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Humphries J, Fletcher NL, Sonderegger SE, Bell CA, Kempe K, Thurecht KJ. Mitigating the Effects of Persistent Antipolymer Immune Reactions in Nanomedicine: Evaluating Materials-Based Approaches Using Molecular Imaging. ACS NANO 2024. [PMID: 39037055 DOI: 10.1021/acsnano.4c07317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
Poly(ethylene glycol) (PEG) is a hydrophilic polymer ubiquitously used in both medical and nonmedical goods. Recent debate surrounding the observed stimulation of immune responses against PEG has spurred the development of materials that may be suitable replacements for this common polymeric component. The underlying view is that these alternative materials with comparable physicochemical properties can overcome the unfavorable and unpredictable effects of antibody-mediated clearance by being chemically, and therefore antigenically, distinct from PEG. However, this hypothesis has not been thoroughly tested in any defined manner, and the immune response observed against PEG has not been rigorously investigated within the context of these emerging materials. Consequently, it remains unclear whether immunity-mediated discrimination between polymeric entities even occurs in vivo and, if this is the case, how it may be exploited. In this study, we utilize positron emission tomography-computed tomography molecular imaging in mice immunized to develop specific antibody responses to PEG and an alternative polymer in order to visualize and quantify the influence of antipolymer antibodies on the biodistribution of synthetic polymers in vivo as a function of immunization status. Under the conditions of this experiment, mice could be primed to exhibit both innate and adaptive immunity to all of the polymer systems to which they were exposed. We demonstrate that alternating between chemically disparate polymers is a viable approach to extend their efficacy when antipolymer humoral immune responses arise.
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Affiliation(s)
- James Humphries
- Centre for Advanced Imaging (CAI) and Australian Institute for Bioengineering and Nanotechnology, ARC Training Centre for Innovation in Biomedical Imaging Technology, The University of Queensland, St. Lucia, Queensland 4072, Australia
| | - Nicholas L Fletcher
- Centre for Advanced Imaging (CAI) and Australian Institute for Bioengineering and Nanotechnology, ARC Training Centre for Innovation in Biomedical Imaging Technology, The University of Queensland, St. Lucia, Queensland 4072, Australia
| | - Stefan E Sonderegger
- Centre for Advanced Imaging (CAI) and Australian Institute for Bioengineering and Nanotechnology, ARC Training Centre for Innovation in Biomedical Imaging Technology, The University of Queensland, St. Lucia, Queensland 4072, Australia
| | - Craig A Bell
- Centre for Advanced Imaging (CAI) and Australian Institute for Bioengineering and Nanotechnology, ARC Training Centre for Innovation in Biomedical Imaging Technology, The University of Queensland, St. Lucia, Queensland 4072, Australia
| | - Kristian Kempe
- Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria 3052, Australia
- Materials Science and Engineering, Monash University, Clayton, Victoria 3800, Australia
| | - Kristofer J Thurecht
- Centre for Advanced Imaging (CAI) and Australian Institute for Bioengineering and Nanotechnology, ARC Training Centre for Innovation in Biomedical Imaging Technology, The University of Queensland, St. Lucia, Queensland 4072, Australia
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2
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Dam M, Centanni M, Friberg LE, Centanni D, Karlsson MO, Stensig Lynggaard L, Johannsdottir IM, Wik HS, Malmros J, Vaitkeviciene GE, Griskevicius L, Hallböök H, Jónsson ÓG, Overgaard U, Schmiegelow K, Hansen SN, Heyman M, Albertsen BK. Increase in peg-asparaginase clearance as a predictor for inactivation in patients with acute lymphoblastic leukemia. Leukemia 2024; 38:712-719. [PMID: 38287133 PMCID: PMC10997509 DOI: 10.1038/s41375-024-02153-6] [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: 11/15/2023] [Revised: 01/05/2024] [Accepted: 01/10/2024] [Indexed: 01/31/2024]
Abstract
