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Hu Z, Persaud Y, Ahuja S. A systematic review and meta-analysis of the effectiveness of primary thromboprophylaxis in acute lymphoblastic leukemia during early-phase therapy including asparaginase or its prolonged form. Crit Rev Oncol Hematol 2024; 197:104347. [PMID: 38583546 DOI: 10.1016/j.critrevonc.2024.104347] [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: 11/04/2023] [Revised: 03/31/2024] [Accepted: 04/04/2024] [Indexed: 04/09/2024] Open
Abstract
Asparaginase is essential in the initial management of acute lymphoblastic leukemia (ALL) but frequently leads to venous thromboembolism (VTE). Using anticoagulants for primary VTE prevention has been studied with no consensus. We conducted a systematic literature search in PubMed, Scopus, and Web of science and performed random-effect meta-analysis using Mantel-Haenszel method in RevMan 5.4 to analyze primary pharmacological thromboprophylaxis during asparaginase treatment in early-phase (induction, consolidation, or intensification phase) therapy in patients with ALL with all ages and followed with subgroup analysis by age. Meta-analysis of 13 articles describing the effect of antithrombin supplementation in 1375 patients showed that antithrombin prophylaxis decreases the risk of VTE by 43% (RR, 0.57; 95% CI, 0.38 - 0.83; p=0.004), with mild heterogeneity (I2=35%, p=0.10) and moderate certainty by GRADE. 8 articles included for meta-analysis of low-molecular weight heparin (LMWH) treatment in 612 patients showed that it decreased the risk of VTE by nearly 40% (RR, 0.61; 95% CI, 0.45 - 0.81; p=0.00081), with minimal heterogeneity (I2=14%, p=0.31) but low certainty. Subgroup analysis showed that only prophylaxis with antithrombin supplementation significantly decreased the VTE rate in adult patients with moderate certainty. In pediatric patients, one nonrandomized prospective study showed that LMWH combined with antithrombin has a better thromboprophylaxis effect than antithrombin alone. In the PREVAPIX-ALL trial, prophylaxis with direct factor Xa inhibitor Apixaban did not benefit children younger than 18 years except for cases of obesity. We concluded that thromboprophylaxis with antithrombin is effective in ALL patients older than 18 years during the early phase of therapy, and LMWH combined with antithrombin supplementation might be effective for pediatric patients with ALL. Apixaban is effective in pediatric ALL patients with obesity and needs further study in other high-risk patients.
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Affiliation(s)
- Zhongbo Hu
- Hospitalist Medicine Program, Department of Oncology, St. Jude Children's Research Hospital, 262 Danny Thomas Place Mail Stop 278, Memphis, TN 38105, USA.
| | - Yogindra Persaud
- Department of Hematology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA
| | - Sanjay Ahuja
- Department of Pediatric Hematology & Oncology, University Hospitals Rainbow Babies and Children's Hospital, 11100 Euclid Ave, Cleveland, OH 44106, USA
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Chen R, Liu X, Law AD, Kanfar S, Maze D, Chan SM, Gupta V, Yee KW, Minden MD, Schimmer AD, Schuh AC, McNamara CJ, Murphy T, Xu A, Falcone U, Seki J, Sibai H. Risk of Thrombosis in Adult Philadelphia-Positive ALL Treated with an Asparaginase-Free ALL Regimen. Curr Oncol 2020; 28:128-137. [PMID: 33704181 PMCID: PMC7816186 DOI: 10.3390/curroncol28010016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 12/15/2020] [Accepted: 12/17/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND venous thromboembolism (VTE) is a well-known complication in adults with acute lymphoblastic leukemia (ALL), especially in patients treated with asparaginase (ASNase)-including regiments. However, VTE risk in adult Philadelphia-positive ALL (Ph+ve ALL) patients treated with non-hyperCVAD chemotherapy is unclear. In this study, we examined VTE incidence in adult Ph+ve ALL patients treated with imatinib plus a pediatric-inspired asparaginase (ASNase)-free regimen modified from the Dana Farber Cancer Institute (DFCI) ALL protocol. METHODS a single centre retrospective review of Ph+ve ALL patients treated at Princess Margaret Cancer Center (PMCC) from 2008-2019 with imatinib plus modified DFCI protocol was conducted. RESULTS of the 123 patients included, 30 (24.3%) had at least 1 radiology confirmed VTE event from diagnosis to the end of maintenance therapy. 86.7% (26/30) of the VTE events occurred during active treatment. Of all VTE events, the majority (53.3%) were DVT and/or PE while another significant portion were catheter-related (40.0%). Major bleeding was observed in 1 patient on VTE treatment with low molecular weight heparin (LMWH). CONCLUSION a high VTE incidence (24.3%) was observed in adults Ph+ve ALL patients treated with imatinib plus an ASNase-free modified DFCI pediatric ALL protocol, suggesting prophylactic anticoagulation should be considered for all adult Ph+ve ALL patients including those treated with ASNase-free regimens.
