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Genetic inhibition of NFATC2 attenuates asparaginase hypersensitivity in mice. Blood Adv 2020; 4:4406-4416. [PMID: 32931581 DOI: 10.1182/bloodadvances.2020002478] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/12/2020] [Indexed: 12/22/2022] Open
Abstract
The family of nuclear factor of activated T cells (NFAT) transcription factors plays a critical role in mediating immune responses. Our previous clinical pharmacogenetic studies suggested that NFATC2 is associated with the risk of hypersensitivity reactions to the chemotherapeutic agent L-asparaginase (ASNase) that worsen outcomes during the treatment of pediatric acute lymphoblastic leukemia. We therefore hypothesized that the genetic inhibition of NFATC2 would protect against the development of anti-ASNase antibodies and ASNase hypersensitivity. Our study demonstrates that ASNase-immunized NFATC2-deficient mice are protected against ASNase hypersensitivity and develop lower antigen-specific and total immunoglobulin E (IgE) levels compared with wild-type (WT) controls. Furthermore, ASNase-immunized NFATC2-deficient mice develop more CD4+ regulatory T cells, fewer CD4+ interleukin-4-positive (IL-4+) cells, higher IL-10/TGF-β1 levels, and lower IL-4/IL-13 levels relative to WT mice. Basophils and peritoneal mast cells from ASNase-immunized, but not naïve, NFATC2-deficient mice had lower FcεRI expression and decreased IgE-mediated mast cell activation than WT mice. Furthermore, ASNase-immunized, but not naïve, NFATC2-deficient mice developed less severe shock than WT mice after induction of passive anaphylaxis or direct histamine administration. Thus, inhibition of NFATC2 protects against ASNase hypersensitivity by impairing T helper 2 responses, which may provide a novel strategy for attenuating hypersensitivity and the development of antidrug antibodies, including to ASNase.
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52
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Therapeutic Drug Monitoring of Asparaginase: Intra-individual Variability and Predictivity in Children With Acute Lymphoblastic Leukemia Treated With PEG-Asparaginase in the AIEOP-BFM Acute Lymphoblastic Leukemia 2009 Study. Ther Drug Monit 2020; 42:435-444. [DOI: 10.1097/ftd.0000000000000727] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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53
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Capria S, Molica M, Mohamed S, Bianchi S, Moleti ML, Trisolini SM, Chiaretti S, Testi AM. A review of current induction strategies and emerging prognostic factors in the management of children and adolescents with acute lymphoblastic leukemia. Expert Rev Hematol 2020; 13:755-769. [PMID: 32419532 DOI: 10.1080/17474086.2020.1770591] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Acute lymphoblastic leukemia is the most frequent hematologic malignancy in children. Almost 95% of children potentially achieve a complete remission after the induction treatment, but over the last years, new insights in the genomic disease profile and in minimal residual disease detection techniques have led to an improvement in the prognostic stratification, identifying selected patients' subgroups with peculiar therapeutic needs. AREAS COVERED According to a comprehensive search of peer-review literature performed in Pubmed, in this review we summarize the recent evidences on the induction treatment strategies comprised in the children acute lymphoblastic leukemia scenario, focusing on the role of key drugs such as corticosteroids and asparaginase and discussing the crucial significance of the genomic characterization at baseline which may drive the proper induction treatment choice. EXPERT OPINION Current induction strategies already produce durable remissions in a significant proportion of standard-risk children with acute lymphoblastic leukemia. A broader knowledge of the biologic features related to acute lymphoblastic leukemia subtypes with worse prognosis, and an optimization of targeted drugs now available, might lead to the achievement of long-term molecular remissions in this setting.
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Affiliation(s)
- Saveria Capria
- Hematology, Department of Translational and Precision Medicine, 'Sapienza" University of Rome , Rome, Italy
| | - Matteo Molica
- Hematology, Department of Translational and Precision Medicine, 'Sapienza" University of Rome , Rome, Italy
| | - Sara Mohamed
- Hematology, Department of Translational and Precision Medicine, 'Sapienza" University of Rome , Rome, Italy
| | - Simona Bianchi
- Hematology, Department of Translational and Precision Medicine, 'Sapienza" University of Rome , Rome, Italy
| | - Maria Luisa Moleti
- Hematology, Department of Translational and Precision Medicine, 'Sapienza" University of Rome , Rome, Italy
| | - Silvia Maria Trisolini
- Hematology, Department of Translational and Precision Medicine, 'Sapienza" University of Rome , Rome, Italy
| | - Sabina Chiaretti
- Hematology, Department of Translational and Precision Medicine, 'Sapienza" University of Rome , Rome, Italy
| | - Anna Maria Testi
- Hematology, Department of Translational and Precision Medicine, 'Sapienza" University of Rome , Rome, Italy
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Abstract
Acute lymphoblastic leukaemia develops in both children and adults, with a peak incidence between 1 year and 4 years. Most acute lymphoblastic leukaemia arises in healthy individuals, and predisposing factors such as inherited genetic susceptibility or environmental exposure have been identified in only a few patients. It is characterised by chromosomal abnormalities and genetic alterations involved in differentiation and proliferation of lymphoid precursor cells. Along with response to treatment, these abnormalities are important prognostic factors. Disease-risk stratification and the development of intensified chemotherapy protocols substantially improves the outcome of patients with acute lymphoblastic leukaemia, particularly in children (1-14 years), but also in adolescents and young adults (15-39 years). However, the outcome of older adults (≥40 years) and patients with relapsed or refractory acute lymphoblastic leukaemia remains poor. New immunotherapeutic strategies, such as monoclonal antibodies and chimeric antigen receptor (CAR) T cells, are being developed and over the next few years could change the options for acute lymphoblastic leukaemia treatment.
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Affiliation(s)
- Florent Malard
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France; Sorbonne University, INSERM, Saint-Antoine Research Centre, Paris, France
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France; Sorbonne University, INSERM, Saint-Antoine Research Centre, Paris, France.
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55
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Lima GM, Effer B, Biasoto HP, Feijoli V, Pessoa A, Palmisano G, Monteiro G. Glycosylation of L-asparaginase from E. coli through yeast expression and site-directed mutagenesis. Biochem Eng J 2020. [DOI: 10.1016/j.bej.2020.107516] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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56
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Immunogenicity assessment of fungal l-asparaginases: an in silico approach. SN APPLIED SCIENCES 2020. [DOI: 10.1007/s42452-020-2021-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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57
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Nadeem K, Colantonio D, Kircanski I, Naqvi A, Hitzler J, Whitlock JA, Dupuis LL. Clinical decisions following implementation of asparaginase activity monitoring in pediatric patients with acute lymphoblastic leukemia: Experience from a single-center study. Pediatr Blood Cancer 2020; 67:e28044. [PMID: 31625674 DOI: 10.1002/pbc.28044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 09/24/2019] [Accepted: 09/30/2019] [Indexed: 11/08/2022]
Abstract
We undertook this retrospective study to describe decisions made following asparaginase activity monitoring implementation at our center. Clinically apparent reactions (CARs) and asparaginase activity monitoring costs were described. Patients with acute lymphoblastic leukemia, aged <18 years who received asparaginase between April 2016 and September 2017, were included. Decisions made following receipt of asparaginase activity results were categorized as continuation, modification, premedication, or discontinuation. We included 129 patients (median age: 5.33 years) receiving 565 asparaginase doses. CARs were observed following 25 asparaginase doses (19/361 [5.3%] pegaspargase). A total of 224 asparaginase activity levels were ordered in 88 patients. Following receipt of 190 asparaginase activity results, asparaginase therapy was continued, modified, or premedicated in 188 (98.9%), 1 (0.005%), and 1 (0.005%) cases, respectively. Inadequate asparaginase activity was observed in three patients receiving Erwinia asparaginase. Asparaginase activity monitoring allowed patients with pegaspargase-associated CAR and adequate activity to continue therapy unchanged and was cost neutral.
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Affiliation(s)
- Komail Nadeem
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - David Colantonio
- Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Canada.,The Ottawa Hospital/Eastern Ontario Regional Laboratory Association, Ottawa, Canada
| | - Ida Kircanski
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Ahmed Naqvi
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Johann Hitzler
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,Developmental and Stem Cell Biology, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - James A Whitlock
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - L Lee Dupuis
- Department of Pharmacy, The Hospital for Sick Children, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
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58
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Battistel AP, Rocha BSD, Santos MTD, Daudt LE, Michalowski MB. Allergic reactions to asparaginase: retrospective cohort study in pediatric patients with acute lymphoid leukemia. Hematol Transfus Cell Ther 2020; 43:9-14. [PMID: 32014473 PMCID: PMC7910154 DOI: 10.1016/j.htct.2019.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/03/2019] [Accepted: 11/20/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION To assess the frequency of allergic reactions to asparaginase (ASP) and possible risk factors for reactions in a cohort of pediatric patients. METHOD The study was performed based on retrospective data from patients under acute lymphoid leukemia treatment in a general university hospital located in southern Brazil. Information on patients who used ASP from 2010 to 2017 was collected. Allergic reactions were identified in electronic medical records. RESULTS Among the 98 patients included in the study, 16 (16.3 %) experienced an allergic reaction to native l-asparaginase (L-ASP). Of the 22 patients (22.4 %) that received only intravenous (IV) administration of l-ASP, 10 (62.5 %) had allergic reactions, while 48 patients (49 %) received intramuscular (IM) administration and 28 (28.6 %) received IV and IM administrations. The occurrence of allergic reactions differed between the groups (p < 0.001), and IV administration was associated with allergic reactions. Association was also observed between the severity of the reaction and the route of administration, with the IM route associated with grade 2 and IV route associated with grade 3. Occurrence of allergic reactions was higher when the commercial formulation of l-ASP, Leuginase®, was used (p = 0.0009 in the analysis per patient and p = 0.0003 in the analysis per administration). CONCLUSIONS The IV administration and commercial Leuginase® presentation were associated with more allergic reactions in the study population, which corroborates the findings in the literature. The IV route was also associated with higher severity of reactions in the present study.
