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Andrade KCR, Homem-de-Mello M, Motta JA, Borges MG, de Abreu JAC, de Souza PM, Pessoa A, Pappas GJ, de Oliveira Magalhães P. A Structural In Silico Analysis of the Immunogenicity of L-Asparaginase from Penicillium cerradense. Int J Mol Sci 2024; 25:4788. [PMID: 38732010 PMCID: PMC11084778 DOI: 10.3390/ijms25094788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
L-asparaginase is an essential drug used to treat acute lymphoid leukemia (ALL), a cancer of high prevalence in children. Several adverse reactions associated with L-asparaginase have been observed, mainly caused by immunogenicity and allergenicity. Some strategies have been adopted, such as searching for new microorganisms that produce the enzyme and applying protein engineering. Therefore, this work aimed to elucidate the molecular structure and predict the immunogenic profile of L-asparaginase from Penicillium cerradense, recently revealed as a new fungus of the genus Penicillium and producer of the enzyme, as a motivation to search for alternatives to bacterial L-asparaginase. In the evolutionary relationship, L-asparaginase from P. cerradense closely matches Aspergillus species. Using in silico tools, we characterized the enzyme as a protein fragment of 378 amino acids (39 kDa), including a signal peptide containing 17 amino acids, and the isoelectric point at 5.13. The oligomeric state was predicted to be a homotetramer. Also, this L-asparaginase presented a similar immunogenicity response (T- and B-cell epitopes) compared to Escherichia coli and Dickeya chrysanthemi enzymes. These results suggest a potentially useful L-asparaginase, with insights that can drive strategies to improve enzyme production.
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Affiliation(s)
- Kellen Cruvinel Rodrigues Andrade
- Laboratory of Natural Products, Department of Pharmacy, Faculty of Health Sciences, University of Brasilia, Brasilia 70910-900, Brazil; (K.C.R.A.)
| | - Mauricio Homem-de-Mello
- inSiliTox, Department of Pharmacy, Faculty of Health Sciences, University of Brasilia, Brasilia 70910-900, Brazil
| | - Julia Almeida Motta
- inSiliTox, Department of Pharmacy, Faculty of Health Sciences, University of Brasilia, Brasilia 70910-900, Brazil
| | - Marina Guimarães Borges
- Laboratory of Natural Products, Department of Pharmacy, Faculty of Health Sciences, University of Brasilia, Brasilia 70910-900, Brazil; (K.C.R.A.)
| | - Joel Antônio Cordeiro de Abreu
- Laboratory of Natural Products, Department of Pharmacy, Faculty of Health Sciences, University of Brasilia, Brasilia 70910-900, Brazil; (K.C.R.A.)
| | - Paula Monteiro de Souza
- Laboratory of Natural Products, Department of Pharmacy, Faculty of Health Sciences, University of Brasilia, Brasilia 70910-900, Brazil; (K.C.R.A.)
| | - Adalberto Pessoa
- Department of Biochemical and Pharmaceutical Technology, School of Pharmaceutical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
| | - Georgios J. Pappas
- Department Cell Biology, Institute Biological Sciences, University of Brasilia, Brasilia 70910-900, Brazil
| | - Pérola de Oliveira Magalhães
- Laboratory of Natural Products, Department of Pharmacy, Faculty of Health Sciences, University of Brasilia, Brasilia 70910-900, Brazil; (K.C.R.A.)
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Choed-Amphai C, Khorana J, Sathitsamitphong L, Natesirinilkul R, Charoenkwan P. Predictive factors for L-asparaginase hypersensitivity in pediatric acute lymphoblastic leukemia. Int J Hematol 2024; 119:442-449. [PMID: 38421487 DOI: 10.1007/s12185-024-03725-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 01/18/2024] [Accepted: 01/25/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND L-Asparaginase is a crucial component of acute lymphoblastic leukemia (ALL) treatment. However, hypersensitivity is a common adverse event. This study aimed to identify risk factors for L-asparaginase hypersensitivity in childhood ALL. METHODS Children treated for ALL at Chiang Mai University Hospital, Thailand, between 2005 and 2020 were included. Demographic data, clinical characteristics, and factors related to L-asparaginase were retrospectively reviewed. RESULTS L-Asparaginase hypersensitivity was observed in 24 of 216 children with ALL (11.1%). All patients received native L-asparaginase intramuscularly, and events occurred exclusively during the post-induction phase without concurrent corticosteroid use. Univariable analysis showed that relapsed ALL, higher accumulated doses, increased exposure days, and longer interval between drug administrations were potential risk factors. In multivariable logistic regression analysis, interruption of L-asparaginase administration for ≥ 52 weeks and exposure duration of ≥ 15 days were independent risk factors, with adjusted odds ratio of 16.481 (95% CI 3.248-83.617, p = 0.001) and 4.919 (95% CI 1.138-21.263, p = 0.033), respectively. CONCLUSIONS Children with ALL who require re-exposure to L-asparaginase after 52-week interruption or who have received L-asparaginase for ≥ 15 exposure days are at risk of developing L-asparaginase hypersensitivity. Further management strategies in this setting should be evaluated.
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Affiliation(s)
- Chane Choed-Amphai
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Sriphum, Muang, Chiang Mai, 50200, Thailand.
| | - Jiraporn Khorana
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Center of Clinical Epidemiology and Clinical Statistic, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
- Clinical Surgical Research Center, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Lalita Sathitsamitphong
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Sriphum, Muang, Chiang Mai, 50200, Thailand
| | - Rungrote Natesirinilkul
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Sriphum, Muang, Chiang Mai, 50200, Thailand
| | - Pimlak Charoenkwan
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chiang Mai University, 110 Intawaroros Road, Sriphum, Muang, Chiang Mai, 50200, Thailand
- Thalassemia and Hematology Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Tong WH, Rizzari C. Back to the future: the amazing journey of the therapeutic anti-leukemia enzyme asparaginase Erwinia chrysanthemi. Haematologica 2023; 108:2606-2615. [PMID: 37470157 PMCID: PMC10542841 DOI: 10.3324/haematol.2022.282324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/10/2023] [Indexed: 07/21/2023] Open
Abstract
For several decades, asparaginase has been considered world-wide as an essential component of combination chemotherapy for the treatment of childhood acute lymphoblastic leukemia (ALL). Discovered over 60 years ago, two main unmanipulated asparaginase products originated from primary bacteria sources, namely Escherichia coli and Erwinia chrysanthemi, have been available for clinical use. A pegylated product of the Escherichia coli asparaginase was subsequently developed and is now the main product used by several international co-operative groups. The various asparaginase products all display the same mechanism of action (hydrolysis of circulating asparagine) and are associated with similar efficacy and toxicity patterns. However, their different pharmacokinetics, pharmacodynamics and immunological properties require distinctive modalities of application and monitoring. Erwinia chrysanthemi asparaginase was initially used as a first-line product, but subsequently became a preferred second-line product for children who experienced immunological reactions to the Escherichia coli asparaginase products. An asparaginase product displaying the same characteristics of the Erwinia chrysanthemi asparaginase has recently been produced by use of recombinant technology, thus securing a preparation available for use as an alternative, or as a back-up in case of shortages, for the non-recombinant product. The long journey of the Erwinia chrysanthemi asparaginase product as it has developed throughout the last several decades has made it possible for almost every child and adult with ALL to complete the asparaginase-based protocol treatment when an immunological reaction has occurred to any Escherichia coli asparaginase product.