Asparaginase is an essential component of acute lymphoblastic leukemia (ALL) therapy, yet its associated toxicities often lead to treatment discontinuation, increasing the risk of relapse. Hypersensitivity reactions include clinical allergies, silent inactivation, or allergy-like responses. We hypothesized that even moderate increases in asparaginase clearance are related to later inactivation. We therefore explored mandatory monitoring of asparaginase enzyme activity (AEA) in patients with ALL aged 1-45 years treated according to the ALLTogether pilot protocol in the Nordic and Baltic countries to relate mean AEA to inactivation, to build a pharmacokinetic model to better characterize the pharmacokinetics of peg-asparaginase and assess whether an increased clearance relates to subsequent inactivation. The study analyzed 1631 real-time AEA samples from 253 patients, identifying inactivation in 18.2% of the patients. This inactivation presented as mild allergy (28.3%), severe allergy (50.0%), or silent inactivation (21.7%). A pharmacokinetic transit compartment model was used to describe AEA-time profiles, revealing that 93% of patients with inactivation exhibited prior increased clearance, whereas 86% of patients without hypersensitivity maintained stable clearance throughout asparaginase treatment. These findings enable prediction of inactivation and options for either dose increments or a shift to alternative asparaginase formulations to optimize ALL treatment strategies.
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Affiliation(s)
- Merete Dam
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Lena E Friberg
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | | | | | - Line Stensig Lynggaard
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Johan Malmros
- Astrid Lindgren Children's Hospital, Karolinska University Hospital and Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Helene Hallböök
- Dept Of Medical Sciences, Haematology, Uppsala University, Uppsala, Sweden
| | | | - Ulrik Overgaard
- Department of Haematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Mats Heyman
- Astrid Lindgren Children's Hospital, Karolinska University Hospital and Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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3
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Tan YQ, Loh CK, Makpol S. A Review of L-Asparaginase Hypersensitivity in Paediatric Acute Lymphoblastic Leukaemia Patients with Regard to the Measurement of Anti-Asparaginase Antibodies and Their Genetic Predisposition. Malays J Med Sci 2023; 30:40-51. [PMID: 37928798 PMCID: PMC10624446 DOI: 10.21315/mjms2023.30.5.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 05/22/2022] [Indexed: 11/07/2023] Open
Abstract
L-asparaginase is effective as part of the first line childhood acute lymphoblastic leukaemia (ALL) treatment regimen but suffers the risk of antibody production causing immune-mediated sequelae. This article aimed to describe the clinical implication of L-asparaginase hypersensitivity and review the types of antibodies and genetic polymorphisms contributing to it. Clinical or subclinical L-asparaginase hypersensitivity may lead to suboptimum therapeutic effect and jeopardise the clinical outcome in ALL children. Anti-asparaginase antibodies immunoglobulin (Ig)G, IgM and IgE were identified in the L-asparaginase hypersensitivities. Enzyme-linked immunosorbent assay (ELISA) is commonly used to quantify the IgG and IgM levels. The role of IgE in mediating L-asparaginase hypersensitivity is contradictory. Moreover, the presence of antibodies may not necessarily correlate inversely with the L-asparaginase efficacies in some studies. Patients with specific genetic variants have been shown to be more susceptible to clinical hypersensitivity of L-asparaginase. With the advance of technology, gene polymorphisms have been identified among Caucasians using whole-genome or exon sequencing, but the evidence is scanty among Asians. There is lack of pre-clinical study models that could help in understanding the pathophysiological pathway co-relating the gene expression and anti-asparaginase antibody formation. In conclusion, future research studies are required to fill the current gap in understanding the immune mediated reactions towards L-asparaginase upon its administration and its potential impact to the disease outcome.
