1
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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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2
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Chen Y, Buhlinger K, Perissinotti AJ, Schepers AJ, Benitez L, Auten J, Chen SL, Bixby DL, Burke PW, Pettit KM, Marini BL. Solving coagulation conundrums: comparing prophylaxis strategies in adult patients receiving PEG-asparaginase. Leuk Lymphoma 2022; 63:2663-2670. [DOI: 10.1080/10428194.2022.2087066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- YeeAnn Chen
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Kaitlyn Buhlinger
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Anthony J. Perissinotti
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Allison J. Schepers
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Lydia Benitez
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Jessica Auten
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Sheh-Li Chen
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Dale L. Bixby
- Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Patrick W. Burke
- Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Kristen M. Pettit
- Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Bernard L. Marini
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
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3
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Prevention of venous thromboembolism in hematologic neoplasms: an expert consensus from SEHH-SETH. Clin Transl Oncol 2021; 24:770-783. [PMID: 34850351 DOI: 10.1007/s12094-021-02735-1] [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: 08/19/2021] [Accepted: 11/10/2021] [Indexed: 10/19/2022]
Abstract
Venous thromboembolism (VTE) is a serious complication in hematologic neoplasms, so finding adequate prevention strategies is an urgent requirement. However, prospective studies with large enough cohorts are scarce, limiting the development of evidence-based thromboprophylaxis guidelines. The present position paper is addressed to all hematologists treating patients affected by hematologic neoplasms with the aim to provide clinicians with a useful tool for the prevention of VTE.
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4
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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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5
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Freyer CW, Carulli A, Ganetsky A, Hughes ME, Krause TM, Timlin C, Frey NV, Gill SI, Hexner EO, Loren AW, Mangan JK, Martin ME, McCurdy SR, Perl AE, Pratz K, Porter DL, Luger SM. Venous thromboembolism following pegaspargase in adults receiving antithrombin supplementation. Leuk Lymphoma 2020; 61:2200-2207. [DOI: 10.1080/10428194.2020.1765239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Craig W. Freyer
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Alison Carulli
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Alex Ganetsky
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mitchell E. Hughes
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Tracy M. Krause
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Colleen Timlin
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Noelle V. Frey
- Department of Medicine, Hematology-Oncology Section, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Saar I. Gill
- Department of Medicine, Hematology-Oncology Section, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth O. Hexner
- Department of Medicine, Hematology-Oncology Section, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Alison W. Loren
- Department of Medicine, Hematology-Oncology Section, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - James K. Mangan
- Department of Medicine, Hematology-Oncology Section, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Mary Ellen Martin
- Department of Medicine, Hematology-Oncology Section, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Shannon R. McCurdy
- Department of Medicine, Hematology-Oncology Section, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Alexander E. Perl
- Department of Medicine, Hematology-Oncology Section, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Keith Pratz
- Department of Medicine, Hematology-Oncology Section, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - David L. Porter
- Department of Medicine, Hematology-Oncology Section, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Selina M. Luger
- Department of Medicine, Hematology-Oncology Section, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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6
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George G, Rezazadeh A, Zook F, Pearl N, McCoy C, Carlson K, Runaas L, Abedin S, Guru Murthy GS, Michaelis LC, Atallah E, Baumann-Kreuziger L. Reducing venous thrombosis with antithrombin supplementation in patients undergoing treatment for ALL with Peg-asparaginase-A real world study. Leuk Res 2020; 94:106368. [PMID: 32442786 DOI: 10.1016/j.leukres.2020.106368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/23/2020] [Accepted: 04/29/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Gemlyn George
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
| | - Alexandra Rezazadeh
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Felicia Zook
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Nicole Pearl
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Cole McCoy
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Karen Carlson
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA; Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
| | - Lyndsey Runaas
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Sameem Abedin
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | | | - Laura C Michaelis
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Ehab Atallah
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Lisa Baumann-Kreuziger
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI 53226, USA; Blood Research Institute, Blood Center of Wisconsin, Milwaukee, WI, USA
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7
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Fulcher J, Carrier M. Thromboembolism prophylaxis during L-asparaginase therapy in acute lymphoblastic leukemia - time to reconsider current approaches? Thromb Res 2020; 188:100-102. [PMID: 32120278 DOI: 10.1016/j.thromres.2020.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/11/2020] [Accepted: 02/17/2020] [Indexed: 01/19/2023]
Abstract
Acute Lymphoblastic Leukemia (ALL) is the commonest malignancy in childhood with a second incidence peak in adulthood. Improvements in pediatric therapy including the addition of L-asparaginase (L-ASP) have enabled cure rates in excess of 90% to be achieved in children. More recently L-ASP-containing pediatric protocols are being used to treat younger adults with ALL and have improved survival by approximately 2-fold. However, a toxicity associated with L-ASP-containing therapy in ALL is venous thromboembolism (VTE) which is associated with significant morbidity in this patient population and results in interruptions in L-ASP therapy that can impact on survival outcomes. The incidence of VTE among adult patients with ALL receiving L-ASP containing therapy has been reported to be as high as 43%. Despite this, there is a lack of evidence-based recommendations for VTE prophylaxis in this clinical context; low-molecular weight heparin (LMWH) and/or AT replacement have mostly been used. The low-quality data and inconveniences associated with these VTE prophylaxis regimens highlight the need to evaluate alternatives such as direct oral anticoagulants for the prevention of L-ASP-associated VTE in ALL. This narrative will review the body of evidence on primary thromboprophylaxis in adult patients with ALL receiving L-ASP containing therapy.