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Affiliation(s)
- Wing H Tong
- Department of Public Health and Primary Care (PHEG), Leiden University Medical Center, Leiden, The Netherlands; Argos Zorggroep "DrieMaasStede", Center for Specialized Geriatric Care, Schiedam.
| | - Carmelo Rizzari
- Department of Pediatrics, Foundation IRCCS San Gerardo dei Tintori, Monza, Italy; Department of Medicine and Surgery, University of Milano-Bicocca
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Brigitha LJ, Fiocco M, Pieters R, Albertsen BK, Escherich G, Lopez-Lopez E, Mondelaers V, Vora A, Vrooman L, Schmiegelow K, van der Sluis IM. Hypersensitivity to Pegylated E.colia sparaginase as first-line treatment in contemporary paediatric acute lymphoblastic leukaemia protocols: a meta-analysis of the Ponte di Legno Toxicity working group. Eur J Cancer 2021; 162:65-75. [PMID: 34954438 DOI: 10.1016/j.ejca.2021.11.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/05/2021] [Accepted: 11/08/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Hypersensitivity reactions to asparaginase challenge its use and occur frequently (30-75%) after native Escherichia Coli (E.coli) asparaginase. Comparison of incidence of allergic reactions to pegylated E.coli asparaginase (PEGasparaginase) across contemporary paediatric acute lymphoblastic leukaemia (ALL) protocols is lacking. METHOD AND PATIENTS Questionnaires were sent to all members of the international ALL Ponte di Legno Toxicity Working Group. Meta-analyses were conducted to estimate the incidence of three types of hypersensitivity (allergy, allergic-like reaction and silent inactivation). Information on protocol level regarding PEGasparaginase dosing regimen, administration route and use of therapeutic drug monitoring was collected for risk analysis. RESULTS Newly diagnosed patients with ALL (n = 5880), aged 1-24 years old, were enrolled in seven different upfront ALL protocols using PEGasparaginase as first-line treatment. The incidence of allergic reactions (sum of allergies and allergic-like reactions) [95% confidence interval] was 2% [1%; 3%] during induction and 8% [5%; 11%] during postinduction. Route of administration, number of doses, dosage and number of PEGasparaginase-free weeks did not significantly influence risk of hypersensitivity. Multivariate meta-regression analysis suggests that initiation of PEGasparaginase in postinduction and higher number of PEGasparaginase-free intervals increased the risk for allergic reactions. 9-16% and 23-29% of all hypersensitivities were allergic-like reactions and silent inactivation, respectively. CONCLUSION The incidence of allergic reactions is lower in protocols using PEGasparaginase as first-line treatment compared with that reported for E.coli asparaginase or PEGasparaginase after E.coli asparaginase. Postinduction phase, a higher number of PEGasparaginase-free intervals, and initiation of PEGasparaginase in postinduction phase are risk factors for allergic reactions. These results are important for planning of PEGasparaginase administrations in future frontline therapy.
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Affiliation(s)
- Leiah J Brigitha
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Marta Fiocco
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Medical Statistics, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands; Mathematical Institute, Leiden University, the Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Dutch Childhood Oncology Group, Utrecht, the Netherlands
| | - Birgitte K Albertsen
- Children and Adolescent Health, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Gabriele Escherich
- University Medical Center Eppendorf, Clinic of Pediatric Hematology and Oncology, Hamburg, Germany
| | - Elixabet Lopez-Lopez
- Department of Genetics, Physical Anthropology & Animal Physiology, Faculty of Science & Technology, University of the Basque Country (UPV/EHU), Barrio Sarriena S/n, 48940, Leioa, Spain
| | - Veerle Mondelaers
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Ajay Vora
- Departments of Bone Marrow Transplant and Haematology, Great Ormond Street Hospital for Children, London, UK
| | - Lynda Vrooman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Inge M van der Sluis
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; Dutch Childhood Oncology Group, Utrecht, the Netherlands.
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Tong WH. Comment on "Comparison of hypersensitivity rates to intravenous and intramuscular PEGasparaginase in children with acute lymphoblastic leukemia: A meta-analysis and systematic review". Pediatr Blood Cancer 2021; 68:e29250. [PMID: 34288392 DOI: 10.1002/pbc.29250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/11/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Wing H Tong
- Department of Public Health and Primary Care (PHEG), Leiden University Medical Center, Leiden, The Netherlands.,Argos Zorggroep "DrieMaasStede,", Center for Specialized Geriatric Care, Schiedam, The Netherlands
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Freitas M, Souza P, Cardoso S, Cruvinel K, Abrunhosa LS, Ferreira Filho EX, Inácio J, Pinho DB, Pessoa A, O. Magalhães P. Filamentous Fungi Producing l-Asparaginase with Low Glutaminase Activity Isolated from Brazilian Savanna Soil. Pharmaceutics 2021; 13:1268. [PMID: 34452229 PMCID: PMC8401000 DOI: 10.3390/pharmaceutics13081268] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/31/2021] [Accepted: 08/06/2021] [Indexed: 11/22/2022] Open
Abstract
l-asparaginase is an enzyme used as treatment for acute lymphoblastic leukemia (ALL) due to its ability to hydrolyze l-asparagine, an essential amino acid synthesized by normal cells unlike neoplastic cells. The adverse effects of l-asparaginase formulations are associated with its glutaminase activity and bacterial origin; therefore, it is important to find new sources of l-asparaginase-producing eukaryotic microorganisms with low glutaminase activity. This work evaluated the biotechnological potential of filamentous fungi isolated from Brazilian Savanna soil and plants for l-asparaginase production. Thirty-nine isolates were screened for enzyme production using the plate assay, followed by measuring enzymatic activity in cells after submerged fermentation. The variables influencing l-asparaginase production were evaluated using Plackett-Burman design. Cell disruption methods were evaluated for l-asparaginase release. Penicillium sizovae 2DSST1 and Fusarium proliferatum DCFS10 showed the highest l-asparaginase activity levels and the lowest glutaminase activity levels. Penicillium sizovae l-asparaginase was repressed by carbon sources, whereas higher carbon concentrations enhanced l-asparaginase by F. proliferatum. Maximum enzyme productivity, specific enzyme yield and the biomass conversion factor in the enzyme increased after Plackett-Burman design. Freeze-grinding released 5-fold more l-asparaginase from cells than sonication. This study shows two species, which have not yet been reported, as sources of l-asparaginase with possible reduced immunogenicity for ALL therapy.
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Affiliation(s)
- Marcela Freitas
- Health Sciences School, University of Brasília, Brasília 70910-900, Brazil; (M.F.); (P.S.); (S.C.); (K.C.); (L.S.A.)
| | - Paula Souza
- Health Sciences School, University of Brasília, Brasília 70910-900, Brazil; (M.F.); (P.S.); (S.C.); (K.C.); (L.S.A.)
| | - Samuel Cardoso
- Health Sciences School, University of Brasília, Brasília 70910-900, Brazil; (M.F.); (P.S.); (S.C.); (K.C.); (L.S.A.)
| | - Kellen Cruvinel
- Health Sciences School, University of Brasília, Brasília 70910-900, Brazil; (M.F.); (P.S.); (S.C.); (K.C.); (L.S.A.)
| | - Letícia Santos Abrunhosa
- Health Sciences School, University of Brasília, Brasília 70910-900, Brazil; (M.F.); (P.S.); (S.C.); (K.C.); (L.S.A.)
| | - Edivaldo X. Ferreira Filho
- Institute of Biological Sciences, University of Brasília, Brasília 70910-900, Brazil; (E.X.F.F.); (D.B.P.)
| | - João Inácio
- School of Pharmacy and Biomolecular Sciences, University of Brighton, Brighton BN2 4GJ, UK;
| | - Danilo Batista Pinho
- Institute of Biological Sciences, University of Brasília, Brasília 70910-900, Brazil; (E.X.F.F.); (D.B.P.)
| | - Adalberto Pessoa
- Department of Biochemical and Pharmaceutical Technology, University of São Paulo, São Paulo 05508-000, Brazil;
| | - Pérola O. Magalhães
- Health Sciences School, University of Brasília, Brasília 70910-900, Brazil; (M.F.); (P.S.); (S.C.); (K.C.); (L.S.A.)