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Affiliation(s)
- Yan Qi Tan
- Department of Paediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - C-Khai Loh
- Department of Paediatrics, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Suzana Makpol
- Department of Biochemistry, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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4
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Talleur AC, Pui CH, Karol SE. What is Next in Pediatric B-cell Precursor Acute Lymphoblastic Leukemia. LYMPHATICS 2023; 1:34-44. [PMID: 38269058 PMCID: PMC10804398 DOI: 10.3390/lymphatics1010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Cure rates now exceed 90% in many contemporary trials for children with B-cell acute lymphoblastic leukemia (ALL). However, treatment remains suboptimal and therapy is toxic for all patients. New treatment options potentially offer the chance to reduce both treatment resistance and toxicity. Here, we review recent advances in ALL diagnostics, chemotherapy, and immunotherapy. In addition to describing recently published results, we also attempt to project the impact of these new developments into the future to imagine what B-ALL therapy may look like in the next few years.
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Affiliation(s)
- Aimee C Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Seth E Karol
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
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5
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Chong ZX, Ho WY, Yeap SK. Delineating the tumour-regulatory roles of EYA4. Biochem Pharmacol 2023; 210:115466. [PMID: 36849065 DOI: 10.1016/j.bcp.2023.115466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 02/27/2023]
Abstract
Eyes absent homolog 4 (EYA4) is a protein that regulates many vital cellular processes and organogenesis pathways. It possesses phosphatase, hydrolase, and transcriptional activation functions. Mutations in the Eya4 gene can cause sensorineural hearing loss and heart disease. In most non-nervous system cancers such as those of the gastrointestinal tract (GIT), hematological and respiratory systems, EYA4 acts as a putative tumor suppressor. However, in nervous system tumors such as glioma, astrocytoma, and malignant peripheral nerve sheath tumor (MPNST), it plays a putative tumor-promoting role. EYA4 interacts with various signaling proteins of the PI3K/AKT, JNK/cJUN, Wnt/GSK-3β, and cell cycle pathways to exert its tumor-promoting or tumor-suppressing effect. The tissue expression level and methylation profiles of Eya4 can help predict the prognosis and anti-cancer treatment response among cancer patients. Targeting and altering Eya4 expression and activity could be a potential therapeutic strategy to suppress carcinogenesis. In conclusion, EYA4 may have both putative tumor-promoting and tumor-suppressing roles in different human cancers and has the potential to serve as a prognostic biomarker and therapeutic agent in various cancer types.
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Affiliation(s)
- Zhi Xiong Chong
- Faculty of Science and Engineering, University of Nottingham Malaysia, 43500 Semenyih, Selangor, Malaysia.
| | - Wan Yong Ho
- Faculty of Science and Engineering, University of Nottingham Malaysia, 43500 Semenyih, Selangor, Malaysia.
| | - Swee Keong Yeap
- China-ASEAN College of Marine Sciences, Xiamen University Malaysia, 43900 Sepang, Selangor, Malaysia.
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6
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Cecconello DK, Rechenmacher C, Silva KADS, Scherer FF, Prates TDB, Marques RF, Daudt LE, Michalowski MB. Follow our path with asparaginase activity: one technique, but different uses in clinical practice. Exp Hematol Oncol 2022; 11:86. [PMCID: PMC9635150 DOI: 10.1186/s40164-022-00351-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Acute lymphoblastic leukemia is the most common childhood malignancy. One of the drugs used in the treatment is Asparaginase, and monitoring of its activity levels enables better outcomes. Since 2018, our laboratory has been working to establish a regular analysis of activity. This implementation allowed to qualify care by detecting silent inactivation and also establishing desensitization as a safe way to overcome the lack of Erwinia. We were able to monitor children aged 0 to 18 years who were being treated with PEG-ASNase. The activity was assessed on days 7 (90 samples) and 14 (52 samples) after ASNase infusions. 142 samples were analyzed. 95.7% reached an adequate activity level (≥ 0.1 IU/mL). Patients treated with ASNase can develop allergic reactions. With the activity monitoring, is possible to circumvent situations like these and implement desensitization protocols for patients who had clinical hypersensitivity without inactivation. Desensitization induces temporary unresponsiveness to drug antigens, allowing the patients to proceed with the prescribed chemotherapy. We have received samples from four patients being treated with different desensitization protocols. Patients tolerated the protocols well. Only one had a grade 2 reaction during the infusion and activity < 0.1 IU/mL, which resulted in the switch to Erwinia. The dose adaptation is a possible and more recent use of ASNase monitoring and we were able to confirm the feasibility of PEG-ASNase desensitization protocols.