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Affiliation(s)
| | | | | | - Liane Esteves Daudt
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Porto Alegre, RS, Brazil; Departamento de Pediatria, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS) Porto Alegre, RS, Brazil
| | - Mariana Bohns Michalowski
- Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil; Departamento de Pediatria, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS) Porto Alegre, RS, Brazil; Centro de Pesquisa Experimental (CPE), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, RS, Brazil
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59
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August KJ, Farooki S, Fulbright JM, August A, Portnoy JM, Pommert L, Burke MJ, Guest EM. Desensitization to pegaspargase in children with acute lymphoblastic leukemia and lymphoblastic lymphoma. Pediatr Blood Cancer 2020; 67:e28021. [PMID: 31571395 DOI: 10.1002/pbc.28021] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/08/2019] [Accepted: 09/02/2019] [Indexed: 11/11/2022]
Abstract
Hypersensitivity to pegaspargase is associated with inferior survival in pediatric patients with acute lymphoblastic leukemia and lymphoblastic lymphoma. In the past year, drug-supply shortages have led to the lack of an available alternative to pegaspargase. Rather than omit asparaginase from the treatment of acute lymphoblastic leukemia or lymphoblastic lymphoma patients with hypersensitivity to pegaspargase, we continued pegaspargase treatments for nine pediatric patients, utilizing a rapid desensitization protocol. There were no adverse events related to the pegaspargase during desensitization, and all patients who were checked had asparaginase serum levels above the threshold of 0.1 IU/mL at 7 to 14 days after pegaspargase therapy.
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Affiliation(s)
| | - Sana Farooki
- Children's Mercy Hospitals, Kansas City, Missouri
| | | | | | | | | | | | - Erin M Guest
- Children's Mercy Hospitals, Kansas City, Missouri
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60
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Effect of chemical modification with carboxymethyl dextran on kinetic and structural properties of L-asparaginase. Anal Biochem 2019; 591:113537. [PMID: 31821805 DOI: 10.1016/j.ab.2019.113537] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/30/2019] [Accepted: 12/06/2019] [Indexed: 12/28/2022]
Abstract
l-asparaginase is a chemotherapy agent in the treatment of childhood leukemia. l-asparaginase has several side effects and a short blood half-life in patients. Chemical modification of l-asparaginase can decrease its side effects and improve its pharmacokinetic properties. The aim of this project was twofold: to chemically modify l-asparaginase with carboxymethyl dextran via carbodiimide cross linker, and to evaluate and compare the biochemical and structural properties of the native and modified enzymes. Chemical modification was done at 25 °C, in 0.1 M phosphate buffer, pH 7.2, and in the presence of N-hydroxysuccinimide and carbodiimide. Electrophoresis and free amino groups determination confirmed the chemical modification. Biochemical studies showed that the chemical modification could result in higher specific activity and stability of the modified enzyme. Structural studies further confirmed the chemical modification and revealed conformational changes in the modified enzyme. Taken together, the results showed that chemical modification with carboxymethyl dextran brings about improvement of biochemical properties through several changes in the structural attributes of l-asparaginase and might enhance its applicability in the treatment of childhood leukemia.
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61
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Sharma D, Singh K, Singh K, Mishra A. Insights into the Microbial L-Asparaginases: from Production to Practical Applications. Curr Protein Pept Sci 2019; 20:452-464. [PMID: 30426897 DOI: 10.2174/1389203720666181114111035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 11/01/2018] [Accepted: 11/04/2018] [Indexed: 01/10/2023]
Abstract
L-asparaginase is a valuable protein therapeutic drug utilized for the treatment of leukemia and lymphomas. Administration of asparaginase leads to asparagine starvation causing inhibition of protein synthesis, growth, and proliferation of tumor cells. Besides its clinical significance, the enzyme also finds application in the food sector for mitigation of a cancer-causing agent acrylamide. The numerous applications ensue huge market demands and create a continued interest in the production of costeffective, more specific, less immunogenic and stable formulations which can cater both the clinical and food processing requirements. The current review article approaches the process parameters of submerged and solid-state fermentation strategies for the microbial production of the L-asparaginase from diverse sources, genetic engineering approaches used for the production of L-asparaginase enzyme and major applications in clinical and food sectors. The review also addresses the immunological issues associated with the L-asparaginase usage and the immobilization strategies, drug delivery systems employed to circumvent the toxicity complications are also discussed. The future prospects for microbial Lasparaginase production are discussed at the end of the review article.
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Affiliation(s)
- Deepankar Sharma
- School of Biochemical Engineering, Indian Institute of Technology (BHU), Varanasi-221005, India
| | - Kushagri Singh
- School of Biochemical Engineering, Indian Institute of Technology (BHU), Varanasi-221005, India
| | - Kavita Singh
- School of Biochemical Engineering, Indian Institute of Technology (BHU), Varanasi-221005, India
| | - Abha Mishra
- School of Biochemical Engineering, Indian Institute of Technology (BHU), Varanasi-221005, India
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62
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Hernández-Marqués C, Andión M, Perez-Somarriba M, Madero L, Lassaletta A. Can monitoring asparaginase activity help us to manage toxicity in pediatric acute lymphoblastic leukemia? Leuk Lymphoma 2019; 61:990-992. [PMID: 31749392 DOI: 10.1080/10428194.2019.1691191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Carmen Hernández-Marqués
- Department of Pediatric Hematology-Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Maitane Andión
- Department of Pediatric Hematology-Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Marta Perez-Somarriba
- Department of Pediatric Hematology-Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Luis Madero
- Department of Pediatric Hematology-Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Alvaro Lassaletta
- Department of Pediatric Hematology-Oncology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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63
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Concha S, Barriga F, Ovalle P, Hoyos-Bachiloglu R. A 12-steps desensitization protocol for pediatric patients with hypersensitivity to pegylated asparaginase. Ann Allergy Asthma Immunol 2019; 124:208-210. [PMID: 31734333 DOI: 10.1016/j.anai.2019.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/26/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022]
Affiliation(s)
- S Concha
- Department of Pediatric Infectious Diseases and Immunology School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - F Barriga
- Pediatric Hematology and Oncology Section, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - P Ovalle
- Pediatric Oncology Unit, Hospital Sótero del Río, Servicio de Salud Metropolitano Sur-Oriente, Santiago, Chile
| | - R Hoyos-Bachiloglu
- Department of Pediatric Infectious Diseases and Immunology School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
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64
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Cecconello DK, Magalhães MRD, Werlang ICR, Lee MLDM, Michalowski MB, Daudt LE. Asparaginase: an old drug with new questions. Hematol Transfus Cell Ther 2019; 42:275-282. [PMID: 31801703 PMCID: PMC7417439 DOI: 10.1016/j.htct.2019.07.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/19/2019] [Accepted: 07/20/2019] [Indexed: 02/08/2023] Open
Abstract
The long-term outcome of acute lymphoblastic leukemia has improved dramatically due to the development of more effective treatment strategies. L-asparaginase (ASNase) is one of the main drugs used and causes death of leukemic cells by systematically depleting the non-essential amino acid asparagine. Three main types of ASNase have been used so far: native ASNase derived from Escherichia coli, an enzyme isolated from Erwinia chrysanthemi and a pegylated form of the native E. coli ASNase, the ASNase PEG. Hypersensitivity reactions are the main complication related to this drug. Although clinical allergies may be important, a major concern is that antibodies produced in response to ASNase may cause rapid inactivation of ASNase, leading to a worse prognosis. This reaction is commonly referred to as "silent hypersensitivity" or "silent inactivation". We are able to analyze hypersensitivity and inactivation processes by the measurement of the ASNase activity. The ability to individualize the ASNase therapy in patients, adjusting the dose or switching patients with silent inactivation to an alternate ASNase preparation may help improve outcomes in those patients. This review article aims to describe the pathophysiology of the inactivation process, how to diagnose it and finally how to manage it.
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Affiliation(s)
- Daiane Keller Cecconello
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Hospital de Clínicas de Porto Alegre, RS, Brazil
| | | | - Isabel Cristina Ribas Werlang
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Hospital de Clínicas de Porto Alegre, RS, Brazil
| | | | - Mariana Bohns Michalowski
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Hospital de Clínicas de Porto Alegre, RS, Brazil.
| | - Liane Esteves Daudt
- Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil; Hospital de Clínicas de Porto Alegre, RS, Brazil
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65
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Lanvers-Kaminsky C, Niemann A, Eveslage M, Beck J, Köhnke T, Martin S, de Wit M, Spriewald B, Hauspurg H, Hoelzer D, Boos J, Gökbuget N. Asparaginase activities during intensified treatment with pegylated E. coli asparaginase in adults with newly-diagnosed acute lymphoblastic leukemia. Leuk Lymphoma 2019; 61:138-145. [DOI: 10.1080/10428194.2019.1658099] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Claudia Lanvers-Kaminsky
- Department of Pediatric Hematology and Oncology, University Children’s Hospital of Muenster, Muenster, Germany
| | - Andreas Niemann
- Department of Pediatric Hematology and Oncology, University Children’s Hospital of Muenster, Muenster, Germany
| | - Maria Eveslage
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Joachim Beck
- Department of Medicine III, University Hospital, Mainz, Germany
| | - Thomas Köhnke
- Department of Medicine III, University Hospital Großhadern, München, Germany
| | - Sonja Martin
- Department of Hematology/Oncology, Robert Bosch Hospital, Stuttgart, Germany
| | - Maike de Wit
- Department of Internal Medicine, Hematology, Oncology and Palliative Medicine, Vivantes Klinikum Neukölln, Berlin, Germany
| | - Bernd Spriewald
- Department of Medicine 5, University Hospital, Erlangen, Germany
| | | | - Dieter Hoelzer
- Department of Medicine, University Hospital, Frankfurt A.M, Germany
| | - Joachim Boos
- Department of Pediatric Hematology and Oncology, University Children’s Hospital of Muenster, Muenster, Germany
| | - Nicola Gökbuget
- Department of Medicine, University Hospital, Frankfurt A.M, Germany
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66
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Cooper SL, Young DJ, Bowen CJ, Arwood NM, Poggi SG, Brown PA. Universal premedication and therapeutic drug monitoring for asparaginase-based therapy prevents infusion-associated acute adverse events and drug substitutions. Pediatr Blood Cancer 2019; 66:e27797. [PMID: 31099154 PMCID: PMC8294186 DOI: 10.1002/pbc.27797] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 03/28/2019] [Accepted: 04/09/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND Asparaginase is a critical component of lymphoblastic leukemia therapy, with intravenous pegaspargase (PEG) as the current standard product. Acute adverse events (aAEs) during PEG infusion are difficult to interpret, representing a mix of drug-inactivating hypersensitivity and noninactivating reactions. Asparaginase Erwinia chrysanthemi (ERW) is approved for PEG hypersensitivity, but is less convenient, more expensive, and yields lower serum asparaginase activity (SAA). We began a policy of universal premedication and SAA testing for PEG, hypothesizing this would reduce aAEs and unnecessary drug substitutions. PROCEDURE Retrospective chart review of patients receiving asparaginase before and after universal premedication before PEG was conducted, with SAA performed 1 week later. We excluded patients who had nonallergic asparaginase AEs. Primary end point was substitution to ERW. Secondary end points included aAEs, SAA testing, and cost. RESULTS We substituted to ERW in 21 of 122 (17.2%) patients pre-policy, and 5 of 68 (7.4%) post-policy (RR, 0.427; 95% CI, 0.27-0.69, P = 0.028). All completed doses of PEG yielded excellent SAA (mean, 0.90 units/mL), compared with ERW (mean, 0.15 units/mL). PEG inactivation post-policy was seen in 2 of 68 (2.9%), one silent and one with breakthrough aAE. The rate of aAEs pre/post-policy was 17.2% versus 5.9% (RR, 0.342; 95% CI, 0.20-0.58, P = 0.017). Grade 4 aAE rate pre/post-policy was 15% versus 0%. Cost analysis predicts $125 779 drug savings alone per substitution prevented ($12 402/premedicated patient). CONCLUSIONS Universal premedication reduced substitutions to ERW and aAE rate. SAA testing demonstrated low rates of silent inactivation, and higher SAA for PEG. A substantial savings was achieved. We propose universal premedication for PEG be standard of care.