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Liu C, Huang B, Wu R, Chen J, Tang Y, Hu W, Li J, Chen X, Cai J, Zhou M, Chen C, Shen S. Adequate asparaginase is important to prevent central nervous system and testicular relapse of pediatric Philadelphia chromosome-negative B-cell acute lymphoblastic leukemia. Int J Cancer 2021; 149:158-168. [PMID: 33634856 DOI: 10.1002/ijc.33529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/13/2021] [Accepted: 02/16/2021] [Indexed: 11/11/2022]
Abstract
Asparaginase (Asp) is one of the most important drugs for treating acute lymphoblastic leukemia (ALL). However, off-protocol Asp administration (OPAA) or hypersensitivity may disturb its pharmacokinetic profile. In this retrospective study, we sought to determine whether OPAA and hypersensitivity to Escherichia coli asparaginase (E coli Asp) impaired extramedullary relapse prevention in a pediatric ALL cohort treated according to SCMC-ALL-2005 protocol from 2005 to 2014 at the Shanghai Children's Medical Center (SCMC). In total, 676 patients were enrolled in this study, including 369 with OPAA and 60 exhibiting hypersensitivity to E coli Asp. At the end of the most recent follow-up, 58 patients had extramedullary relapse. The 5-year cumulative extramedullary relapse incidence in patients with OPAA was 11.01%, whereas that in patients without OPAA was 5.28% (P = .0036). Moreover, the 5-year cumulative extramedullary relapse incidence in patients that exhibited hypersensitivity to E coli Asp was 16.48%, whereas that in patients without hypersensitivity was 7.59% (P = .0195). Concerning the relapse site, OPAA not only increased central nervous system (CNS) relapse but testicular relapse as well. Based on Fine and Gray multivariate analysis, OPAA and hypersensitivity to Asp were independent risk factors for extramedullary relapse. In conclusion, to prevent extramedullary relapse of ALL, adequate duration to administrate Asp was more important than the total dosage, and more attention should be paid to Asp inadequate due to hypersensitivity.
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Affiliation(s)
- Chenxi Liu
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, and National Children's Medical Center, Shanghai, China
| | - Binxiao Huang
- Department of Pediatric, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ruichi Wu
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, and National Children's Medical Center, Shanghai, China
| | - Jing Chen
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, and National Children's Medical Center, Shanghai, China
| | - Yanjing Tang
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, and National Children's Medical Center, Shanghai, China
| | - Wenting Hu
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, and National Children's Medical Center, Shanghai, China
| | - Jing Li
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, and National Children's Medical Center, Shanghai, China
| | - Xiaoxiao Chen
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, and National Children's Medical Center, Shanghai, China
| | - Jiaoyang Cai
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, and National Children's Medical Center, Shanghai, China
| | - Min Zhou
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, and National Children's Medical Center, Shanghai, China
| | - Changcheng Chen
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, and National Children's Medical Center, Shanghai, China
| | - Shuhong Shen
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, and National Children's Medical Center, Shanghai, China
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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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9
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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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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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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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12
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Burke MJ, Rheingold SR. Differentiating hypersensitivity versus infusion-related reactions in pediatric patients receiving intravenous asparaginase therapy for acute lymphoblastic leukemia. Leuk Lymphoma 2016; 58:540-551. [DOI: 10.1080/10428194.2016.1213826] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Michael J. Burke
- Division of Pediatric Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Susan R. Rheingold
- Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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13
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Egler RA, Ahuja SP, Matloub Y. L-asparaginase in the treatment of patients with acute lymphoblastic leukemia. J Pharmacol Pharmacother 2016; 7:62-71. [PMID: 27440950 PMCID: PMC4936081 DOI: 10.4103/0976-500x.184769] [Citation(s) in RCA: 152] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute lymphoblastic leukemia (ALL) is a hematologic malignancy that predominantly occurs in children between 2 and 10 years of age. L-asparaginase is an integral component of treatment for patients with ALL and since its introduction into pediatric treatment protocols in the 1960s, survival rates in children have progressively risen to nearly 90%. Outcomes for adolescent and young adult (AYA) patients, aged 15-39 years and diagnosed with ALL, have historically been less favorable. However, recent reports suggest substantially increased survival in AYA patients treated on pediatric-inspired protocols that include a greater cumulative dose of asparaginase. All currently available asparaginases share the same mechanism of action - the deamination and depletion of serum asparagine levels - yet each displays a markedly different pharmacokinetic profile. Pegylated asparaginase derived from the bacterium Escherichia coli is used as first-line therapy; however, up to 30% of patients develop a treatment-limiting hypersensitivity reaction. Patients who experience a hypersensitivity reaction to an E. coli-derived asparaginase can continue treatment with Erwinia chrysanthemi asparaginase. Erwinia asparaginase is immunologically distinct from E. coli-derived asparaginases and exhibits no cross-reactivity. Studies have shown that with adequate dosing, therapeutic levels of Erwinia asparaginase activity can be achieved, and patients switched to Erwinia asparaginase due to hypersensitivity can obtain outcomes similar to patients who do not experience a hypersensitivity reaction. Therapeutic drug monitoring may be required to ensure that therapeutic levels of asparaginase activity are maintained.
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Affiliation(s)
- Rachel A Egler
- Department of Pediatric Hematology/Oncology, Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Sanjay P Ahuja
- Department of Pediatric Hematology/Oncology, Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Yousif Matloub
- Department of Pediatric Hematology/Oncology, Case Western Reserve University School of Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH, USA
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14
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Asselin B. Immunology of infusion reactions in the treatment of patients with acute lymphoblastic leukemia. Future Oncol 2016; 12:1609-21. [DOI: 10.2217/fon-2016-0005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Infusion reactions are potentially dose-limiting adverse events associated with intravenous administration of several common agents used to treat patients with acute lymphoblastic leukemia. True clinical hypersensitivity reactions are antibody-mediated and can occur only after repeated exposure to an antigen. Conversely, anaphylactoid infusion reactions are nonantibody-mediated and often occur on the initial exposure to a drug. Cytokine-release syndrome comprises a subset of nonantibody-mediated infusion reactions associated with the use of monoclonal antibodies and immune therapies. Clinical symptoms of hypersensitivity reactions and nonantibody-mediated infusion reactions heavily overlap and can be difficult to distinguish in practice. Regardless of the underlying mechanism, any infusion reaction can negatively affect treatment efficacy and patient safety. These events require prompt response, and potentially, modification of subsequent therapy.
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Affiliation(s)
- Barbara Asselin
- Golisano Children's Hospital, University of Rochester Medical Center, 601 Elmwood Avenue, Box 667, Rochester, NY, USA
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15
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Thomas X, Le Jeune C. Erythrocyte encapsulated l-asparaginase (GRASPA) in acute leukemia. Int J Hematol Oncol 2016; 5:11-25. [PMID: 30302200 PMCID: PMC6172001 DOI: 10.2217/ijh-2016-0002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 04/19/2016] [Indexed: 11/21/2022] Open
Abstract
l-asparaginase, an enzyme originally derived from Escherichia coli, represents a major drug in the treatment of acute lymphoblastic leukemia. However, the occurrence of major adverse effects often leads to early withdrawal of the enzyme. Main side effects include immune-allergic reactions, coagulopathy, pancreatitis and hepatic disorders. Novel asparaginase formulations and alternative sources have been developed to address this issue, but the results were not totally satisfactory. l-asparaginase loaded red blood cells (RBCs; GRASPA) represent a new asparaginase presentation with reduced immunological adverse reactions. RBCs protect l-asparaginase, enhance its half-life and reduce the occurrence of adverse events. We reviewed the history, biology and clinical experiences with l-asparaginase, and the characteristics and first clinical experiences with GRASPA in the treatment of acute leukemia.
