). Rapid drug desensitization (RDD) protocols have been developed in the case of a confirmed or highly suspected HSR to allow safe administration of the medicine when there is no alternative drug or in the presence of a less effective or more toxic alternative. The aim of this study was to evaluate the characteristics of children who underwent desensitization, the safety and efficacy of RDD in children, as well as, the characteristics and management of breakthrough reactions. METHOD This retrospective study concerned children who underwent RDD due to physician-diagnosed HSRs during or up to 48 hours after the infusion of various drugs between February 2010-February 2021. Patients with a chronic disease needing chronic drug usage and acute infections seen in patients with chronic diseases were included. The results of RDD were documented. RESULTS The study included 48 patients [8.1(IQR = 3.32-13.4) years, 60.4% male] with 58 HSRs of which 62.1% were classified as moderate and 5.2% as severe. Most of the patients were being treated for leukemia (41.7%), solid tumors (29.2%), and infections (6.3%). Skin tests were done for 41 out of 58 HSRs in 35 patients, and twenty of them were positive. A total of 269 RDDs were performed for 18 different drugs. Ninety percent of desensitizations were achieved with no reaction, and 3.7% and 5.6% with mild and moderate reactions, respectively. In multivariate analysis, skin test positivity was the only risk factor for breakthrough reactions (OR = 8.5, CI = 1.72-42.15, p = .009). CONCLUSION We demonstrated the safety and efficacy of RDD in childhood, thereby offered the first line treatment options to children with chronic diseases with hypersensitivity reactions (HSRs).
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Affiliation(s)
- Saliha Esenboga
- Department of Pediatrics, Division of Immunology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ayşegul Akarsu
- Department of Pediatrics, Division of Allergy, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Melike Ocak
- Department of Pediatrics, Division of Allergy, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Pınar Gur Cetinkaya
- Department of Pediatrics, Division of Allergy, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Umit Murat Sahiner
- Department of Pediatrics, Division of Allergy, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Bulent Enis Sekerel
- Department of Pediatrics, Division of Allergy, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ozge Soyer
- Department of Pediatrics, Division of Allergy, Hacettepe University Faculty of Medicine, Ankara, Turkey
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14
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Bender C, Maese L, Carter-Febres M, Verma A. Clinical Utility of Pegaspargase in Children, Adolescents and Young Adult Patients with Acute Lymphoblastic Leukemia: A Review. Blood Lymphat Cancer 2021; 11:25-40. [PMID: 33907490 PMCID: PMC8064615 DOI: 10.2147/blctt.s245210] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 03/12/2021] [Indexed: 01/19/2023]
Abstract
Acute lymphoblastic leukemia (ALL) is a heterogenous hematological malignancy representing 25% of all cancers in children less than 15 years of age. Significant improvements in survival and cure rates have been made over the past four decades in pediatric ALL treatment. Asparaginases, derived from Escherichia coli and Erwinia chrysanthemi, have become a critical component of ALL therapy since the 1960s. Asparaginases cause depletion of serum asparagine, leading to deprivation of this critical amino acid for protein synthesis, and hence limit survival of lymphoblasts. Pegaspargase, a conjugate of monomethoxypolyethylene glycol (mPEG) and L-asparaginase, has become an integral component of pediatric upfront and relapsed ALL protocols due to its longer half-life and improved immunogenicity profile compared to native asparaginase preparations. Over the past two decades great strides have been made in outcomes for pediatric ALL due to risk stratification, incorporation of multiagent chemotherapy protocols, and central nervous system prophylaxis with pegaspargase having played an important role in this success. However, adolescents and young adults (AYA) with ALL when treated on contemporaneous trials using adult ALL regimens, continue to have poor outcomes. There is increasing realization of adapting pediatric trial regimens for treating AYAs, especially those incorporating higher intensity of chemotherapeutic agents with pegaspargase being one such agent. Dose or treatment-limiting toxicity is observed in 25-30% of patients, most notable being hypersensitivity reactions. Other toxicities include asparaginase-associated pancreatitis, thrombosis, liver dysfunction, osteonecrosis, and dyslipidemia. Discontinuation or subtherapeutic levels of asparaginase are associated with inferior disease-free survival leading to higher risk of relapse, and in cases of relapse, a higher risk for remission failure. This article provides an overview of available evidence for use of pegaspargase in pediatric acute lymphoblastic leukemia.
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Affiliation(s)
- Cynthia Bender
- Department of Pharmacy, Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Luke Maese
- Division of Hematology/Oncology, Department of Pediatrics, University of Utah and Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Maria Carter-Febres
- Division of Hematology/Oncology, Department of Pediatrics, University of Utah and Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Anupam Verma
- Division of Hematology/Oncology, Department of Pediatrics, University of Utah and Primary Children’s Hospital, Salt Lake City, UT, USA
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15
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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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