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Affiliation(s)
- Stacy L. Cooper
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland,Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - David J. Young
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland,Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Caitlin J. Bowen
- Institute of Human Genetics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nicole M. Arwood
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sarah G. Poggi
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Patrick A. Brown
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, Maryland,Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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Verma A, Chen K, Bender C, Gorney N, Leonard W, Barnette P. PEGylated E. coli asparaginase desensitization: an effective and feasible option for pediatric patients with acute lymphoblastic leukemia who have developed hypersensitivity to pegaspargase in the absence of asparaginase Erwinia chrysanthemi availability. Pediatr Hematol Oncol 2019; 36:277-286. [PMID: 31296092 DOI: 10.1080/08880018.2019.1634778] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Asparaginase is an important component of multi-agent chemotherapy for the treatment of pediatric acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LLy). Hypersensitivity to the PEGylated form, pegaspargase, is the most common toxicity observed and is ideally addressed by substituting multiple doses of erwinia asparaginase for each subsequent dose of pegaspargase. An international shortage of erwinia asparaginase has limited the therapeutic options for those experiencing pegaspargase hypersensitivity. Here, we report pegaspargase can be safely administered, while maintaining sustained levels of asparaginase activity, to patients who have had a prior hypersensitivity reaction to pegaspargase by using a standard rapid desensitization protocol. Ten patients with prior hypersensitivity reactions to pegaspargase were treated by using a standardized rapid desensitization protocol. Eight patients had therapeutic asparaginase levels between days 4 and 7 of ≥0.05 IU/mL, and seven patients continued to have sustained levels above ≥0.1 IU/mL between days 10 and 14. Based on chemotherapy regimens, five of these patients successfully received more than one dose of pegaspargase utilizing this protocol.
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Affiliation(s)
- Anupam Verma
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Utah, School of Medicine , Salt Lake City , Utah , USA
| | - Karin Chen
- Department of Pediatrics, Division of Allergy & Immunology, University of Utah, School of Medicine , Salt Lake City , Utah , USA
| | - Cynthia Bender
- Department of Pharmacy, Primary Children's Hospital , Salt Lake City , Utah , USA
| | - Nathan Gorney
- Department of Pharmacy, Primary Children's Hospital , Salt Lake City , Utah , USA
| | - Whitney Leonard
- Department of Pharmacy, Primary Children's Hospital , Salt Lake City , Utah , USA
| | - Phillip Barnette
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Utah, School of Medicine , Salt Lake City , Utah , USA
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68
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Rathod S, Ramsey M, DiGiorgio D, Berrios R, Finkelman FD, Fernandez CA. Asparaginase immune complexes induce Fc-γRIII-dependent hypersensitivity in naive mice. FASEB J 2019; 33:10996-11005. [PMID: 31284767 DOI: 10.1096/fj.201900857] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Asparaginase (ASNase) is an important drug for the treatment of leukemias. However, hypersensitivity to ASNase can increase the risk of leukemia relapse. Two mechanisms of ASNase hypersensitivity have been identified in mice. The existence of a pathway involving anti-ASNase IgG and Fc-γ receptor III (Fc-γRIII) implies that IgG and ASNase immune complexes (ICs) could directly induce hypersensitivity. The aim of this study was to detect ASNase ICs in mice after hypersensitivity reactions and determine their role in hypersensitivity. Protein G beads were used to detect plasma ASNase ICs by flow cytometry. Anti-ASNase IgG was purified from the plasma of sensitized mice, and ASNase ICs were prepared ex vivo at various ratios of ASNase to anti-ASNase IgG. The levels of ASNase ICs detected after hypersensitivity reactions correlated with reaction severity (R2 = 0.796; P = 0.0005). ASNase ICs prepared ex vivo required high levels of anti-ASNase IgG for formation, and binding to naive and sensitized immune cells depended on soluble anti-ASNase IgG, antigen:antibody ratio, and Fc-γRIII. Similarly, basophil activation by ASNase ICs depended on the antigen:antibody ratio and Fc-γRIII. Consistent with the ex vivo results, naive mice receiving ASNase ICs developed hypersensitivity reactions. Our data demonstrate that ASNase ICs can directly contribute to the onset and severity of ASNase hypersensitivity.-Rathod, S., Ramsey, M., DiGiorgio, D., Berrios, R., Finkelman, F. D., Fernandez, C. A. Asparaginase immune complexes induce Fc-γRIII-dependent hypersensitivity in naive mice.
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Affiliation(s)
- Sanjay Rathod
- Center for Pharmacogenetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Manda Ramsey
- Center for Pharmacogenetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Danielle DiGiorgio
- Center for Pharmacogenetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Roberto Berrios
- Center for Pharmacogenetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Fred D Finkelman
- Division of Immunology, Allergy, and Rheumatology, Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA.,Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Christian A Fernandez
- Center for Pharmacogenetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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69
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Merlen C, Bonnefoy A, Afeich C, Théorêt Y, Laverdière C, Leclerc JM, Rivard GE. Antithrombin and fibrinogen levels as predictors for plasma L-asparaginase activity in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2019; 66:e27729. [PMID: 30938058 DOI: 10.1002/pbc.27729] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/08/2019] [Accepted: 02/27/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND L-asparaginase is a cornerstone treatment for children with acute lymphoblastic leukemia (ALL). However, immune reaction to the drug may increase the clearance or impair the function of L-asparaginase and reduces its therapeutic efficacy. The objective of this study was to identify potential plasma proteins that could be used as proxies for L-asparaginase activity. METHODS Fibrinogen, von Willebrand factor antigen (VWF:Ag), total protein, and albumin levels as well as antithrombin (AT) and L-asparaginase activities were measured in 97 children with ALL treated for prolonged period of time with L-asparaginase. Binary logistic regression and a receiver operating characteristic (ROC) curve analysis were performed to evaluate the predictive value of plasma proteins for L-asparaginase activity. RESULTS Median E. coli L-asparaginase activity was 220 IU/L (range, 0-1308) throughout the treatment period. L-asparaginase activity was below 100 IU/L in 23% of measured samples. L-asparaginase activity was inversely associated with AT activity, fibrinogen, total protein, and albumin levels (r = -0.63, -0.62, -0.57, and -0.45, respectively; P < 0.0001), but not with VWF:Ag. ROC curve analyses showed an intermediate accuracy of AT activity (area under the ROC curve [AUC] = 0.77) to detect specimens with subtherapeutic level of L-asparaginase. An optimal accuracy was found when AT and fibrinogen were combined (AUC = 0.82; sensitivity = 75%; specificity = 82%; positive predictive value = 55%; negative predictive value = 92%) with cutoff values of 0.73 IU/mL and 1.85 g/L, respectively. CONCLUSIONS AT combined with fibrinogen levels could be used as a proxy to identify patients with therapeutic level of L-asparaginase activity in the absence of real-time asparaginase measurement during prolonged exposure to L-asparaginase.
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Affiliation(s)
- Clémence Merlen
- Department of Hematology/Oncology, CHU Sainte-Justine, Montreal, QC, Canada
| | - Arnaud Bonnefoy
- Department of Hematology/Oncology, CHU Sainte-Justine, Montreal, QC, Canada
| | - Cynthia Afeich
- Department of Pharmacology, CHU Sainte-Justine, Montreal, QC, Canada
| | - Yves Théorêt
- Department of Pharmacology, CHU Sainte-Justine, Montreal, QC, Canada
| | | | - Jean-Marie Leclerc
- Department of Hematology/Oncology, CHU Sainte-Justine, Montreal, QC, Canada
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70
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Belén LH, Lissabet JB, de Oliveira Rangel-Yagui C, Effer B, Monteiro G, Pessoa A, Farías Avendaño JG. A structural in silico analysis of the immunogenicity of l-asparaginase from Escherichia coli and Erwinia carotovora. Biologicals 2019; 59:47-55. [DOI: 10.1016/j.biologicals.2019.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 03/03/2019] [Accepted: 03/04/2019] [Indexed: 12/20/2022] Open
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Lauschke VM, Zhou Y, Ingelman-Sundberg M. Novel genetic and epigenetic factors of importance for inter-individual differences in drug disposition, response and toxicity. Pharmacol Ther 2019; 197:122-152. [PMID: 30677473 PMCID: PMC6527860 DOI: 10.1016/j.pharmthera.2019.01.002] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Individuals differ substantially in their response to pharmacological treatment. Personalized medicine aspires to embrace these inter-individual differences and customize therapy by taking a wealth of patient-specific data into account. Pharmacogenomic constitutes a cornerstone of personalized medicine that provides therapeutic guidance based on the genomic profile of a given patient. Pharmacogenomics already has applications in the clinics, particularly in oncology, whereas future development in this area is needed in order to establish pharmacogenomic biomarkers as useful clinical tools. In this review we present an updated overview of current and emerging pharmacogenomic biomarkers in different therapeutic areas and critically discuss their potential to transform clinical care. Furthermore, we discuss opportunities of technological, methodological and institutional advances to improve biomarker discovery. We also summarize recent progress in our understanding of epigenetic effects on drug disposition and response, including a discussion of the only few pharmacogenomic biomarkers implemented into routine care. We anticipate, in part due to exciting rapid developments in Next Generation Sequencing technologies, machine learning methods and national biobanks, that the field will make great advances in the upcoming years towards unlocking the full potential of genomic data.