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Affiliation(s)
- Xavier Thomas
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud Hospital, Bât.1G, 165 chemin du Grand Revoyet, 69495 Pierre-Bénite, France
| | - Caroline Le Jeune
- Hospices Civils de Lyon, Hematology Department, Lyon-Sud Hospital, Bât.1G, 165 chemin du Grand Revoyet, 69495 Pierre-Bénite, France
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16
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Shrivastava A, Khan AA, Khurshid M, Kalam MA, Jain SK, Singhal PK. Recent developments in l-asparaginase discovery and its potential as anticancer agent. Crit Rev Oncol Hematol 2016; 100:1-10. [DOI: 10.1016/j.critrevonc.2015.01.002] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/17/2014] [Accepted: 01/05/2015] [Indexed: 11/24/2022] Open
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17
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Figueiredo L, Cole PD, Drachtman RA. Asparaginase Erwinia chrysanthemi as a component of a multi-agent chemotherapeutic regimen for the treatment of patients with acute lymphoblastic leukemia who have developed hypersensitivity to E. coli-derived asparaginase. Expert Rev Hematol 2016; 9:227-34. [PMID: 26765930 DOI: 10.1586/17474086.2016.1142370] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Asparaginase has been a mainstay of therapy in the treatment of acute lymphoblastic leukemia since the 1970s. There are two major preparations available and FDA approved in the United States today, one derived from Escherichia coli and the other from Erwinia chrysanthemi. Erwinia asparaginase is antigenically distinct from and has a considerably shorter biological half-life than E coli asparaginase. Erwinia asparaginase has been used in cases of hypersensitivity to E. coli-derived asparaginases, which has been reported in up to 30% of patients. While PEG asparaginase is increasingly used in front-line therapy for ALL, hypersensitivity still occurs with this preparation, and a change to a non-cross-reactive preparation may be necessary.
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Affiliation(s)
- Lisa Figueiredo
- a Pediatric Hematology/Oncology , Children's Hospital at Montefiore, Albert Einstein College of Medicine , Bronx , NY , USA
| | - Peter D Cole
- a Pediatric Hematology/Oncology , Children's Hospital at Montefiore, Albert Einstein College of Medicine , Bronx , NY , USA
| | - Richard A Drachtman
- b Pediatic Hematology/Oncology , Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School , New Brunswick , NJ , USA
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18
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Hijiya N, van der Sluis IM. Asparaginase-associated toxicity in children with acute lymphoblastic leukemia. Leuk Lymphoma 2015; 57:748-57. [PMID: 26457414 PMCID: PMC4819847 DOI: 10.3109/10428194.2015.1101098] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Asparaginase is an integral component of multiagent chemotherapy regimens for the treatment of children with acute lymphoblastic leukemia. Positive outcomes are seen in patients who are able to complete their entire prescribed course of asparaginase therapy. Toxicities associated with asparaginase use include hypersensitivity (clinical and subclinical), pancreatitis, thrombosis, encephalopathy, and liver dysfunction. Depending on the nature and severity of the toxicity, asparaginase therapy may be altered or discontinued in some patients. Clinical hypersensitivity is the most common asparaginase-associated toxicity requiring treatment discontinuation, occurring in up to 30% of patients receiving Escherichia coli-derived asparaginase. The ability to rapidly identify and manage asparaginase-associated toxicity will help ensure patients receive the maximal benefit from asparaginase therapy. This review will provide an overview of the common toxicities associated with asparaginase use and recommendations for treatment management.
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Affiliation(s)
- Nobuko Hijiya
- a Division of Hematology/Oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine , Northwestern University , Chicago , IL , USA
| | - Inge M van der Sluis
- b Department of Pediatric Oncology/Hematology , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
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19
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Chen SH. Asparaginase Therapy in Pediatric Acute Lymphoblastic Leukemia: A Focus on the Mode of Drug Resistance. Pediatr Neonatol 2015; 56:287-93. [PMID: 25603726 DOI: 10.1016/j.pedneo.2014.10.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 08/28/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022] Open
Abstract
Asparaginase is one of the most important chemotherapeutic agents against pediatric acute lymphoblastic leukemia (ALL), the most common form of childhood cancer. The therapeutic efficacy (e.g., chemoresistance) and adverse effects of asparaginase (e.g., hypersensivity and pancreatitis) have been investigated over the past four decades. It was suggested early on that leukemic cells are resistant to asparaginase because of their increased asparagine synthetase activity. Afterward, other mechanisms associated with asparaginase resistance were reported. Not only leukemic cells but also patients themselves may play a role in causing asparaginase resistance, which has been associated with unfavorable outcome in children with ALL. This article will briefly review asparaginase therapy in children with ALL and comprehensively analyze recent reports on the potential mechanisms of asparaginase resistance.
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Affiliation(s)
- Shih-Hsiang Chen
- Division of Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, 5 Fu-Shin Street, Kwei-Shan 333, Taoyuan, Taiwan.
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20
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Lorentz KM, Kontos S, Diaceri G, Henry H, Hubbell JA. Engineered binding to erythrocytes induces immunological tolerance to E. coli asparaginase. SCIENCE ADVANCES 2015; 1:e1500112. [PMID: 26601215 PMCID: PMC4646778 DOI: 10.1126/sciadv.1500112] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 05/14/2015] [Indexed: 05/29/2023]
Abstract
Antigen-specific immune responses to protein drugs can hinder efficacy and compromise safety because of drug neutralization and secondary clinical complications. We report a tolerance induction strategy to prevent antigen-specific humoral immune responses to therapeutic proteins. Our modular, biomolecular approach involves engineering tolerizing variants of proteins such that they bind erythrocytes in vivo upon injection, on the basis of the premise that aged erythrocytes and the payloads they carry are cleared tolerogenically, driving the deletion of antigen-specific T cells. We demonstrate that binding the clinical therapeutic enzyme Escherichia coli l-asparaginase to erythrocytes in situ antigen-specifically abrogates development of antibody titers by >1000-fold and extends the pharmacodynamic effect of the drug 10-fold in mice. Additionally, a single pretreatment dose of erythrocyte-binding asparaginase tolerized mice to multiple subsequent doses of the wild-type enzyme. This strategy for reducing antigen-specific humoral responses may enable more effective and safer treatment with therapeutic proteins and drug candidates that are hampered by immunogenicity.
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Affiliation(s)
- Kristen M. Lorentz
- Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne, CH-1015 Lausanne, Switzerland
- Anokion SA, CH-1024 Ecublens, Switzerland
| | - Stephan Kontos
- Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne, CH-1015 Lausanne, Switzerland
- Anokion SA, CH-1024 Ecublens, Switzerland
| | - Giacomo Diaceri
- Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne, CH-1015 Lausanne, Switzerland
| | - Hugues Henry
- Centre Hospitalier Universitaire Vaudois, University Hospital of Lausanne, CH-1011 Lausanne, Switzerland
| | - Jeffrey A. Hubbell
- Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne, CH-1015 Lausanne, Switzerland
- Anokion SA, CH-1024 Ecublens, Switzerland
- Institute for Molecular Engineering, University of Chicago, Chicago, IL 60637, USA
- Materials Science Division, Argonne National Laboratory, Argonne, IL 60439, USA
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21
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Rajić V, Debeljak M, Goričar K, Jazbec J. Polymorphisms in GRIA1 gene are a risk factor for asparaginase hypersensitivity during the treatment of childhood acute lymphoblastic leukemia. Leuk Lymphoma 2015; 56:3103-8. [PMID: 25697915 DOI: 10.3109/10428194.2015.1020802] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
l-asparaginase is an effective antineoplastic agent used in chemotherapy of acute lymphoblastic leukemia. The drug effect may be compromised by an elicited immune response, resulting in the production of anti-asparaginase antibodies causing an anaphylactic reaction or silent inactivation of the enzyme. To elucidate possible genetic predisposition for inter-individual differences in asparaginase hypersensitivity, we studied single nucleotide polymorphisms (SNPs) in the GRIA1 gene in 146 pediatric patients treated with l-asparaginase. Allergic reaction to l-asparaginase occurred in 49.3% of patients. We observed a statistically significant association between SNPs in the GRIA1 gene and the occurrence of asparaginase allergy: rs4958351 with p = 0.003, rs4958676 with p = 0.005, rs6889909 with p = 0.005, rs6890057 with p = 0.005 and rs10070447 with p = 0.006. We found a statistically significant correlation between asparaginase allergy and event-free survival (p-value 0.005).