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Affiliation(s)
- Ruiqi Chen
- Princess Margaret Cancer Centre, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C1, Canada; (R.C.); (A.D.L.); (S.K.); (D.M.); (S.M.C.); (V.G.); (K.W.Y.); (M.D.M.); (A.D.S.); (A.C.S.); (C.J.M.); (T.M.); (J.S.)
| | - Xing Liu
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2, Canada; (X.L.); (A.X.)
- Department of Pharmacy, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Arjun D. Law
- Princess Margaret Cancer Centre, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C1, Canada; (R.C.); (A.D.L.); (S.K.); (D.M.); (S.M.C.); (V.G.); (K.W.Y.); (M.D.M.); (A.D.S.); (A.C.S.); (C.J.M.); (T.M.); (J.S.)
| | - Solaf Kanfar
- Princess Margaret Cancer Centre, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C1, Canada; (R.C.); (A.D.L.); (S.K.); (D.M.); (S.M.C.); (V.G.); (K.W.Y.); (M.D.M.); (A.D.S.); (A.C.S.); (C.J.M.); (T.M.); (J.S.)
| | - Dawn Maze
- Princess Margaret Cancer Centre, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C1, Canada; (R.C.); (A.D.L.); (S.K.); (D.M.); (S.M.C.); (V.G.); (K.W.Y.); (M.D.M.); (A.D.S.); (A.C.S.); (C.J.M.); (T.M.); (J.S.)
| | - Steven M. Chan
- Princess Margaret Cancer Centre, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C1, Canada; (R.C.); (A.D.L.); (S.K.); (D.M.); (S.M.C.); (V.G.); (K.W.Y.); (M.D.M.); (A.D.S.); (A.C.S.); (C.J.M.); (T.M.); (J.S.)
| | - Vikas Gupta
- Princess Margaret Cancer Centre, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C1, Canada; (R.C.); (A.D.L.); (S.K.); (D.M.); (S.M.C.); (V.G.); (K.W.Y.); (M.D.M.); (A.D.S.); (A.C.S.); (C.J.M.); (T.M.); (J.S.)
| | - Karen W. Yee
- Princess Margaret Cancer Centre, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C1, Canada; (R.C.); (A.D.L.); (S.K.); (D.M.); (S.M.C.); (V.G.); (K.W.Y.); (M.D.M.); (A.D.S.); (A.C.S.); (C.J.M.); (T.M.); (J.S.)
| | - Mark D. Minden
- Princess Margaret Cancer Centre, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C1, Canada; (R.C.); (A.D.L.); (S.K.); (D.M.); (S.M.C.); (V.G.); (K.W.Y.); (M.D.M.); (A.D.S.); (A.C.S.); (C.J.M.); (T.M.); (J.S.)
| | - Aaron D. Schimmer
- Princess Margaret Cancer Centre, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C1, Canada; (R.C.); (A.D.L.); (S.K.); (D.M.); (S.M.C.); (V.G.); (K.W.Y.); (M.D.M.); (A.D.S.); (A.C.S.); (C.J.M.); (T.M.); (J.S.)
| | - Andre C. Schuh
- Princess Margaret Cancer Centre, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C1, Canada; (R.C.); (A.D.L.); (S.K.); (D.M.); (S.M.C.); (V.G.); (K.W.Y.); (M.D.M.); (A.D.S.); (A.C.S.); (C.J.M.); (T.M.); (J.S.)
| | - Caroline J. McNamara
- Princess Margaret Cancer Centre, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C1, Canada; (R.C.); (A.D.L.); (S.K.); (D.M.); (S.M.C.); (V.G.); (K.W.Y.); (M.D.M.); (A.D.S.); (A.C.S.); (C.J.M.); (T.M.); (J.S.)
| | - Tracy Murphy
- Princess Margaret Cancer Centre, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C1, Canada; (R.C.); (A.D.L.); (S.K.); (D.M.); (S.M.C.); (V.G.); (K.W.Y.); (M.D.M.); (A.D.S.); (A.C.S.); (C.J.M.); (T.M.); (J.S.)
| | - Anna Xu
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2, Canada; (X.L.); (A.X.)
| | - Umberto Falcone
- Department of Haematology, Istituto Nazionale Tumori IRCCS Fondazione Pascale, 80131 Naples, Italy;
| | - Jack Seki
- Princess Margaret Cancer Centre, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C1, Canada; (R.C.); (A.D.L.); (S.K.); (D.M.); (S.M.C.); (V.G.); (K.W.Y.); (M.D.M.); (A.D.S.); (A.C.S.); (C.J.M.); (T.M.); (J.S.)