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Affiliation(s)
- Volker M Lauschke
- Department of Physiology and Pharmacology, Section of Pharmacogenetics, Biomedicum 5B, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Yitian Zhou
- Department of Physiology and Pharmacology, Section of Pharmacogenetics, Biomedicum 5B, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Magnus Ingelman-Sundberg
- Department of Physiology and Pharmacology, Section of Pharmacogenetics, Biomedicum 5B, Karolinska Institutet, SE-171 77 Stockholm, Sweden.
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72
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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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Rocha W, Costa‐Silva T, Agamez‐Montalvo G, Feitosa V, Machado S, Souza Lima G, Pessoa‐ A, Alves H. Screening and optimizing fermentation production of
l
‐asparaginase by
Aspergillus terreus
strain S‐18 isolated from the Brazilian Caatinga Biome. J Appl Microbiol 2019; 126:1426-1437. [DOI: 10.1111/jam.14221] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 02/06/2019] [Accepted: 02/06/2019] [Indexed: 11/30/2022]
Affiliation(s)
- W.R.V. Rocha
- State University of Paraíba Campina Grande PB Brazil
| | - T.A. Costa‐Silva
- Faculty of Pharmaceutical Sciences University of São Paulo São Paulo SP Brazil
| | | | - V.A. Feitosa
- Faculty of Pharmaceutical Sciences University of São Paulo São Paulo SP Brazil
| | - S.E.F. Machado
- Federal University of Pernambuco Cidade Universitária Recife PE Brazil
| | - G.M. Souza Lima
- Federal University of Pernambuco Cidade Universitária Recife PE Brazil
| | - A. Pessoa‐
- Faculty of Pharmaceutical Sciences University of São Paulo São Paulo SP Brazil
| | - H.S. Alves
- State University of Paraíba Campina Grande PB Brazil
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74
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Walenciak J, Wyka K, Janczar S, Młynarski W, Zalewska-Szewczyk B. Dynamic changes in specific anti-L-asparaginase antibodies generation during acute lymphoblastic leukemia treatment. Pharmacol Rep 2019; 71:311-318. [PMID: 30826572 DOI: 10.1016/j.pharep.2018.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND L-asparaginase (L-asp) remains one of the key components of acute lymphoblastic leukemia therapy. Immune reactions to the drug are associated with its diminished activity. The aim of the study was to determine the level of IgM, IgG and IgE-class anti-L-asp antibodies during the induction and reinduction phases of acute lymphoblastic leukemia therapy and their influence on L-asp activity. METHODS The study group comprised 65 patients treated for acute lymphoblastic leukemia in one pediatric oncology center. L-asp antibodies were assessed using ELISA at the end of the induction and reinduction phases. L-asp activity was assessed prior to each drug administration by colorimetry. RESULTS At the end of the first exposure to L-asp antibodies were detected in 35 patients (54%). In the reinduction phase of the treatment anti-L-asp antibodies were found in 38/55 patients (69%). In the induction phase patients with inadequate L-asp activity had higher IgM concentrations (median 5.88 versus 2.81 μg/mL, p = 0.03). In the reinduction phase IgG and IgM levels correlated inversely with L-asp activity. Patients with L-asp allergy had higher levels of IgG (median 61.6 versus 18.36 μg/mL, p = 0.01), whereas higher IgE levels were noted in the group of patients with inadequate drug activity (median 0.91 versus 0.64 μg/mL, p = 0.03). CONCLUSIONS Subsequent exposure to L-asp in the treatment of acute lymphoblastic leukemia was associated with the increase of anti-L-asp antibodies in all studied classes. However, the changes observed in specific classes of antibodies were not distinctive for L-asp hypersensitivity or inactivation, suggesting that the mechanism is more complex.
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Affiliation(s)
- Justyna Walenciak
- Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Lodz, Łódź, Poland
| | - Krystyna Wyka
- Laboratory of Immunopathology and Genetics, Medical University of Lodz, Łódź, Poland
| | - Szymon Janczar
- Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Lodz, Łódź, Poland
| | - Wojciech Młynarski
- Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Lodz, Łódź, Poland
| | - Beata Zalewska-Szewczyk
- Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Lodz, Łódź, Poland.
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HAP1 loss confers l-asparaginase resistance in ALL by downregulating the calpain-1-Bid-caspase-3/12 pathway. Blood 2019; 133:2222-2232. [PMID: 30819925 DOI: 10.1182/blood-2018-12-890236] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/26/2019] [Indexed: 02/07/2023] Open
Abstract
l-Asparaginase (l-ASNase) is a strategic component of treatment protocols for acute lymphoblastic leukemia (ALL). It causes asparagine deficit, resulting in protein synthesis inhibition and subsequent leukemic cell death and ALL remission. However, patients often relapse because of the development of resistance, but the underlying mechanism of ALL cell resistance to l-asparaginase remains unknown. Through unbiased genome-wide RNA interference screening, we identified huntingtin associated protein 1 (HAP1) as an ALL biomarker for l-asparaginase resistance. Knocking down HAP1 induces l-asparaginase resistance. HAP1 interacts with huntingtin and the intracellular Ca2+ channel, inositol 1,4,5-triphosphate receptor to form a ternary complex that mediates endoplasmic reticulum (ER) Ca2+ release upon stimulation with inositol 1,4,5-triphosphate3 Loss of HAP1 prevents the formation of the ternary complex and thus l-asparaginase-mediated ER Ca2+ release. HAP1 loss also inhibits external Ca2+ entry, blocking an excessive rise in [Ca2+]i, and reduces activation of the Ca2+-dependent calpain-1, Bid, and caspase-3 and caspase-12, leading to reduced number of apoptotic cells. These findings indicate that HAP1 loss prevents l-asparaginase-induced apoptosis through downregulation of the Ca2+-mediated calpain-1-Bid-caspase-3/12 apoptotic pathway. Treatment with BAPTA-AM [1,2-bis(2-aminophenoxy)ethane-N,N,N',N'-tetraacetic acid tetrakis(acetoxymethyl ester)] reverses the l-asparaginase apoptotic effect in control cells, supporting a link between l-asparaginase-induced [Ca2+]i increase and apoptotic cell death. Consistent with these findings, ALL patient leukemic cells with lower HAP1 levels showed resistance to l-asparaginase, indicating the clinical relevance of HAP1 loss in the development of l-asparaginase resistance, and pointing to HAP1 as a functional l-asparaginase resistance biomarker that may be used for the design of effective treatment of l-asparaginase-resistant ALL.
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Cong J, Yang L, Ye J, Wei LQ, Li X, Wang JW. [Management of toxicities associated with pegaspargase in treatment of patients with lymphoid malignancy: experience from 443 cases in a single center]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 39:654-660. [PMID: 30180467 PMCID: PMC7342831 DOI: 10.3760/cma.j.issn.0253-2727.2018.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
目的 总结培门冬酶治疗淋巴系统肿瘤的不良反应以及处理经验。 方法 通过回顾性分析北京同仁医院血液科2011年8月至2015年12月使用培门冬酶患者的临床资料,总结培门冬酶相关的不良反应以及处理经验。 结果 129例患者使用培门冬酶,累计共使用443例次,不良反应发生情况:2例(1.6%)患者出现过敏反应;19例(14.7%)患者发生胰腺炎(其中包括6例急性症状性胰腺炎、13例单纯胰酶升高的化学性胰腺炎),15例(11.6%)患者出现高甘油三酯血症,85例(65.9%)患者出现高血糖,7例(5.4%)患者出现低血糖;25例(19.4%)患者出现2级以上的转氨酶增高,21例(15.5%)患者发生高胆红素血症,62例(48.1%)患者发生低白蛋白血症;61例(47.3%)患者出现APTT延长,22例(17.1%)患者出现PT延长,15例(11.6%)患者出现TT延长,75例(58.1%)患者出现低纤维蛋白原血症,有11例患者(8.5%)出现血栓事件,有3例(2.3%)患者出现活动性出血。以上不良反应,分别经过抗过敏、抑制胰液分泌、降脂、降糖、保肝、补充血浆、止血等对症治疗后症状均好转。部分严重不良反应影响培门冬酶的按计划应用甚至导致停用。 结论 培门冬酶的不良反应非常广泛,有些非常严重,需要治疗时密切监测。
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Affiliation(s)
- J Cong
- Department of Hematology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
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Rodrigues D, Pillaca-Pullo O, Torres-Obreque K, Flores-Santos J, Sánchez-Moguel I, Pimenta MV, Basi T, Converti A, Lopes AM, Monteiro G, Fonseca LP, Pessoa AJ. Fed-Batch Production of Saccharomyces cerevisiae L-Asparaginase II by Recombinant Pichia pastoris MUT s Strain. Front Bioeng Biotechnol 2019; 7:16. [PMID: 30800657 PMCID: PMC6375902 DOI: 10.3389/fbioe.2019.00016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 01/22/2019] [Indexed: 01/31/2023] Open
Abstract
L-Asparaginase (ASNase) is used in the treatment of acute lymphoblastic leukemia, being produced and commercialized only from bacterial sources. Alternative Saccharomyces cerevisiae ASNase II coded by the ASP3 gene was biosynthesized by recombinant Pichia pastoris MUT s under the control of the AOX1 promoter, using different cultivation strategies. In particular, we applied multistage fed-batch cultivation divided in four distinct phases to produce ASNase II and determine the fermentation parameters, namely specific growth rate, biomass yield, and enzyme activity. Cultivation of recombinant P. pastoris under favorable conditions in a modified defined medium ensured a dry biomass concentration of 31 gdcw.L-1 during glycerol batch phase, corresponding to a biomass yield of 0.77 gdcw.gglycerol - 1 and a specific growth rate of 0.21 h-1. After 12 h of glycerol feeding under limiting conditions, cell concentration achieved 65 gdcw.L-1 while ethanol concentration was very low. During the phase of methanol induction, biomass concentration achieved 91 gdcw.L-1, periplasmic specific enzyme activity 37.1 U.gdcw - 1 , volumetric enzyme activity 3,315 U.L-1, overall enzyme volumetric productivity 31 U.L-1.h-1, while the specific growth rate fell to 0.039 h-1. Our results showed that the best strategy employed for the ASNase II production was using glycerol fed-batch phase with pseudo exponential feeding plus induction with continuous methanol feeding.