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Affiliation(s)
- Vladan Rajić
- a Department of Hematology and Oncology , University Children's Hospital , Ljubljana , Slovenia
| | - Maruša Debeljak
- b Unit of Special Laboratory Diagnostics, Centre for Medical Genetics, University Medical Centre Ljubljana , Ljubljana , Slovenia
| | - Katja Goričar
- c Institute of Biochemistry, Medical Faculty, University of Ljubljana , Ljubljana , Slovenia
| | - Janez Jazbec
- a Department of Hematology and Oncology , University Children's Hospital , Ljubljana , Slovenia
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22
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Abstract
Asparaginase is widely used in chemotherapeutic regimens for the treatment of acute lymphoblastic leukemia (ALL) and has led to a substantial improvement in cure rates, especially in children. Optimal therapeutic effects depend on a complete and sustained depletion of serum asparagine. However, pronounced interpatient variability, differences in pharmacokinetic properties between asparaginases and the formation of asparaginase antibodies make it difficult to predict the degree of asparagine depletion that will result from a given dose of asparaginase. The pharmacological principles underlying asparaginase therapy in the treatment of ALL are summarized in this article. A better understanding of the many factors that influence asparaginase activity and subsequent asparagine depletion may allow physicians to tailor treatment to the individual, maximizing therapeutic effect and minimizing treatment-related toxicity. Therapeutic drug monitoring provides a means of assessing a patient's current depletion status and can be used to better evaluate the potential benefit of treatment adjustments.
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Affiliation(s)
- Barbara Asselin
- a Department of Pediatrics , Golisano Children's Hospital, University of Rochester School of Medicine , Rochester , NY , USA
| | - Carmelo Rizzari
- b Department of Pediatrics , Pediatric Hematology-Oncology Unit, University of Milano-Bicocca, MBBM Foundation, San Gerardo Hospital , Monza , Italy
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23
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Ramya LN, Pulicherla KK. Studies on Deimmunization of Antileukaemic L-Asparaginase to have Reduced Clinical Immunogenicity- An in silico Approach. Pathol Oncol Res 2015; 21:909-20. [DOI: 10.1007/s12253-015-9912-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Accepted: 02/16/2015] [Indexed: 01/09/2023]
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24
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Henriksen LT, Harila-Saari A, Ruud E, Abrahamsson J, Pruunsild K, Vaitkeviciene G, Jónsson ÓG, Schmiegelow K, Heyman M, Schrøder H, Albertsen BK. PEG-asparaginase allergy in children with acute lymphoblastic leukemia in the NOPHO ALL2008 protocol. Pediatr Blood Cancer 2015; 62:427-33. [PMID: 25418987 DOI: 10.1002/pbc.25319] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 09/22/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND L-Asparaginase is an effective drug in the treatment of childhood acute lymphoblastic leukemia (ALL). The use of L-asparaginase may be limited by serious adverse events of which allergy is the most frequent. The objective of this study was to describe the clinical aspects of PEG-asparaginase allergy in children treated according to the Nordic Society of Paediatric Haematology and Oncology (NOPHO) ALL2008 protocol. PROCEDURE Children (1-17 years) enrolled in the NOPHO ALL2008 protocol between July 2008 and August 2011, who developed PEG-asparaginase allergy were identified through the NOPHO ALL2008 toxicity registry. In the NOPHO ALL2008 protocol, patients are randomized to 8 or 15 doses of intramuscular PEG-asparaginase (Oncaspar®) 1,000 IU/m(2) /dose administered at 2 or 6 weeks intervals during a total period of 30 weeks. (Clinical trials.gov no: NCT00819351). RESULTS Of 615 evaluable patients, 79 patients developed clinical PEG-asparaginase allergy (cumulative risk; 13.2%) and discontinued PEG-asparaginase therapy for that reason. PEG-asparaginase allergy occurred after a median of two doses (75% range 2-4, max 14). In 58% of PEG-asparaginase hypersensitive patients, the clinical allergic reactions appeared within 2 hr after PEG-asparaginase administration and ranged from mild symptoms to systemic anaphylaxis. Nine patients experienced an anaphylactic reaction within 1 hr and 50 min from asparaginase administration; none were fatal. Four of 68 patients (6%) who subsequently received Erwinase therapy also reacted allergic to Erwinase. CONCLUSION Clinical allergy to PEG-asparaginase occurred early in treatment, was in general moderate in severity, and mostly developed within 2 hr after PEG-asparaginase administration. The risk of subsequent Erwinase allergic reactions was low.
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25
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Fernandez CA, Smith C, Karol SE, Ramsey LB, Liu C, Pui CH, Jeha S, Evans WE, Finkelman FD, Relling MV. Effect of premedications in a murine model of asparaginase hypersensitivity. J Pharmacol Exp Ther 2015; 352:541-51. [PMID: 25573198 DOI: 10.1124/jpet.114.220780] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
A murine model was developed that recapitulates key features of clinical hypersensitivity to Escherichia coli asparaginase. Sensitized mice developed high levels of anti-asparaginase IgG antibodies and had immediate hypersensitivity reactions to asparaginase upon challenge. Sensitized mice had complete inhibition of plasma asparaginase activity (P = 4.2 × 10(-13)) and elevated levels of mouse mast cell protease 1 (P = 6.1 × 10(-3)) compared with nonsensitized mice. We investigated the influence of pretreatment with triprolidine, cimetidine, the platelet activating factor (PAF) receptor antagonist CV-6209 [2-(2-acetyl-6-methoxy-3,9-dioxo-4,8-dioxa-2,10-diazaoctacos-1-yl)-1-ethyl-pyridinium chloride], or dexamethasone on the severity of asparaginase-induced allergies. Combining triprolidine and CV-6209 was best for mitigating asparaginase-induced hypersensitivity compared with nonpretreated, sensitized mice (P = 1.2 × 10(-5)). However, pretreatment with oral dexamethasone was the only agent capable of mitigating the severity of the hypersensitivity (P = 0.03) and partially restoring asparaginase activity (P = 8.3 × 10(-4)). To rescue asparaginase activity in sensitized mice without requiring dexamethasone, a 5-fold greater dose of asparaginase was needed to restore enzyme activity to a similar concentration as in nonsensitized mice. Our results suggest a role of histamine and PAF in asparaginase-induced allergies and indicate that mast cell-derived proteases released during asparaginase allergy may be a useful marker of clinical hypersensitivity.
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Affiliation(s)
- Christian A Fernandez
- Department of Pharmaceutical Sciences (C.A.F., C.S., S.E.K., L.B.R., C.L., W.E.E., M.V.R.) and Department of Oncology (S.E.K., C.-H.P., S.J.), St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Medicine, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio (F.D.F.); Department of Internal Medicine, Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, Ohio (F.D.F.); and Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (F.D.F.)
| | - Colton Smith
- Department of Pharmaceutical Sciences (C.A.F., C.S., S.E.K., L.B.R., C.L., W.E.E., M.V.R.) and Department of Oncology (S.E.K., C.-H.P., S.J.), St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Medicine, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio (F.D.F.); Department of Internal Medicine, Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, Ohio (F.D.F.); and Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (F.D.F.)
| | - Seth E Karol
- Department of Pharmaceutical Sciences (C.A.F., C.S., S.E.K., L.B.R., C.L., W.E.E., M.V.R.) and Department of Oncology (S.E.K., C.-H.P., S.J.), St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Medicine, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio (F.D.F.); Department of Internal Medicine, Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, Ohio (F.D.F.); and Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (F.D.F.)
| | - Laura B Ramsey
- Department of Pharmaceutical Sciences (C.A.F., C.S., S.E.K., L.B.R., C.L., W.E.E., M.V.R.) and Department of Oncology (S.E.K., C.-H.P., S.J.), St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Medicine, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio (F.D.F.); Department of Internal Medicine, Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, Ohio (F.D.F.); and Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (F.D.F.)