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON M5S 3M2, Canada; (X.L.); (A.X.)
- Department of Pharmacy, Princess Margaret Cancer Centre, University Health Network, Toronto, ON M5G 2M9, Canada
| | - Hassan Sibai
- Princess Margaret Cancer Centre, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON M5G 2C1, Canada; (R.C.); (A.D.L.); (S.K.); (D.M.); (S.M.C.); (V.G.); (K.W.Y.); (M.D.M.); (A.D.S.); (A.C.S.); (C.J.M.); (T.M.); (J.S.)
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Rank CU, Lynggaard LS, Als-Nielsen B, Stock W, Toft N, Nielsen OJ, Frandsen TL, Tuckuviene R, Schmiegelow K. Prophylaxis of thromboembolism during therapy with asparaginase in adults with acute lymphoblastic leukaemia. Cochrane Database Syst Rev 2020; 10:CD013399. [PMID: 33038027 PMCID: PMC9831116 DOI: 10.1002/14651858.cd013399.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The risk of venous thromboembolism is increased in adults and enhanced by asparaginase-based chemotherapy, and venous thromboembolism introduces a secondary risk of treatment delay and premature discontinuation of key anti-leukaemic agents, potentially compromising survival. Yet, the trade-off between benefits and harms of primary thromboprophylaxis in adults with acute lymphoblastic leukaemia (ALL) treated according to asparaginase-based regimens is uncertain. OBJECTIVES: The primary objectives were to assess the benefits and harms of primary thromboprophylaxis for first-time symptomatic venous thromboembolism in adults with ALL receiving asparaginase-based therapy compared with placebo or no thromboprophylaxis. The secondary objectives were to compare the benefits and harms of different groups of primary systemic thromboprophylaxis by stratifying the main results per type of drug (heparins, vitamin K antagonists, synthetic pentasaccharides, parenteral direct thrombin inhibitors, direct oral anticoagulants, and blood-derived products for antithrombin substitution). SEARCH METHODS We conducted a comprehensive literature search on 02 June 2020, with no language restrictions, including (1) electronic searches of Pubmed/MEDLINE; Embase/Ovid; Scopus/Elsevier; Web of Science Core Collection/Clarivate Analytics; and Cochrane Central Register of Controlled Trials (CENTRAL) and (2) handsearches of (i) reference lists of identified studies and related reviews; (ii) clinical trials registries (ClinicalTrials.gov registry; the International Standard Randomized Controlled Trial Number (ISRCTN) registry; the World Health Organisation's International Clinical Trials Registry Platform (ICTRP); and pharmaceutical manufacturers of asparaginase including Servier, Takeda, Jazz Pharmaceuticals, Ohara Pharmaceuticals, and Kyowa Pharmaceuticals), and (iii) conference proceedings (from the annual meetings of the American Society of Hematology (ASH); the European Haematology Association (EHA); the American Society of Clinical Oncology (ASCO); and the International Society on Thrombosis and Haemostasis (ISTH)). We conducted all searches from 1970 (the time of introduction of asparaginase in ALL treatment). We contacted the authors of relevant studies to identify any unpublished material, missing data, or information regarding ongoing studies. SELECTION CRITERIA Randomised controlled trials (RCTs); including quasi-randomised, controlled clinical, cross-over, and cluster-randomised trial designs) comparing any parenteral/oral preemptive anticoagulant or mechanical intervention with placebo or no thromboprophylaxis, or comparing two different pre-emptive anticoagulant interventions in adults aged at least 18 years with ALL treated according to asparaginase-based chemotherapy regimens. For the description of harms, non-randomised observational studies with a control group were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Using a standardised data collection form, two review authors independently screened and selected studies, extracted data, assessed risk of bias for each outcome using standardised tools (RoB 2.0 tool for RCTs and ROBINS-I tool for non-randomised studies) and the certainty of evidence for each outcome using the GRADE approach. Primary outcomes included first-time symptomatic venous thromboembolism, all-cause mortality, and major bleeding. Secondary outcomes included asymptomatic venous thromboembolism, venous thromboembolism-related mortality, adverse events (i.e. clinically relevant non-major bleeding and heparin-induced thrombocytopenia for trials using heparins), and quality of life. Analyses were performed according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. For non-randomised studies, we evaluated all studies (including studies judged to be at critical risk of bias in at least one of the ROBINS-I domains) in a sensitivity analysis exploring confounding. MAIN RESULTS: We identified 23 non-randomised studies that met the inclusion criteria of this review, of which 10 studies provided no outcome data for adults with ALL. We included the remaining 13 studies in the 'Risk of bias' assessment, in which we identified invalid control group definition in two studies and judged outcomes of nine studies to be at critical risk of bias in at least one of the ROBINS-I domains and outcomes of two studies at serious risk of bias. We did not assess the benefits of thromboprophylaxis, as no RCTs were included. In the main descriptive analysis of harms, we included two retrospective non-randomised studies with outcomes judged to be at serious risk of bias. One study evaluated antithrombin concentrates compared to no antithrombin concentrates. We are