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Affiliation(s)
- David Rodrigues
- Bioengineering Department of Instituto Superior Técnico, Institute of Bioengineering and Biosciences, Universidade de Lisboa, Lisbon, Portugal
| | - Omar Pillaca-Pullo
- Department of Pharmaceutical-Biochemical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Karin Torres-Obreque
- Department of Pharmaceutical-Biochemical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Juan Flores-Santos
- Department of Pharmaceutical-Biochemical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Ignacio Sánchez-Moguel
- Department of Pharmaceutical-Biochemical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Marcela V. Pimenta
- Department of Pharmaceutical-Biochemical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Tajindar Basi
- Department of Pharmacy, King's College London, London, United Kingdom
| | - Attilio Converti
- Department of Civil, Chemical and Environmental Engineering, Genova, Italy
| | - André M. Lopes
- Faculty of Pharmaceutical Sciences, University of Campinas, Campinas, Brazil
| | - Gisele Monteiro
- Department of Pharmaceutical-Biochemical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Luís P. Fonseca
- Bioengineering Department of Instituto Superior Técnico, Institute of Bioengineering and Biosciences, Universidade de Lisboa, Lisbon, Portugal
| | - Adalberto Jr. Pessoa
- Department of Pharmaceutical-Biochemical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
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Brumano LP, da Silva FVS, Costa-Silva TA, Apolinário AC, Santos JHPM, Kleingesinds EK, Monteiro G, Rangel-Yagui CDO, Benyahia B, Junior AP. Development of L-Asparaginase Biobetters: Current Research Status and Review of the Desirable Quality Profiles. Front Bioeng Biotechnol 2019; 6:212. [PMID: 30687702 PMCID: PMC6335324 DOI: 10.3389/fbioe.2018.00212] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 12/21/2018] [Indexed: 01/23/2023] Open
Abstract
L-Asparaginase (ASNase) is a vital component of the first line treatment of acute lymphoblastic leukemia (ALL), an aggressive type of blood cancer expected to afflict over 53,000 people worldwide by 2020. More recently, ASNase has also been shown to have potential for preventing metastasis from solid tumors. The ASNase treatment is, however, characterized by a plethora of potential side effects, ranging from immune reactions to severe toxicity. Consequently, in accordance with Quality-by-Design (QbD) principles, ingenious new products tailored to minimize adverse reactions while increasing patient survival have been devised. In the following pages, the reader is invited for a brief discussion on the most recent developments in this field. Firstly, the review presents an outline of the recent improvements on the manufacturing and formulation processes, which can severely influence important aspects of the product quality profile, such as contamination, aggregation and enzymatic activity. Following, the most recent advances in protein engineering applied to the development of biobetter ASNases (i.e., with reduced glutaminase activity, proteolysis resistant and less immunogenic) using techniques such as site-directed mutagenesis, molecular dynamics, PEGylation, PASylation and bioconjugation are discussed. Afterwards, the attention is shifted toward nanomedicine including technologies such as encapsulation and immobilization, which aim at improving ASNase pharmacokinetics. Besides discussing the results of the most innovative and representative academic research, the review provides an overview of the products already available on the market or in the latest stages of development. With this, the review is intended to provide a solid background for the current product development and underpin the discussions on the target quality profile of future ASNase-based pharmaceuticals.
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Affiliation(s)
- Larissa Pereira Brumano
- Department of Biochemical and Pharmaceutical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Francisco Vitor Santos da Silva
- Department of Biochemical and Pharmaceutical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Tales Alexandre Costa-Silva
- Department of Biochemical and Pharmaceutical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Alexsandra Conceição Apolinário
- Department of Biochemical and Pharmaceutical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - João Henrique Picado Madalena Santos
- Department of Biochemical and Pharmaceutical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
- Department of Chemistry, CICECO, Aveiro Institute of Materials, University of Aveiro, Aveiro, Portugal
| | - Eduardo Krebs Kleingesinds
- Department of Biochemical and Pharmaceutical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Gisele Monteiro
- Department of Biochemical and Pharmaceutical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Carlota de Oliveira Rangel-Yagui
- Department of Biochemical and Pharmaceutical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
| | - Brahim Benyahia
- Department of Chemical Engineering, Loughborough University, Loughborough, United Kingdom
| | - Adalberto Pessoa Junior
- Department of Biochemical and Pharmaceutical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
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79
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Rathod S, Ramsey M, Relling MV, Finkelman FD, Fernandez CA. Hypersensitivity reactions to asparaginase in mice are mediated by anti-asparaginase IgE and IgG and the immunoglobulin receptors FcεRI and FcγRIII. Haematologica 2018; 104:319-329. [PMID: 30237274 PMCID: PMC6355496 DOI: 10.3324/haematol.2018.199448] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 09/20/2018] [Indexed: 01/16/2023] Open
Abstract
Asparaginase is an important drug for the treatment of leukemias. However, anti-asparaginase antibodies often develop, which can decrease asparaginase drug levels and increase the risk of relapse. The aim of this study is to identify the immunoglobulin isotypes and receptors responsible for asparaginase hypersensitivities. Mice immunized with asparaginase developed anti-asparaginase IgG1 and IgE antibodies, and challenging the sensitized mice with asparaginase induced severe hypersensitivity reactions. Flow cytometry analysis indicated that macrophages/monocytes, neutrophils, and basophils bind asparaginase ex vivo through FcγRIII. In contrast, asparaginase binding to basophils was dependent on FcγRIII and IgE. Consistent with the asparaginase binding data, basophil activation by asparaginase occurred via both IgG/FcγRIII and IgE/FcεRI. Depleting >95% of B cells suppressed IgG but not IgE-dependent hypersensitivity, while depleting CD4+ T cells provided complete protection. Combined treatment with either anti-IgE mAb plus a platelet-activating factor receptor antagonist or anti-FcγRIII mAb plus a H1 receptor antagonist suppressed asparaginase hypersensitivity. The observations indicate that asparaginase hypersensitivity is mediated by antigen-specific IgG and/or IgE through the immunoglobulin receptors FcγRIII and FcεRI, respectively. Provided that these results apply to humans, they emphasize the importance of monitoring both IgE- and IgG-mediated asparaginase hypersensitivities in patients receiving this agent.
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Affiliation(s)
- Sanjay Rathod
- Center for Pharmacogenetics and Department of Pharmaceutical Sciences, University of Pittsburgh, PA
| | - Manda Ramsey
- Center for Pharmacogenetics and Department of Pharmaceutical Sciences, University of Pittsburgh, PA
| | - Mary V Relling
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Fred D Finkelman
- Department of Internal Medicine, Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine and the Division of Immunobiology, Cincinnati Children's Hospital Medical Center, OH, USA
| | - Christian A Fernandez
- Center for Pharmacogenetics and Department of Pharmaceutical Sciences, University of Pittsburgh, PA
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80
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Dholaria HG, Davies A, Kotecha RS, Gottardo NG, Walwyn T. Comment on: Comparison of hypersensitivity rates to intravenous and intramuscular PEG-asparaginase in children with acute lymphoblastic leukemia: A meta-analysis and systematic review. Pediatr Blood Cancer 2018; 65:e27065. [PMID: 29630778 DOI: 10.1002/pbc.27065] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 02/27/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Hetal G Dholaria
- Department of Paediatric Haematology and Oncology, Princess Margaret Hospital for Children, Perth, Australia.,Division of Paediatrics, School of Medicine, University of Western Australia, Perth, Australia
| | - Amy Davies
- Department of Paediatric Haematology and Oncology, Princess Margaret Hospital for Children, Perth, Australia
| | - Rishi S Kotecha
- Department of Paediatric Haematology and Oncology, Princess Margaret Hospital for Children, Perth, Australia.,Division of Paediatrics, School of Medicine, University of Western Australia, Perth, Australia.,Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Nicholas G Gottardo
- Department of Paediatric Haematology and Oncology, Princess Margaret Hospital for Children, Perth, Australia.,Division of Paediatrics, School of Medicine, University of Western Australia, Perth, Australia.,Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Thomas Walwyn
- Department of Paediatric Haematology and Oncology, Princess Margaret Hospital for Children, Perth, Australia.,Division of Paediatrics, School of Medicine, University of Western Australia, Perth, Australia
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81
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Vyas C, Jain S, Kapoor G, Mehta A, Takkar Chugh P. Experience with generic pegylated L-asparaginase in children with acute lymphoblastic leukemia and monitoring of serum asparaginase activity. Pediatr Hematol Oncol 2018; 35:331-340. [PMID: 30488741 DOI: 10.1080/08880018.2018.1538277] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Pegylated asparaginase (P-Asp) though integral to acute lymphoblastic leukemia (ALL) therapy is often not accessible to patients in developing countries. We share our clinical experience with generic P-Asp along with monitoring of asparaginase activity. METHODS In this prospective observational study, patients ≤18 years of age with ALL were assigned to receive either generic P-Asp or native asparaginase (N-Asp) in a non-randomized manner. Treatment protocol was based on ALL BFM-95 backbone. The dose of P-Asp was 1500 IU/m2 by intravenous route during induction (Ia) and re-induction (IIa) phase of therapy. RESULTS N-Asp or P-Asp was administered to 52 and 54 of the 106 eligible patients respectively. Demographic and disease characteristics were comparable in both arms. The mean trough levels for N-Asp and P-Asp were 156.87 ± 22.35 IU/L and 216.03 ± 73.40 IU/L, respectively (p value <0.001) and all patients achieved therapeutic levels during Ia. Incidence of asparaginase-attributable toxicity was similar in the two arms in both phases of treatment, although hospitalization due to noninfectious causes was more common in P-Asp arm during Ia (13% versus 0%, p value, 0.01). Clinical hypersensitivity and silent inactivation were not observed during Ia while these occurred in 13% and 5% of patients in the N-Asp arm and P-Asp arms of IIa, respectively. The 2-year event free survival for P-Asp and N-Asp groups was 84% and 80.7%, respectively (p value 0.85). CONCLUSION Generic P-Asp was observed to be efficacious and well tolerated in our patients and adequate therapeutic levels were sustained for 2 weeks.