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Affiliation(s)
- Daiane Keller Cecconello
- grid.8532.c0000 0001 2200 7498Post Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Translational Pediatrics Laboratory, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Ciliana Rechenmacher
- grid.8532.c0000 0001 2200 7498Post Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Translational Pediatrics Laboratory, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Klerize Anecely de Souza Silva
- grid.8532.c0000 0001 2200 7498Post Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS Brazil
| | - Fernanda Fetter Scherer
- grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Thomas Dal Bem Prates
- grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Rebeca Ferreira Marques
- grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Liane Esteves Daudt
- grid.8532.c0000 0001 2200 7498Post Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Translational Pediatrics Laboratory, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Mariana Bohns Michalowski
- grid.8532.c0000 0001 2200 7498Post Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Translational Pediatrics Laboratory, Experimental Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil ,grid.414449.80000 0001 0125 3761Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
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7
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Skipper MT, Rank CU, Jarvis KB, Lynggaard LS, Andrés‐Jensen L, Quist‐Paulsen P, Semaskeviciene R, Hallböök H, Waitiovaara‐Kautto U, Ranta S, Trakymiene S, Abrahamsson J, Huttunen P, Albertsen BK, Schmiegelow K, Tuckuviene R. Cerebral sinovenous thrombosis and asparaginase re‐exposure in patients aged 1–45 years with acute lymphoblastic leukaemia: A NOPHO ALL2008 study. EJHAEM 2022; 3:754-763. [PMID: 36051071 PMCID: PMC9422014 DOI: 10.1002/jha2.484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 11/22/2022]
Abstract
Cerebral sinovenous thrombosis (CSVT) is a serious complication during asparaginase therapy in patients with acute lymphoblastic leukaemia (ALL). We identified 46 patients with CSVT among 2651 patients (1‒45 years) treated according to the Nordic Society of Paediatric Haematology and Oncology (NOPHO) ALL2008 protocol between 2008 and 2018. CSVT cases were prospectively registered in the NOPHO database with retrospective updates. We examined the frequency of asparaginase re‐exposure after CSVT, potential factors associated with asparaginase truncation, and sequelae after CSVT. This work was supported by the Danish Cancer Society and the Danish Childhood Cancer Foundation. The 2.5‐year cumulative incidence of CSVT was 1.9% (95% confidence interval 1.4%–2.5%). The majority of patients (74%, n = 31) were re‐exposed to asparaginase (with low‐molecular‐weight heparin coverage), one of whom had a second CSVT, without neurological sequelae. Patients re‐exposed to asparaginase were earlier in ALL treatment and lacked more asparaginase doses than non‐re‐exposed patients at CSVT diagnosis (median 50 vs. 81 days, p = 0.03; mean 11.2 vs. 8.4 asparaginase doses, p = 0.04). No other examined factors had an impact on asparaginase re‐exposure. At the last follow‐up (median 4.5 years after CSVT), 61% of patients had normal neurological status, and 57% had complete recanalisation of CSVT, with no significant difference between patients re‐exposed and non‐re‐exposed to asparaginase. Our results indicate that re‐exposure to asparaginase is safe after CSVT during anticoagulation.