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Affiliation(s)
- J Fulcher
- Department of Medicine, the Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada.
| | - M Carrier
- Department of Medicine, the Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada
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8
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Zwicker JI, Wang TF, DeAngelo DJ, Lauw MN, Connors JM, Falanga A, McMasters M, Carrier M. The prevention and management of asparaginase-related venous thromboembolism in adults: Guidance from the SSC on Hemostasis and Malignancy of the ISTH. J Thromb Haemost 2020; 18:278-284. [PMID: 31999063 DOI: 10.1111/jth.14671] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 10/25/2019] [Indexed: 02/01/2023]
Abstract
Venous thromboembolism is a common complication of asparaginase-based chemotherapy regimens for the treatment of acute lymphoblastic leukemia. Thrombosis associated with asparaginase administration poses a number of specific and often clinically challenging management decisions. This review provides guidance on the prevention and treatment of thrombosis associated with asparaginase in adults including discussions on antithrombin repletion, pharmacologic thromboprophylaxis, cerebral venous thrombosis, and therapeutic anticoagulation.
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Affiliation(s)
- Jeffrey I Zwicker
- Division of Hematology and Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tzu-Fei Wang
- Division of Hematology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Daniel J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mandy N Lauw
- Department of Hematology, Erasmus MC, Rotterdam, the Netherlands
- Department of Hematology, Amsterdam UMC, Amsterdam, the Netherlands
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Anna Falanga
- University of Milan Bicocca, Milan, Italy
- Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Malgorzata McMasters
- Division of Hematologic Malignancies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, ON, Canada
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9
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Young J, Sawyer J, Jenkins M, O'Brien M, Luchtman-Jones L, Breese EH. Capped antithrombin III dosing is cost effective in the management of asparaginase-associated thrombosis. Pediatr Blood Cancer 2019; 66:e27719. [PMID: 30900794 DOI: 10.1002/pbc.27719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 02/13/2019] [Accepted: 02/27/2019] [Indexed: 01/19/2023]
Abstract
Asparaginase therapy induces a transient antithrombin III (ATIII) deficiency, which contributes to the risk of asparaginase-induced thrombosis. At Cincinnati Children's Hospital Medical Center, management of asparaginase-induced thrombosis includes ATIII supplementation during therapeutic anticoagulation with enoxaparin. Due to the expense associated with ATIII, a capped dosing approach for ATIII was evaluated in this population. Peak ATIII levels were obtained following capped doses to evaluate response. In this pilot evaluation, 11 patients received a total of 138 capped doses for a total cost savings of $803 782. This pilot evaluation represents the first reported analysis of capped ATIII dosing in oncology patients.
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Affiliation(s)
- Jennifer Young
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jaclyn Sawyer
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Meredith Jenkins
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Maureen O'Brien
- Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lori Luchtman-Jones
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Erin H Breese
- Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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10
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Bade NA, Lu C, Patzke CL, Baer MR, Duong VH, Law JY, Lee ST, Sausville EA, Zimrin AB, Duffy AP, Lawson J, Emadi A. Optimizing pegylated asparaginase use: An institutional guideline for dosing, monitoring, and management. J Oncol Pharm Pract 2019; 26:74-92. [PMID: 30917738 DOI: 10.1177/1078155219838316] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The incorporation of L-asparaginase and pegylated asparaginase into pediatric-inspired regimens has conferred a survival advantage in treatment of adults with acute lymphoblastic leukemia. Use of asparaginase products requires careful prevention, monitoring, and management of adverse effects including hypersensitivity, hepatotoxicity, pancreatitis, coagulopathy, and thrombosis. Currently, there is limited published literature to offer guidance on management of these toxicities. At the University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, a standard of practice guideline was created to prevent and manage asparaginase-related adverse events. By sharing our long-term experience with asparaginase products and clinical management of asparaginase-induced toxicities, this article aims to improve patient safety and optimize treatment outcomes.
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Affiliation(s)
- Najeebah A Bade
- Division of Hematology/Oncology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Crystal Lu
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ciera L Patzke
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, Piscataway, NJ, USA.,Department of Pharmacy, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Maria R Baer
- Division of Hematology/Oncology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Vu H Duong
- Division of Hematology/Oncology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jennie Y Law
- Division of Hematology/Oncology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Seung T Lee
- Division of Hematology/Oncology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Edward A Sausville
- Division of Hematology/Oncology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ann B Zimrin
- Division of Hematology/Oncology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alison P Duffy
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Justin Lawson
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ashkan Emadi
- Division of Hematology/Oncology, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
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11
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Chen J, Ngo D, Aldoss I, Shayani S, Tsai NC, Pullarkat V. Antithrombin supplementation did not impact the incidence of pegylated asparaginase-induced venous thromboembolism in adults with acute lymphoblastic leukemia. Leuk Lymphoma 2018; 60:1187-1192. [DOI: 10.1080/10428194.2018.1519811] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Jason Chen
- Department of Pharmacy, City of Hope National Medical Center, Duarte, CA, USA
| | - Dat Ngo
- Department of Pharmacy, City of Hope National Medical Center, Duarte, CA, USA
| | - Ibrahim Aldoss
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Sepideh Shayani
- Department of Pharmacy, City of Hope National Medical Center, Duarte, CA, USA
| | - Ni-Chun Tsai
- Department of Information Sciences, City of Hope National Medical Center, Duarte, CA, USA
| | - Vinod Pullarkat
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
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