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Affiliation(s)
- Chintan Vyas
- a Department of Pediatric Hematology Oncology , Rajiv Gandhi Cancer Institute and Research Centre , New Delhi , India
| | - Sandeep Jain
- a Department of Pediatric Hematology Oncology , Rajiv Gandhi Cancer Institute and Research Centre , New Delhi , India
| | - Gauri Kapoor
- a Department of Pediatric Hematology Oncology , Rajiv Gandhi Cancer Institute and Research Centre , New Delhi , India
| | - Anurag Mehta
- c Department of Laboratory Services, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
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82
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Thu Huynh V, Bergeron S. Asparaginase Toxicities: Identification and Management in Patients With Acute Lymphoblastic Leukemia
. Clin J Oncol Nurs 2018; 21:E248-E259. [PMID: 28945721 DOI: 10.1188/17.cjon.e248-e259] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Acute lymphoblastic leukemia (ALL) is a common cancer in children, and outcomes have greatly improved because of the refinement of multiagent chemotherapy regimens that include intensified asparaginase therapy. Asparaginase, a cornerstone of modern pediatric chemotherapy regimens for ALL and asparaginase-containing protocols, is increasingly used in adolescent and adult patients historically treated with asparaginase-free regimens.
. OBJECTIVES This article is an overview of commonly encountered asparaginase-
associated toxicities and offers recommendations for treatment management.
. METHODS A literature review was conducted, reviewing asparaginase and common toxicities, specifically hypersensitivity, pancreatitis, thrombosis, hyperbilirubinemia, and hyperglycemia.
. FINDINGS The rapid identification and management of common asparaginase-associated adverse events can reduce symptom severity and limit potential interruptions to therapy, possibly improving outcomes.
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83
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Monitoring of asparagine depletion and anti-L-asparaginase antibodies in adult acute lymphoblastic leukemia treated in the pediatric-inspired GRAALL-2005 trial. Blood Cancer J 2018; 8:45. [PMID: 29795175 PMCID: PMC5966449 DOI: 10.1038/s41408-018-0084-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Revised: 03/07/2018] [Accepted: 03/19/2018] [Indexed: 11/21/2022] Open
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84
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Rau RE, Dreyer Z, Choi MR, Liang W, Skowronski R, Allamneni KP, Devidas M, Raetz EA, Adamson PC, Blaney SM, Loh ML, Hunger SP. Outcome of pediatric patients with acute lymphoblastic leukemia/lymphoblastic lymphoma with hypersensitivity to pegaspargase treated with PEGylated Erwinia asparaginase, pegcrisantaspase: A report from the Children's Oncology Group. Pediatr Blood Cancer 2018; 65:10.1002/pbc.26873. [PMID: 29090524 PMCID: PMC5839116 DOI: 10.1002/pbc.26873] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 10/03/2017] [Accepted: 10/03/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Erwinia asparaginase is a Food and Drug Administration approved agent for the treatment of acute lymphoblastic leukemia (ALL) for patients who develop hypersensitivity to Escherichia coli derived asparaginases. Erwinia asparaginase is efficacious, but has a short half-life, requiring six doses to replace one dose of the most commonly used first-line asparaginase, pegaspargase, a polyethylene glycol (PEG) conjugated E. coli asparaginase. Pegcristantaspase, a recombinant PEGylated Erwinia asparaginase with improved pharmacokinetics, was developed for patients with hypersensitivity to pegaspargase. Here, we report a series of patients treated on a pediatric phase 2 trial of pegcrisantaspase. PROCEDURE Pediatric patients with ALL or lymphoblastic lymphoma and hypersensitivity to pegaspargase enrolled on Children's Oncology Group trial AALL1421 (Jazz 13-011) and received intravenous pegcrisantaspase. Serum asparaginase activity (SAA) was monitored before and after dosing; immunogenicity assays were performed for antiasparaginase and anti-PEG antibodies and complement activation was evaluated. RESULTS Three of the four treated patients experienced hypersensitivity to pegcrisantaspase manifested as clinical hypersensitivity reactions or rapid clearance of SAA. Immunogenicity assays demonstrated the presence of anti-PEG immunoglobulin G antibodies in all three hypersensitive patients, indicating a PEG-mediated immune response. CONCLUSIONS This small series of patients, nonetheless, provides data, suggesting preexisting immunogenicity against the PEG moiety of pegaspargase and poses the question as to whether PEGylation may be an effective strategy to optimize Erwinia asparaginase administration. Further study of larger cohorts is needed to determine the incidence of preexisting antibodies against PEG-mediated hypersensitivity to pegaspargase.
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Affiliation(s)
- Rachel E. Rau
- Division of Pediatric Hematology/Oncology, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas,Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, Texas
| | - ZoAnn Dreyer
- Division of Pediatric Hematology/Oncology, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | | | - Wei Liang
- Jazz Pharmaceuticals, Palo Alto, California
| | | | | | - Meenakshi Devidas
- Department of Biostatistics, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville, Florida
| | | | - Peter C. Adamson
- Department of Pediatrics and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan M. Blaney
- Division of Pediatric Hematology/Oncology, Texas Children's Cancer Center, Baylor College of Medicine, Houston, Texas
| | - Mignon L Loh
- Department of Pediatrics, University of California School of Medicine, San Francisco, California
| | - Stephen P. Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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85
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Sourani Z, Shirzad H, Shirzad M, Pourgheysari B. Interaction between Gallic acid and Asparaginase to potentiate anti-proliferative effect on lymphoblastic leukemia cell line. Biomed Pharmacother 2017; 96:1045-1054. [PMID: 29217160 DOI: 10.1016/j.biopha.2017.11.122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 10/31/2017] [Accepted: 11/27/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Treatment of acute lymphoblastic leukemia (ALL) fails in some cases and the side effects cause mortality in certain patients. Gallic acid (GA), a polyhydroxyphenolic compound has biological functions including anti-proliferative properties. The aim of the present study was to investigate the growth inhibition effects of GA in combination with asparaginase (ASP), as a component of combination chemotherapy, in a lymphoblastic leukemia cell line. METHODS Jurkat cells were incubated with different concentrations of GA with or without ASP. Proliferation inhibition was investigated using MTS test. The level of apoptosis alterations were evaluated using flow cytometry. The expression of Fas gene level and surface expression were investigated by quantitative real time PCR and flow cytometry respectively. RESULTS GA at 50μM concentration and ASP at 0.5 IU/ml inhibited 50% cell proliferation in 48 hours. GA also increased the inhibitory effect of ASP and some combinations had synergistic results. The increase of cell apoptosis and Fas expression were observed in GA-treated cells compared to control. GA increased the effect of ASP on proliferation inhibition, induction of apoptosis and Fas expression. CONCLUSION GA is an effective component in proliferation inhibition, apoptosis induction and enhancement of Fas expression level in Jurkat cell line. GA in some combination with ASP increases the effect of the latter on the cells. The study of the mechanism of these effects could be a further step towards target therapy. This study is a preliminary phase to the use of GA and should be carried out by more comprehensive study and animal models.
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Affiliation(s)
- Zahra Sourani
- Immunology Department, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Hedayatollah Shirzad
- Cellular and Molecular Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Moein Shirzad
- Clinical Biochemistry Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Batoul Pourgheysari
- Pathology and Hematology Department, Shahrekord University of Medical Sciences, Shahrekord, Iran; Medical Plant Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord, Iran.
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86
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Kloos RQH, Uyl-de Groot CA, van Litsenburg RRL, Kaspers GJL, Pieters R, van der Sluis IM. A cost analysis of individualized asparaginase treatment in pediatric acute lymphoblastic leukemia. Pediatr Blood Cancer 2017; 64. [PMID: 28766887 DOI: 10.1002/pbc.26651] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 04/21/2017] [Accepted: 04/26/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Therapeutic drug monitoring (TDM) of asparaginase is necessary to respond to variability in asparaginase activity levels, detect silent inactivation, and distinguish between real allergies and allergic-like reactions with and without asparaginase neutralization, respectively. In this study, the costs of an individualized and fixed asparaginase dosing schedule were compared. PROCEDURE Patients, treated according to the Dutch Childhood Oncology Group ALL-11 protocol (individualized PEGasparaginase treatment, starting dose: 1,500 IU/m2 ) or ALL-10 protocol (native Escherichia coli asparaginase followed by 2,500 IU/m2 PEGasparaginase), were included. To focus on TDM of PEGasparaginase, the costs were also calculated excluding patients treated with Erwinia asparaginase and compared to a hypothetical protocol with a fixed dose of 1,500 IU/m2 PEGasparaginase. Direct asparaginase-related medical costs, including costs for asparaginase use (calculated with the absolute dose), TDM, laboratory tests, daycare treatment, and outpatient clinic visits, were calculated. RESULTS Eighty-three ALL-10 patients and 51 ALL-11 patients were included. The asparaginase-related costs were 30.8% lower in ALL-11 than in ALL-10 ($29,048 vs. $41,960). The ALL-11 costs of nonallergic patients were 20.4% lower, when using TDM, than the hypothetical protocol with a fixed dose of 1,500 IU/m2 ($13,178 vs. $16,551). TDM accounted for 12.4% of the costs. Including asparaginase waste, TDM in ALL-11 will be cost saving if three doses can be prepared out of one vial compared to a fixed dose of 1,500 IU/m2 . CONCLUSIONS TDM of asparaginase is cost saving if calculated with the absolute asparaginase dose and will be if the waste is minimalized by preparing multiple doses out of one vial.