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Affiliation(s)
- Mette Tiedemann Skipper
- Department of Paediatrics and Adolescent Medicine Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Cecilie Utke Rank
- Department of Paediatrics and Adolescent Medicine Rigshospitalet University Hospital Copenhagen Denmark
| | | | - Line Stensig Lynggaard
- Department of Paediatrics and Adolescent Medicine Aarhus University Hospital Aarhus Denmark
| | - Liv Andrés‐Jensen
- Department of Paediatrics and Adolescent Medicine Rigshospitalet University Hospital Copenhagen Denmark
| | | | - Ruta Semaskeviciene
- Oncology and Transfusion Medicine Centre Vilnius University Hospital Santaros Klinikos Vilnius Lithuania
| | - Helene Hallböök
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Ulla Waitiovaara‐Kautto
- Department of Haematology Comprehensive Cancer Centre Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Susanna Ranta
- Astrid Lindgren Children's Hospital Karolinska University Hospital and Childhood Cancer Research Unit Department of Women's and Children's Health Karolinska Institute Stockholm Sweden
| | - Sonata Trakymiene
- Clinic of Children's Diseases Faculty of Medicine Vilnius University Vilnius University Hospital Santaros Klinikos Vilnius Lithuania
| | - Jonas Abrahamsson
- Department of Paediatrics Institution of Clinical Science Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Pasi Huttunen
- Department of Paediatric Haematology Oncology and SCT New Children's Hospital Helsinki University Hospital Helsinki Finland
| | - Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine Rigshospitalet University Hospital Copenhagen Denmark
| | - Ruta Tuckuviene
- Department of Paediatrics and Adolescent Medicine Rigshospitalet University Hospital Copenhagen Denmark
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8
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Sidhu J, Masurekar AN, Gogoi MP, Fong C, Ioannou T, Lodhi T, Parker C, Liu J, Kirkwood AA, Moorman AV, Das K, Goulden NJ, Vora A, Saha V, Krishnan S. Activity and toxicity of intramuscular 1000 iu/m 2 polyethylene glycol-E. coli L-asparaginase in the UKALL 2003 and UKALL 2011 clinical trials. Br J Haematol 2022; 198:142-150. [PMID: 35348200 PMCID: PMC9314843 DOI: 10.1111/bjh.18158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 11/26/2022]
Abstract
In successive UK clinical trials (UKALL 2003, UKALL 2011) for paediatric acute lymphoblastic leukaemia (ALL), polyethylene glycol‐conjugated E. coli L‐asparaginase (PEG‐EcASNase) 1000 iu/m2 was administered intramuscularly with risk‐stratified treatment. In induction, patients received two PEG‐EcASNase doses, 14 days apart. Post‐induction, non‐high‐risk patients (Regimens A, B) received 1–2 doses in delayed intensification (DI) while high‐risk Regimen C patients received 6–10 PEG‐EcASNase doses, including two in DI. Trial substudies monitored asparaginase (ASNase) activity, ASNase‐related toxicity and ASNase‐associated antibodies (total, 1112 patients). Median (interquartile range) trough plasma ASNase activity (14 ± 2 days post dose) following first and second induction doses and first DI dose was respectively 217 iu/l (144–307 iu/l), 265 iu/l (165–401 iu/l) and 292 iu/l (194–386 iu/l); 15% (138/910) samples showed subthreshold ASNase activity (<100 iu/l) at any trough time point. Older age was associated with lower (regression coefficient −9.5; p < 0.0001) and DI time point with higher ASNase activity (regression coefficient 29.9; p < 0.0001). Clinical hypersensitivity was observed in 3.8% (UKALL 2003) and 6% (UKALL 2011) of patients, and in 90% or more in Regimen C. A 7% (10/149) silent inactivation rate was observed in UKALL 2003. PEG‐EcASNase schedule in UKALL paediatric trials is associated with low toxicity but wide interpatient variability. Therapeutic drug monitoring potentially permits optimisation through individualised asparaginase dosing.