| | - Chengcheng Liu
- Department of Pharmaceutical Sciences (C.A.F., C.S., S.E.K., L.B.R., C.L., W.E.E., M.V.R.) and Department of Oncology (S.E.K., C.-H.P., S.J.), St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Medicine, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio (F.D.F.); Department of Internal Medicine, Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, Ohio (F.D.F.); and Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (F.D.F.)
| | - Ching-Hon Pui
- Department of Pharmaceutical Sciences (C.A.F., C.S., S.E.K., L.B.R., C.L., W.E.E., M.V.R.) and Department of Oncology (S.E.K., C.-H.P., S.J.), St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Medicine, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio (F.D.F.); Department of Internal Medicine, Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, Ohio (F.D.F.); and Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (F.D.F.)
| | - Sima Jeha
- Department of Pharmaceutical Sciences (C.A.F., C.S., S.E.K., L.B.R., C.L., W.E.E., M.V.R.) and Department of Oncology (S.E.K., C.-H.P., S.J.), St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Medicine, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio (F.D.F.); Department of Internal Medicine, Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, Ohio (F.D.F.); and Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (F.D.F.)
| | - William E Evans
- Department of Pharmaceutical Sciences (C.A.F., C.S., S.E.K., L.B.R., C.L., W.E.E., M.V.R.) and Department of Oncology (S.E.K., C.-H.P., S.J.), St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Medicine, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio (F.D.F.); Department of Internal Medicine, Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, Ohio (F.D.F.); and Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (F.D.F.)
| | - Fred D Finkelman
- Department of Pharmaceutical Sciences (C.A.F., C.S., S.E.K., L.B.R., C.L., W.E.E., M.V.R.) and Department of Oncology (S.E.K., C.-H.P., S.J.), St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Medicine, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio (F.D.F.); Department of Internal Medicine, Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, Ohio (F.D.F.); and Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (F.D.F.)
| | - Mary V Relling
- Department of Pharmaceutical Sciences (C.A.F., C.S., S.E.K., L.B.R., C.L., W.E.E., M.V.R.) and Department of Oncology (S.E.K., C.-H.P., S.J.), St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Medicine, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio (F.D.F.); Department of Internal Medicine, Division of Immunology, Allergy and Rheumatology, University of Cincinnati College of Medicine, Cincinnati, Ohio (F.D.F.); and Division of Immunobiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio (F.D.F.)
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Abstract
Outcomes for children with acute lymphoblastic leukemia (ALL) have improved significantly in recent decades, primarily due to dose-intensified, multi-agent chemotherapy regimens, of which asparaginase has played a prominent role. Despite this success, hypersensitivity remains a significant problem, often requiring the termination of asparaginase. Failure to complete the entire asparaginase therapy course due to clinical hypersensitivity, subclinical hypersensitivity (i.e., silent inactivation), or other treatment-related toxicity is associated with poor ALL outcomes. Thus, it is critical to rapidly identify patients who develop clinical/subclinical hypersensitivity and switch these patients to an alternate asparaginase formulation. This article provides an overview of asparaginase hypersensitivity, identification and management of hypersensitivity and subclinical hypersensitivity, and issues related to switching patients to asparaginase Erwinia chrysanthemi following hypersensitivity reaction.
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Affiliation(s)
- Michael J Burke
- Division of Pediatric Oncology, Medical College of Wisconsin, Milwaukee, WI, USA.
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Borek D, Kozak M, Pei J, Jaskolski M. Crystal structure of active site mutant of antileukemicl-asparaginase reveals conserved zinc-binding site. FEBS J 2014; 281:4097-111. [DOI: 10.1111/febs.12906] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 06/16/2014] [Accepted: 07/01/2014] [Indexed: 02/03/2023]
Affiliation(s)
- Dominika Borek
- Department of Crystallography; Faculty of Chemistry; A. Mickiewicz University; Poznan Poland
| | - Maciej Kozak
- Department of Crystallography; Faculty of Chemistry; A. Mickiewicz University; Poznan Poland
- Department of Macromolecular Physics; Faculty of Physics; A. Mickiewicz University; Poznan Poland
| | - Jimin Pei
- Howard Hughes Medical Institute; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Mariusz Jaskolski
- Department of Crystallography; Faculty of Chemistry; A. Mickiewicz University; Poznan Poland
- Center for Biocrystallographic Research; Institute of Bioorganic Chemistry; Polish Academy of Sciences; Poznan Poland
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Abstract
Asparaginase is a therapeutic enzyme used to treat leukemia and lymphoma, with immune responses resulting in suboptimal drug exposure and a greater risk of relapse. To elucidate whether there is a genetic component to the mechanism of asparaginase-induced immune responses, we imputed human leukocyte antigen (HLA) alleles in patients of European ancestry enrolled on leukemia trials at St. Jude Children's Research Hospital (n = 541) and the Children's Oncology Group (n = 1329). We identified a higher incidence of hypersensitivity and anti-asparaginase antibodies in patients with HLA-DRB1*07:01 alleles (P = 7.5 × 10(-5), odds ratio [OR] = 1.64; P = 1.4 × 10(-5), OR = 2.92, respectively). Structural analysis revealed that high-risk amino acids were located within the binding pocket of the HLA protein, possibly affecting the interaction between asparaginase epitopes and the HLA-DRB1 protein. Using a sequence-based consensus approach, we predicted the binding affinity of HLA-DRB1 alleles for asparaginase epitopes, and patients whose HLA genetics predicted high-affinity binding had more allergy (P = 3.3 × 10(-4), OR = 1.38). Our results suggest a mechanism of allergy whereby HLA-DRB1 alleles that confer high-affinity binding to asparaginase epitopes lead to a higher frequency of reactions. These trials were registered at www.clinicaltrials.gov as NCT00137111, NCT00549848, NCT00005603, and NCT00075725.
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Gervais D, Corn T, Downer A, Smith S, Jennings A. Measurement of subvisible particulates in lyophilised Erwinia chrysanthemi L-asparaginase and relationship with clinical experience. AAPS JOURNAL 2014; 16:784-90. [PMID: 24854894 PMCID: PMC4070265 DOI: 10.1208/s12248-014-9612-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Accepted: 04/25/2014] [Indexed: 11/30/2022]
Abstract
In order to generate further characterisation data for the lyophilised product Erwinia chrysanthemi L-asparaginase, reconstituted drug product (DP; marketed as Erwinase or Erwinaze) was analysed for subvisible (2-10 μm) particulate content using both the light obscuration (LO) method and the newer flow-imaging microscopy (FIM) technique. No correlation of subvisible particulate counts exists between FIM and LO nor do the counts correlate with activity at both release and on stability. The subvisible particulate content of lyophilised Erwinia L-asparaginase appears to be consistent and stable over time and in line with other parenteral biopharmaceutical products. The majority (ca. 75%) of subvisible particulates in L-asparaginase DP were at the low end of the measurement range by FIM (2-4 μm). In this size range, FIM was unable to definitively classify the particulates as either protein or non-protein. More sensitive measurement techniques would be needed to classify the particulates in lyophilised L-asparaginase into type (protein and non-protein), so the LO technique has been chosen for on-going DP analyses. E. chrysanthemi L-asparaginase has a lower rate of hypersensitivity compared with native Escherichia coli preparations, but a subset of patients develop hypersensitivity to the Erwinia enzyme. A DP lot that had subvisible particulate counts on the upper end of the measurement range by both LO and FIM had the same incidence of allergic hypersensitivity in clinical experience as lots at all levels of observed subvisible particulate content, suggesting that the presence of L-asparaginase subvisible particulates is not important with respect to allergic response.