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Affiliation(s)
- Robin Q H Kloos
- Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Carin A Uyl-de Groot
- Institute of Health Care Policy and Management/Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands
| | - Raphaële R L van Litsenburg
- Department of Pediatric Oncology/Hematology, VU University Medical Center, Amsterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Gertjan J L Kaspers
- Department of Pediatric Oncology/Hematology, VU University Medical Center, Amsterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Inge M van der Sluis
- Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
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87
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Tram Henriksen L, Gottschalk Højfeldt S, Schmiegelow K, Frandsen TL, Skov Wehner P, Schrøder H, Klug Albertsen B. Prolonged first-line PEG-asparaginase treatment in pediatric acute lymphoblastic leukemia in the NOPHO ALL2008 protocol-Pharmacokinetics and antibody formation. Pediatr Blood Cancer 2017; 64. [PMID: 28660740 DOI: 10.1002/pbc.26686] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 05/02/2017] [Accepted: 05/18/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND As pegylated asparaginase is becoming the preferred first-line asparaginase preparation in the chemotherapy regimens of childhood acute lymphoblastic leukemia (ALL), there is a need to evaluate this treatment. METHODS The aim of this study was to evaluate the pharmacokinetics of prolonged upfront biweekly PEG-asparaginase (where PEG is polyethylene glycol) treatment by measuring serum l-asparaginase activity and formation of anti-PEG-asparaginase antibodies. A total of 97 evaluable patients (1-17 years), diagnosed with ALL, and treated according to the NOPHO ALL2008 protocol (where NOPHO is Nordic Society of Paediatric Haematology and Oncology) were included. In the NOPHO ALL2008 protocol, patients are randomized to 8 or 15 doses of intramuscular PEG-asparaginase (Oncaspar® ) 1,000 IU/m²/dose, at 2-week or 6-week intervals with a total of 30-week treatment (Clinical trials.gov. no.: NCT00819351). RESULTS The pharmacological target of treatment (l-asparaginase activity above 100 IU/l) was reached in 612 of 652 (94%) samples obtained 14 ± 2 days after PEG-asparaginase administration. Mean l-asparaginase activity was 338 IU/l. Six patients had l-asparaginase activity below 50 IU/l in all samples. A total of 25 patients (26%) developed Immunoglobulin G (IgG) anti-PEG-asparaginase antibodies, but there was no correlation between anti-PEG-asparaginase antibodies and low levels of asparaginase activity. CONCLUSION We conclude that prolonged first-line biweekly PEG-asparaginase therapy, 1,000 IU/m²/dose was above the pharmacological target in the vast majority of patients. Presence of anti-PEG-asparaginase antibodies was not a predictor of l-asparaginase activity.
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Affiliation(s)
| | | | - Kjeld Schmiegelow
- Department of Pediatric and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark.,Faculty of Medicine, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Leth Frandsen
- Department of Pediatric and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peder Skov Wehner
- Department of Pediatrics, Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Henrik Schrøder
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
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88
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Lopez-Santillan M, Iparraguirre L, Martin-Guerrero I, Gutierrez-Camino A, Garcia-Orad A. Review of pharmacogenetics studies of L-asparaginase hypersensitivity in acute lymphoblastic leukemia points to variants in the GRIA1 gene. Drug Metab Pers Ther 2017; 32:1-9. [PMID: 28259867 DOI: 10.1515/dmpt-2016-0033] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 02/07/2017] [Indexed: 12/17/2022]
Abstract
Acute lymphoblastic leukemia (ALL) is a major pediatric cancer in developed countries. Although treatment outcome has improved owing to advances in chemotherapy, there is still a group of patients who experience severe adverse events. L-Asparaginase is an effective antineoplastic agent used in chemotherapy of ALL. Despite its indisputable indication, hypersensitivity reactions are common. In those cases, discontinuation of treatment is usually needed and anti-asparaginase antibody production may also attenuate asparaginase activity, compromising its antileukemic effect. Till now, six pharmacogenetic studies have been performed in order to elucidate possible genetic predisposition for inter-individual differences in asparaginase hypersensitivity. In this review we have summarized the results of those studies which describe the involvement of four different genes, being polymorphisms in the glutamate receptor, ionotropic, AMPA 1 (GRIA1) the most frequently associated with asparaginase hypersensitivity. We also point to new approaches focusing on epigenetics that could be interesting for consideration in the near future.
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89
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Liang J, Shi P, Guo X, Li J, He L, Wang Y, Wei Q, Huang F, Fan Z, Xu B. A retrospective comparison of Escherichia coli and polyethylene glycol-conjugated asparaginase for the treatment of adolescents and adults with newly diagnosed acute lymphoblastic leukemia. Oncol Lett 2017; 15:75-82. [PMID: 29387211 PMCID: PMC5769219 DOI: 10.3892/ol.2017.7271] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 05/16/2017] [Indexed: 11/10/2022] Open
Abstract
Data from clinical trials suggest that polyethylene glycol-conjugated asparaginase (PEG asparaginase) should be recommended as a replacement for Escherichia coli (E. coli) asparaginase in the treatment of pediatric acute lymphoblastic leukemia (ALL) due to its prolonged effect, similar safety profile and convenience. The present study investigated the efficacy and safety of PEG asparaginase in adolescents and adults with newly diagnosed ALL. The clinical data of 122 patients, ≥14 years old with de novo ALL, who received either PEG asparaginase or E. coli asparaginase as part of an induction regimen, were retrospectively analyzed. The results revealed that PEG asparaginase had a comparable complete remission rate (95.65 vs. 90.79%), median overall survival time (14.07 vs. 16.29 months) and median relapse-free survival time (10.00 vs. 8.57 months) with E. coli asparaginase. In addition, patients <35 years old receiving PEG asparaginase obtained a higher median RFS time compared with those receiving E. coli asparaginase (10.93 vs. 8.97 months; P=0.037). Patients treated with E. coli asparaginase exhibited a significantly higher incidence of central nervous system leukemia (CNSL) compared with those treated with PEG asparaginase (27.63 vs. 10.87%; P=0.028) during the consolidation phase. Toxic events, including allergy, grade III–IV liver dysfunction, renal function damage and pancreatic lesions were similar between the two groups. A longer duration of coagulation dysfunction (9.80±5.51 vs. 6.80±4.21 days; P=0.002) and agranulocytosis (18.89±8.79 vs. 12.03±8.34 days; P<0.01), and a higher incidence of grade IV–V infections (22.73 vs. 7.25%; P=0.018) were observed in the PEG asparaginase group. However, these did not increase bleeding events or infection-associated mortalities. When taking the convenience and superior efficacy in preventing CNSL into consideration, PEG asparaginase is a candidate for first-line treatment of adolescent and adult ALL. A larger prospective clinical trial is required to further confirm this point of view.
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Affiliation(s)
- Jiabao Liang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China.,Department of Hematology, The First People Hospital of Foshan, Affiliated Hospital of Sun Yat-Sen University, Foshan, Guangdong 528000, P.R. China
| | - Pengcheng Shi
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Xutao Guo
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Jie Li
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Lingli He
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Yan Wang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Qi Wei
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Bing Xu
- Department of Hematology, The First Affiliated Hospital of Xiamen University, Xiamen, Fujian 361003, P.R. China
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90
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Salzer W, Bostrom B, Messinger Y, Perissinotti AJ, Marini B. Asparaginase activity levels and monitoring in patients with acute lymphoblastic leukemia. Leuk Lymphoma 2017; 59:1797-1806. [DOI: 10.1080/10428194.2017.1386305] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Wanda Salzer
- U.S. Army, Medical Research and Materiel Command, Fort Detrick, MD, USA
| | | | | | | | - Bernard Marini
- University of Michigan, College of Pharmacy, Ann Arbor, MI, USA
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91
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Marini BL, Perissinotti AJ, Bixby DL, Brown J, Burke PW. Catalyzing improvements in ALL therapy with asparaginase. Blood Rev 2017; 31:328-338. [DOI: 10.1016/j.blre.2017.06.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/11/2017] [Accepted: 06/19/2017] [Indexed: 11/25/2022]
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92
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Cloning and characterization of Halomonas elongata L-asparaginase, a promising chemotherapeutic agent. Appl Microbiol Biotechnol 2017; 101:7227-7238. [DOI: 10.1007/s00253-017-8456-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 10/19/2022]
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93
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94
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Koprivnikar J, McCloskey J, Faderl S. Safety, efficacy, and clinical utility of asparaginase in the treatment of adult patients with acute lymphoblastic leukemia. Onco Targets Ther 2017; 10:1413-1422. [PMID: 28331334 PMCID: PMC5348069 DOI: 10.2147/ott.s106810] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Adults with acute lymphoblastic leukemia (ALL) are known to have inferior outcomes compared to the pediatric population. Although the reasons for this are likely manyfold, the agents utilized and the increased intensity of pediatric treatments compared to adult treatments are likely significant contributing factors. Asparaginase, an enzyme that converts asparagine to aspartic acid, forms the backbone of almost all pediatric regimens and works by depleting extracellular asparagine, which ALL cells are unable to synthesize. Asparaginase toxicities, which include hypersensitivity reactions, pancreatitis, liver dysfunction, and thrombosis, have hindered its widespread use in the adult population. Here, we review the toxicity and efficacy of asparaginase in adult patients with ALL. With the proper precautions, it is a safe and effective agent in the treatment of younger adults with ALL with response rates in the frontline setting ranging from 78% to 96%, compared to most trials showing a 4-year overall survival of 50% or better. The age cutoff for consideration of treatment with pediatric-inspired regimens is not clear, but recent studies show promise particularly in the adolescent and young adult population. New formulations of asparaginase are actively in development, including erythrocyte-encapsulated asparaginase, which is designed to minimize the toxicity and improve the delivery of the drug.