uncertain whether antithrombin concentrates have an effect on all-cause mortality (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.26 to 1.19 (intention-to-treat analysis); one study, 40 participants; very low certainty of evidence). We are uncertain whether antithrombin concentrates have an effect on venous thromboembolism-related mortality (RR 0.10, 95% CI 0.01 to 1.94 (intention-to-treat analysis); one study, 40 participants; very low certainty of evidence). We do not know whether antithrombin concentrates have an effect on major bleeding, clinically relevant non-major bleeding, and quality of life in adults with ALL treated with asparaginase-based chemotherapy, as data were insufficient. The remaining study (224 participants) evaluated prophylaxis with low-molecular-weight heparin versus no prophylaxis. However, this study reported insufficient data regarding harms including all-cause mortality, major bleeding, venous thromboembolism-related mortality, clinically relevant non-major bleeding, heparin-induced thrombocytopenia, and quality of life. In the sensitivity analysis of harms, exploring the effect of confounding, we also included nine non-randomised studies with outcomes judged to be at critical risk of bias primarily due to uncontrolled confounding. Three studies (179 participants) evaluated the effect of antithrombin concentrates and six studies (1224 participants) evaluated the effect of prophylaxis with different types of heparins. When analysing all-cause mortality; venous thromboembolism-related mortality; and major bleeding (studies of heparin only) including all studies with extractable outcomes for each comparison (antithrombin and low-molecular-weight heparin), we observed small study sizes; few events; wide CIs crossing the line of no effect; and substantial heterogeneity by visual inspection of the forest plots. Although the observed heterogeneity could arise through the inclusion of a small number of studies with differences in participants; interventions; and outcome assessments, the likelihood that bias due to uncontrolled confounding was the cause of heterogeneity is inevitable. Subgroup analyses were not possible due to insufficient data. AUTHORS' CONCLUSIONS: We do not know from the currently available evidence, if thromboprophylaxis used for adults with ALL treated according to asparaginase-based regimens is associated with clinically appreciable benefits and acceptable harms. The existing research on this question is solely of non-randomised design, seriously to critically confounded, and underpowered with substantial imprecision. Any estimates of effect based on the existing insufficient evidence is very uncertain and is likely to change with future research.
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Affiliation(s)
- Cecilie U Rank
- Department of Hematology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Line Stensig Lynggaard
- Department of Child and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Bodil Als-Nielsen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Wendy Stock
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Nina Toft
- Department of Hematology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ove Juul Nielsen
- Department of Hematology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Thomas Leth Frandsen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ruta Tuckuviene
- Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
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Sibai H, Chen R, Liu X, Falcone U, Schimmer A, Schuh A, Law A, McNamara C, Maze D, Yee K, Minden M, Chan SM, Gupta V, Murphy T, Sakurai N, Atenafu EG, Brandwein JM, Seki JT. Anticoagulation prophylaxis reduces venous thromboembolism rate in adult acute lymphoblastic leukaemia treated with asparaginase‐based therapy. Br J Haematol 2020; 191:748-754. [DOI: 10.1111/bjh.16695] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/07/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Hassan Sibai
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Ruiqi Chen
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Xing Liu
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Biostatistics Princess Margaret Cancer Centre University Health Network Toronto ON Canada
| | - Umberto Falcone
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Aaron Schimmer
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Andre Schuh
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Arjun Law
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Caroline McNamara
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Dawn Maze
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Karen Yee
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Mark Minden
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Steven M. Chan
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Vikas Gupta
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Tracy Murphy
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Department of Medicine University of Toronto Toronto ON Canada
| | - Naoko Sakurai
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
| | - Eshetu G. Atenafu
- Department of Biostatistics Princess Margaret Cancer Centre University Health Network Toronto ON Canada
| | | | - Jack T. Seki
- Princess Margaret Cancer Centre University Health Network Toronto ON Canada
- Leslie Dan Faculty of Pharmacy University of Toronto Toronto ON Canada
- Department of Pharmacy Princess Margaret Cancer Centre University Health Network Toronto ON Canada
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