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Affiliation(s)
- David Gervais
- Microbiology Services, Development and Production, Public Health England, Porton Down, Wiltshire, Salisbury, SP4 0JG, UK,
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A prospective study on drug monitoring of PEGasparaginase and Erwinia asparaginase and asparaginase antibodies in pediatric acute lymphoblastic leukemia. Blood 2014; 123:2026-33. [PMID: 24449211 DOI: 10.1182/blood-2013-10-534347] [Citation(s) in RCA: 169] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study prospectively analyzed the efficacy of very prolonged courses of pegylated Escherichia coli asparaginase (PEGasparaginase) and Erwinia asparaginase in pediatric acute lymphoblastic leukemia (ALL) patients. Patients received 15 PEGasparaginase infusions (2500 IU/m(2) every 2 weeks) in intensification after receiving native E coli asparaginase in induction. In case of allergy to or silent inactivation of PEGasparaginase, Erwinia asparaginase (20 000 IU/m(2) 2-3 times weekly) was given. Eighty-nine patients were enrolled in the PEGasparaginase study. Twenty (22%) of the PEGasparaginase-treated patients developed an allergy; 7 (8%) showed silent inactivation. The PEGasparaginase level was 0 in all allergic patients (grade 1-4). Patients without hypersensitivity to PEGasparaginase had serum mean trough levels of 899 U/L. Fifty-nine patients were included in the Erwinia asparaginase study; 2 (3%) developed an allergy and none silent inactivation. Ninety-six percent had at least 1 trough level ≥100 U/L. The serum asparagine level was not always completely depleted with Erwinia asparaginase in contrast to PEGasparaginase. The presence of asparaginase antibodies was related to allergies and silent inactivation, but with low specificity (64%). Use of native E coli asparaginase in induction leads to high hypersensitivity rates to PEGasparaginase in intensification. Therefore, PEGasparaginase should be used upfront in induction, and we suggest that the dose could be lowered. Switching to Erwinia asparaginase leads to effective asparaginase levels in most patients. Therapeutic drug monitoring has been added to our ALL-11 protocol to individualize asparaginase therapy.
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[Update on L-asparaginase treatment in paediatrics]. An Pediatr (Barc) 2013; 79:329.e1-329.e11. [PMID: 23727426 DOI: 10.1016/j.anpedi.2013.03.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 03/19/2013] [Accepted: 03/20/2013] [Indexed: 11/22/2022] Open
Abstract
L-asparaginase (L-ASP) is one of the cornerstones of the treatment of acute lymphoblastic leukemia and non-Hodgkin lymphoma. It is an enzyme of bacterial origin capable of transforming L-asparagine to aspartic acid. The extracellular depletion of L-asparagine inhibits protein synthesis in lymphoblasts, inducing their apoptosis. Numerous studies have demonstrated that treatment with L-ASP improves survival of patients, but there are clear differences in the characteristics of the three currently available formulations. This article reviews the dosage, activity and side effects of the two L-ASP derived from Escherichia coli (native and pegylated), and the one derived from Erwinia chrysanthemi (Erwinia ASP). Despite its indisputable indication over the past50 years, there are still many points of contention, and its use is still marked by the side effects of the inhibition of protein synthesis. The short half-life of native forms, and the most frequently used parenteral administration by intramuscular injections, affects the quality of life of the patients. Therefore, recent studies claim to evaluate alternatives, such as the formulation of longer half-life pegylated L-ASP, and the use of intravenous formulations. There are encouraging results to date with both preparations. Still, further studies are needed to establish which should be the formulation and frontline indicated route of administration, optimal dosing, and management of adverse effects.
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Salzer W, Seibel N, Smith M. Erwinia asparaginase in pediatric acute lymphoblastic leukemia. Expert Opin Biol Ther 2012; 12:1407-14. [DOI: 10.1517/14712598.2012.718327] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Anti–Escherichia coli asparaginase antibody levels determine the activity of second-line treatment with pegylated E coli asparaginase: a retrospective analysis within the ALL-BFM trials. Blood 2011; 118:5774-82. [DOI: 10.1182/blood-2011-07-367904] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Hypersensitivity reactions limit the use of the antileukemic enzyme asparaginase (ASE). We evaluated Ab levels against Escherichia coli ASE and ASE activity in 1221 serum samples from 329 patients with acute lymphoblastic leukemia who had received ASE treatment according to the ALL-BFM 2000 or the ALL-REZ BFM 2002 protocol for primary or relapsed disease. ASE activity during first-line treatment with native E coli ASE and second-line treatment with pegylated E coli ASE was inversely related to anti–E coli ASE Ab levels (P < .0001; Spearman rank order correlation). An effect on ASE activity during second-line treatment with pegylated E coli ASE was, however, only observed when anti–E coli ASE Ab levels were high (> 200 AU/mL). In the presence of moderate or intermediate Ab levels (6.25-200 AU/mL) the switch from native to pegylated E coli ASE resulted in a significant increase of ASE activity above the threshold of 100 U/L (P < .05). Erwinia chrysanthemi ASE activity was not correlated with anti–E coli ASE Ab levels. Erwinia ASE was found to be the best ASE alternative if Ab levels against E coli ASE exceed 200 AU/mL. This retrospective analysis is the first to describe the relationship between the level of anti–E coli ASE Abs and serum activity of pegylated E coli ASE used second-line after native E coli ASE. These studies are registered at http://clinicaltrials.org as NTC00430118 and NCT00114348.
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Pieters R, Hunger SP, Boos J, Rizzari C, Silverman L, Baruchel A, Goekbuget N, Schrappe M, Pui CH. L-asparaginase treatment in acute lymphoblastic leukemia: a focus on Erwinia asparaginase. Cancer 2010; 117:238-49. [PMID: 20824725 DOI: 10.1002/cncr.25489] [Citation(s) in RCA: 410] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 05/20/2010] [Accepted: 05/20/2010] [Indexed: 01/19/2023]
Abstract
Asparaginases are a cornerstone of treatment protocols for acute lymphoblastic leukemia (ALL) and are used for remission induction and intensification treatment in all pediatric regimens and in the majority of adult treatment protocols. Extensive clinical data have shown that intensive asparaginase treatment improves clinical outcomes in childhood ALL. Three asparaginase preparations are available: the native asparaginase derived from Escherichia coli (E. coli asparaginase), a pegylated form of this enzyme (PEG-asparaginase), and a product isolated from Erwinia chrysanthemi, ie, Erwinia asparaginase. Clinical hypersensitivity reactions and silent inactivation due to antibodies against E. coli asparaginase, lead to inactivation of E. coli asparaginase in up to 60% of cases. Current treatment protocols include E. coli asparaginase or PEG-asparaginase for first-line treatment of ALL. Typically, patients exhibiting sensitivity to one formulation of asparaginase are switched to another to ensure they receive the most efficacious treatment regimen possible. Erwinia asparaginase is used as a second- or third-line treatment in European and US protocols. Despite the universal inclusion of asparaginase in such treatment protocols, debate on the optimal formulation and dosage of these agents continues. This article provides an overview of available evidence for optimal use of Erwinia asparaginase in the treatment of ALL.
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Affiliation(s)
- Rob Pieters
- Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.
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37
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Thomas X, Cannas G, Chelghoum Y, Gougounon A. Alternatives thérapeutiques à la L-asparaginase native dans le traitement de la leucémie aiguë lymphoblastique de l'adulte. Bull Cancer 2010; 97:1105-1117. [DOI: 10.1684/bdc.2010.1168] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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38
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Zalewska-Szewczyk B, Andrzejewski W, Młynarski W, Jedrychowska-Dańska K, Witas H, Bodalski J. The anti-asparagines antibodies correlate withl-asparagines activity and may affect clinical outcome of childhood acute lymphoblastic leukemia. Leuk Lymphoma 2009; 48:931-6. [PMID: 17487737 DOI: 10.1080/10428190701292049] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The primary aim of the study was to evaluate the importance of anti-asparaginase antibodies for l-asparaginase activity in children with standard and medium risk acute lymphoblastic leukemia (ALL). Forty-seven children with newly diagnosed ALL were included into the prospective study. Enzyme activity and the presence of anti-asparaginase antibodies (IgG and IgM class) were determined. Anti-asparaginase antibodies were identified in 13/47 (IgM class) and 10/47 (IgG class) patients in the induction and in 19/47 (IgM class) and 20/47 (IgG class) patients in the reinduction phase of treatment. The enzyme activity was lower in patients that were positive for anti-asparaginase antibodies, especially in reinduction phase (median 37 (20 - 180) vs 355 (141 - 499), p = 0.001). An association between anti-asparaginase antibodies and the allergic reaction to the drug was found. Besides, the children who developed anti-asparaginase antibodies in the induction phase of treatment showed lower event-free survival as well as overall survival in comparison with children without antibodies. Since our study was carried out in a small number of patients, this observation is only speculative and needs to be confirmed by a further study on a larger sample size, with multivariable analysis. However, our data suggest that L-asparaginase activity together with anti-asparaginase antibodies measurements may become useful for effective therapy of ALL.