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Affiliation(s)
- Jamie Koprivnikar
- Division of Leukemia, John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, NJ, USA
| | - James McCloskey
- Division of Leukemia, John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, NJ, USA
| | - Stefan Faderl
- Division of Leukemia, John Theurer Cancer Center at Hackensack University Medical Center, Hackensack, NJ, USA
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95
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Lanvers-Kaminsky C. Asparaginase pharmacology: challenges still to be faced. Cancer Chemother Pharmacol 2017; 79:439-450. [DOI: 10.1007/s00280-016-3236-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/27/2016] [Indexed: 11/28/2022]
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96
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Do immunoglobulin G and immunoglobulin E anti-l-asparaginase antibodies have distinct implications in children with acute lymphoblastic leukemia? A cross-sectional study. Rev Bras Hematol Hemoter 2017; 39:202-209. [PMID: 28830598 PMCID: PMC5567415 DOI: 10.1016/j.bjhh.2016.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 11/18/2016] [Accepted: 11/28/2016] [Indexed: 11/29/2022] Open
Abstract
Background l-Asparaginase is essential in the treatment of childhood acute lymphoblastic leukemia. If immunoglobulin G anti-l-asparaginase antibodies develop, they can lead to faster plasma clearance and reduced efficiency as well as to hypersensitivity reactions, in which immunoglobulin E can also participate. This study investigated the presence of immunoglobulin G and immunoglobulin E anti-l-asparaginase antibodies and their clinical associations. Methods Under 16-year-old patients at diagnosis of B-cell acute lymphoblastic leukemia confirmed by flow cytometry and treated with a uniform l-asparaginase and chemotherapy protocol were studied. Immunoglobulin G anti-l-asparaginase antibodies were measured using an enzyme-linked immunosorbent assay. Intradermal and prick skin testing was performed to establish the presence of specific immunoglobulin E anti-l-asparaginase antibodies in vivo. Statistical analysis was used to investigate associations of these antibodies with relevant clinical events and outcomes. Results Fifty-one children were studied with 42 (82.35%) having anti-l-asparaginase antibodies. In this group immunoglobulin G antibodies alone were documented in 10 (23.8%) compared to immunoglobulin E alone in 18 (42.8%) patients. Immunoglobulin G together with immunoglobulin E were simultaneously present in 14 patients. Children who produced exclusively immunoglobulin G or no antibodies had a lower event-free survival (p-value = 0.024). Eighteen children (35.3%) relapsed with five of nine of this group who had negative skin tests suffering additional relapses (range: 2–4), compared to none of the nine children who relapsed who had positive skin tests (p-value < 0.001). Conclusion Children with acute lymphoblastic leukemia and isolated immunoglobulin G anti-l-asparaginase antibodies had a higher relapse rate, whereas no additional relapses developed in children with immunoglobulin E anti-l-asparaginase antibodies after the first relapse.
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97
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van der Sluis IM, Vrooman LM, Pieters R, Baruchel A, Escherich G, Goulden N, Mondelaers V, Sanchez de Toledo J, Rizzari C, Silverman LB, Whitlock JA. Consensus expert recommendations for identification and management of asparaginase hypersensitivity and silent inactivation. Haematologica 2017; 101:279-85. [PMID: 26928249 DOI: 10.3324/haematol.2015.137380] [Citation(s) in RCA: 147] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
L-asparaginase is an integral component of therapy for acute lymphoblastic leukemia. However, asparaginase-related complications, including the development of hypersensitivity reactions, can limit its use in individual patients. Of considerable concern in the setting of clinical allergy is the development of neutralizing antibodies and associated asparaginase inactivity. Also problematic in the use of asparaginase is the potential for the development of silent inactivation, with the formation of neutralizing antibodies and reduced asparaginase activity in the absence of a clinically evident allergic reaction. Here we present guidelines for the identification and management of clinical hypersensitivity and silent inactivation with Escherichia coli- and Erwinia chrysanthemi- derived asparaginase preparations. These guidelines were developed by a consensus panel of experts following a review of the available published data. We provide a consensus of expert opinions on the role of serum asparaginase level assessment, indications for switching asparaginase preparation, and monitoring after change in asparaginase preparation.
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Affiliation(s)
- Inge M van der Sluis
- Department of Pediatric Hematology/Oncology, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Lynda M Vrooman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Division of Hematology/Oncology, Boston Children's Hospital, MA, USA
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Andre Baruchel
- Department of Pediatric Hematology, Hôpital Robert Debré, Paris and University Paris Diderot, France
| | - Gabriele Escherich
- University Medical Centre Hamburg-Eppendorf, Clinic of Paediatric Hematology and Oncology, Hamburg, Germany
| | | | - Veerle Mondelaers
- Pediatric Hematology/Oncology and Stem cell transplantation, Ghent University Hospital, Belgium
| | - Jose Sanchez de Toledo
- Department of Pediatric Hematology/Oncology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Carmelo Rizzari
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, Hospital S. Gerardo, Monza
| | - Lewis B Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Division of Hematology/Oncology, Boston Children's Hospital, MA, USA
| | - James A Whitlock
- Division of Haematology/Oncology, The Hospital for Sick Children and Department of Paediatrics, University of Toronto, Ontario, Canada
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98
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Hasan H, Shaikh OM, Rassekh SR, Howard AF, Goddard K. Comparison of hypersensitivity rates to intravenous and intramuscular PEG-asparaginase in children with acute lymphoblastic leukemia: A meta-analysis and systematic review. Pediatr Blood Cancer 2017; 64:81-88. [PMID: 27578304 DOI: 10.1002/pbc.26200] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 06/25/2016] [Accepted: 07/15/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pegylated-asparaginase (PEG-ASP) is a critical treatment for pediatric acute lymphoblastic leukemia (ALL) and has traditionally been delivered via intramuscular (IM) injection. In an attempt to reduce pain and anxiety, PEG-ASP has increasingly been delivered via intravenous (IV) administration. The study objective was to perform a meta-analysis and systematic review to compare and generate pooled hypersensitivity rates for IM and IV PEG-ASP. METHODS A systematic literature search was conducted for all epidemiological studies that investigated IV and IM hypersensitivity rates for pediatric ALL. Included studies were critically appraised using the GRACE checklist. Pooled estimates and odds ratios with 95% confidence intervals (CIs) for IM and IV hypersensitivity rates were derived based on either a random or fixed effects model. RESULTS Four studies satisfied the inclusion criteria and were of adequate quality. The random effects pooled hypersensitivity rates were 23.5% (95% CI 14.7-33.7) and 8.7% (95% CI 5.4-12.8) for IV and IM, respectively. The fixed effects pooled odds ratio after adjusting for publication bias was 2.49 (95% CI 1.62-3.83), indicating a significantly higher risk of hypersensitivity for IV over IM PEG-ASP. This risk is far more pronounced for high-risk (HR) patients compared with standard-risk (SR) patients (IV vs. IM: HR ↑35.2% and SR ↓2.9%). CONCLUSIONS Although administering PEG-ASP through IV is preferable for patients, it poses a significantly higher risk of hypersensitivity when compared with IM administration, especially for HR patients. We recommend pediatric oncologists consider treating patients with HR pediatric ALL with IM PEG-ASP to reduce the risk of hypersensitivity.
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Affiliation(s)
- Haroon Hasan
- Department of Radiation Oncology, British Columbia Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada
| | | | - Shahrad Rod Rassekh
- Division of Oncology/Hematology/BMT, British Columbia Children's Hospital, Vancouver, British Columbia, Canada.,Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - A Fuchsia Howard
- School of Nursing, Faculty of Applied Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Karen Goddard
- Department of Radiation Oncology, British Columbia Cancer Agency Vancouver Centre, Vancouver, British Columbia, Canada.,Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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99
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Red blood cells: Supercarriers for drugs, biologicals, and nanoparticles and inspiration for advanced delivery systems. Adv Drug Deliv Rev 2016; 106:88-103. [PMID: 26941164 DOI: 10.1016/j.addr.2016.02.007] [Citation(s) in RCA: 236] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 02/17/2016] [Accepted: 02/19/2016] [Indexed: 12/19/2022]
Abstract
Red blood cells (RBCs) constitute a unique drug delivery system as a biologic or hybrid carrier capable of greatly enhancing pharmacokinetics, altering pharmacodynamics (for example, by changing margination within the intravascular space), and modulating immune responses to appended cargoes. Strategies for RBC drug delivery systems include internal and surface loading, and the latter can be performed both ex vivo and in vivo. A relatively new avenue for RBC drug delivery is their application as a carrier for nanoparticles. Efforts are also being made to incorporate features of RBCs in nanocarriers to mimic their most useful aspects, such as long circulation and stealth features. RBCs have also recently been explored as carriers for the delivery of antigens for modulation of immune response. Therefore, RBC-based drug delivery systems represent supercarriers for a diverse array of biomedical interventions, and this is reflected by several industrial and academic efforts that are poised to enter the clinical realm.
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100
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Kloos RQH, Pieters R, Escherich G, van der Sluis IM. Allergic-like reactions to asparaginase: Atypical allergies without asparaginase inactivation. Pediatr Blood Cancer 2016; 63:1928-34. [PMID: 27376478 DOI: 10.1002/pbc.26123] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 05/19/2016] [Accepted: 06/08/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Asparaginase is an important component of pediatric acute lymphoblastic leukemia (ALL) therapy. Unfortunately, this treatment is hampered by hypersensitivity reactions. In general, allergies - regardless of severity - cause complete inactivation of the drug. However, we report atypical allergic reactions without inactivation of asparaginase, here called allergic-like reactions. PROCEDURE Patients with an allergic-like reaction, who were treated according to the Dutch Childhood Oncology Group ALL-11 or the CoALL 08-09 protocol, were described. The reactions were identified by continual measurement of asparaginase activity levels. Characteristics, including timing of occurrence, symptoms, grade, and the presence of antiasparaginase antibodies, were compared to those of real allergies. RESULTS Fourteen allergic-like reactions occurred in nine patients. Five reactions were to PEGasparaginase and nine to Erwinia asparaginase. Allergic-like reactions occurred relatively late after the start of infusion compared to real allergies. Antibodies were absent in all but one patient with an allergic-like reaction, while they were detected in all patients with a real allergy. Symptoms and grade did not differ between the groups. Asparaginase was continued with the same formulation in six patients of whom four finished treatment with adequate activity levels. CONCLUSIONS In conclusion, allergic-like reactions occur relatively late after the start of infusion and without antibodies. Despite these clinical differences, allergic-like reactions can only be distinguished from real allergies by continually measuring asparaginase activity levels. If clinically tolerated, formulations should not be switched in case of allergic-like reactions. Moreover, failure to recognize these reactions may lead to a less favorable prognosis if asparaginase therapy is terminated unnecessarily.
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Affiliation(s)
- Robin Q H Kloos
- Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Gabriele Escherich
- Clinic of Pediatric Hematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Inge M van der Sluis
- Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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