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39
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The cross-reactivity of anti-asparaginase antibodies against different l-asparaginase preparations. Clin Exp Med 2009; 9:113-6. [DOI: 10.1007/s10238-008-0026-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Accepted: 10/31/2008] [Indexed: 11/26/2022]
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40
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Mann G, Steiner M, Attarbaschi A. Clinical significance of anti-asparaginase antibodies in childhood acute lymphoblastic leukemia. Leuk Lymphoma 2007; 48:849-50. [PMID: 17487724 DOI: 10.1080/10428190701305957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- G Mann
- St. Anna Children's Hospital, Vienna, Austria.
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41
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Avramis VI, Panosyan EH. Pharmacokinetic/pharmacodynamic relationships of asparaginase formulations: the past, the present and recommendations for the future. Clin Pharmacokinet 2005; 44:367-93. [PMID: 15828851 DOI: 10.2165/00003088-200544040-00003] [Citation(s) in RCA: 169] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The discovery of the tumour-inhibitory properties of asparaginase began 50 years ago with the observation that guinea-pig serum-treated lymphoma-bearing mice underwent rapid and often complete regression. Soon afterwards, the asparaginase of bacterial origin was isolated. The asparaginases of bacterial origin induce anti-asparaginase neutralising antibodies in a large proportion of patients (44-60%), thus negating the specific enzymatic activity and resulting in failure of the target amino acid deamination in serum. There is immunological cross-reaction between the antibodies against various formulations of native Escherichia coli-asparaginase and polyethylene glycol (PEG)-asparaginases, but not to Erwinia asparaginase, as suggested by laboratory preclinical findings. This evidence was strongly inferred from the interim analyses in the Children's Cancer Group (CCG)-1961 study. Thus, anti-E. coli or PEG-asparaginase antibodies seropositive patients may benefit from the Erwinia asparaginase. The inter-relationships between asparaginase activity, asparagine (ASN) and glutamine deamination remain largely unexplored in patients. Studies have shown that ASN depletion is insufficient to induce apoptosis in T lymphoblasts in vitro and that the inhibitory concentration of CEM T-cell line is correlated with the asparaginase concentration responsible for 50% glutamine deamination. The optimal catalysis of ASN and glutamine deamination in serum by asparaginase induces apoptosis of leukaemic lymphoblasts. The percentage of ASN and glutamine deamination was predicted by asparaginase activity. Asparaginase activity of 0.1 IU/mL provided insufficient depletion of both amino acids in high-risk acute lymphoblastic leukaemia (ALL) patients. With increasing glutamine deamination, mean asparaginase activities and percentages of post-treatment samples with effective ASN depletion (<3 micromol/L) increase. Both glutamine and ASN deamination are predicted by asparaginase activity. Further population analyses resulted in identification of sigmoid relationships between asparaginase levels and post-treatment glutamine and ASN deamination.Furthermore, pharmacodynamic analyses strongly suggested that >/=90% deamination of glutamine must occur before optimal ASN deamination takes place, due to the de novo ASN biosynthesis by the liver. These pharmacodynamic results from the best-fit population pharmacokinetic/pharmacodynamic model obtained from nonlinear mixed effects model pharmacodynamic analyses for standard-risk ALL patients are similar. These analyses produced the following results: (i) asparaginase activity </=0.4 IU/mL provided insufficient deamination of ASN, whereas >0.4-0.7 IU/mL was required for optimal (90%) ASN and glutamine deamination; and (ii) deamination of glutamine is dependent on asparaginase activity and it correlates with enhanced serum ASN deamination. Thus, glutamine deamination enhances asparaginase efficacy in ALL patients. Deamination of ASN >/=90% of control or ASN concentration <3 micromol/L may be associated with improved survival in this subset of patients. Our findings support the pharmacodynamic mechanism of PEG-asparaginase for disease control in ALL patients. These results taken together strongly support new experimental approaches for application of population pharmacokinetic/pharmacodynamic analyses to further enhance survival of leukaemia patients.
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Affiliation(s)
- Vassilios I Avramis
- Division of Hematology/Oncology, Department of Pediatrics, Keck School of Medicine, University of Southern California, Childrens Hospital Los Angeles, Los Angeles, California, USA.
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Zalewska-Szewczyk B, Andrzejewski W, Bodalski J. Development of anti-asparaginase antibodies in childhood acute lymphoblastic leukemia. Pediatr Blood Cancer 2004; 43:600-2. [PMID: 15382279 DOI: 10.1002/pbc.20064] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
L-asparaginase is a basic agent of antileukemic therapy, but allergic reactions against the drug and the development of anti-asparaginase antibodies are significant side-effects. The aim of our study was to estimate the presence of anti-asparaginase antibodies and to correlate the results with clinically apparent allergic reactions and with L-asparaginase activity during the treatment. We examined 13 children with newly diagnosed acute lymphoblastic leukemia (ALL), treated according to the Polish Pediatric Leukemia/Lymphoma Group protocol, based on ALL-BFM 95. Enzyme activity was estimated in serum samples, collected before each L-asparaginase administration, using the photometrical method. Anti-asparaginase antibody concentration was measured by enzyme-linked immunosorbent assay (ELISA) at the two time points: at the last day of L-asparaginase treatment in the induction and the reinduction phase. The mean L-asparaginase activity was 273 IU/L in the induction phase; no anti-asparaginase antibodies in this phase of treatment were found. The mean L-asparaginase activity was 425 IU/L in the reinduction phase of treatment; in five children anti-asparaginase antibodies were detected. In four of these five children low L-asparaginase activity and/or allergic reactions against L-asparaginase were noted. Our observations suggest a correlation between the presence of anti-asparaginase antibodies and L-asparaginase activity in childhood ALL.
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43
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Pinheiro JPV, Boos J. The best way to use asparaginase in childhood acute lymphatic leukaemia--still to be defined? Br J Haematol 2004; 125:117-27. [PMID: 15059133 DOI: 10.1111/j.1365-2141.2004.04863.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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44
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Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2002; 11:727-42. [PMID: 12512251 DOI: 10.1002/pds.664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Thomas DA, Cortes J, Kantarjian HM. New agents in the treatment of acute lymphocytic leukaemia. Best Pract Res Clin Haematol 2002; 15:771-90. [PMID: 12617876 DOI: 10.1053/beha.2003.0234] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The overall prognosis of adult patients with acute lymphocytic leukaemia (ALL) has improved significantly over the past few decades. Combined modality strategies (e.g. chemotherapy used with targeted therapies such as monoclonal antibodies or tyrosine kinase inhibitors) may improve long-term disease-free survival. Still, most patients succumb to complications of disease progression, with current long-term disease-free survival rates of 30-45% overall. Thus, either new strategies or refinements of old ones are needed to improve the long-term prognosis. An increasing number of unique active new chemotherapeutic and biological agents are available for study. This chapter reviews new agents with the potential to be incorporated into therapeutic strategies for the treatment of ALL.
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Affiliation(s)
- Deborah A Thomas
- Department of Leukemia, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Unit 428, Houston, TX, 77030, USA.
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