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Affiliation(s)
- Jasmeet Sidhu
- Tata Translational Cancer Research Centre, Tata Medical Center, Kolkata, India.,Department of Paediatric Haematology and Oncology, Tata Medical Center, Kolkata, India
| | - Ashish Narayan Masurekar
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Manash Pratim Gogoi
- Tata Translational Cancer Research Centre, Tata Medical Center, Kolkata, India
| | - Caroline Fong
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Tasos Ioannou
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Taha Lodhi
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Catriona Parker
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Jizhong Liu
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Amy A Kirkwood
- Cancer Research UK & UCL Cancer Trials Centre, UCL Cancer Institute, University College, London, UK
| | - Anthony V Moorman
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Kiranmoy Das
- Interdisciplinary Statistical Research Unit, Indian Statistical Institute, Kolkata, India
| | - Nicholas J Goulden
- Department of Haematology, Great Ormond Street Hospital for Children, London, UK
| | - Ajay Vora
- Department of Haematology, Great Ormond Street Hospital for Children, London, UK
| | - Vaskar Saha
- Tata Translational Cancer Research Centre, Tata Medical Center, Kolkata, India.,Department of Paediatric Haematology and Oncology, Tata Medical Center, Kolkata, India.,Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Shekhar Krishnan
- Tata Translational Cancer Research Centre, Tata Medical Center, Kolkata, India.,Department of Paediatric Haematology and Oncology, Tata Medical Center, Kolkata, India.,Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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9
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Impact of Antibodies Against Polyethylene Glycol on the Pharmacokinetics of PEGylated Asparaginase in Children with Acute Lymphoblastic Leukaemia: A Population Pharmacokinetic Approach. Eur J Drug Metab Pharmacokinet 2021; 47:187-198. [PMID: 34878584 PMCID: PMC8917038 DOI: 10.1007/s13318-021-00741-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2021] [Indexed: 11/04/2022]
Abstract
Background and Objectives Besides allergic reactions, antibodies against polyethylene glycol (PEG) have been associated with reduced PEG-asparaginase (PEG-ASNase) activity. Population pharmacokinetics (popPK) allow for an in-depth investigation of the influence of anti-PEG antibodies on PEG-ASNase pharmacokinetics. Methods PEG-ASNase activity (6261 samples) and anti-PEG antibodies (2082/6412 samples prior to/post administration) in 1444 children with acute lymphoblastic leukaemia treated in the AIEOP-BFM ALL 2009 trial were evaluated. Patients received two doses of PEG-ASNase during induction (2500 U/m2, intravenous, biweekly) and a third dose during reinduction treatment. Anti-PEG IgG and IgM measured prior to and post administration were explored for their influence on the initial clearance of PEG-ASNase using a previously established popPK model. Categorical and continuous antibody data, including each isotype individually as well as in combination, were assessed. Results High pre-existing levels of anti-PEG antibodies increase the initial drug clearance. Analysed separately, both anti-PEG IgGprior and IgMprior were significant covariates; the stronger effect was observed for anti-PEG IgMprior. Hockey stick models best described the data. For anti-PEG IgMprior, each additional log unit above the estimated cut point was related to a 41.4% increase in initial clearance after the first dose in induction. Antibody levels below the cut point were not associated with an effect on clearance. The combination of both isotypes did not provide additional information compared to anti-PEG IgMprior alone. Antibody levels post administration were not associated with an effect on clearance. Conclusion Pre-existing antibodies against PEG-ASNase significantly increased the initial clearance in a subgroup of patients showing high antibody levels. (Trial registration: EU clinical trials register; EudraCT No: 2007-004270-43; first registered 23 October 2009.) Supplementary Information The online version contains supplementary material available at 10.1007/s13318-021-00741-w.
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10
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Tong WH. Comment on 'asparaginase activities during intensified treatment with pegylated E. coli asparaginase in adults with newly diagnosed acute lymphoblastic leukemia'. Leuk Lymphoma 2021; 63:509-510. [PMID: 34676805 DOI: 10.1080/10428194.2021.1992760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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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11
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Asparaginase Enzyme Activity Levels and Toxicity in Childhood Acute Lymphoblastic Leukemia: a NOPHO ALL2008 study. Blood Adv 2021; 6:138-147. [PMID: 34625787 PMCID: PMC8753199 DOI: 10.1182/bloodadvances.2021005631] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/01/2021] [Indexed: 01/19/2023] Open
Abstract
Overall asparaginase-associated toxicity and relapse were not significantly associated with increased asparaginase enzyme activity levels. The risk of pancreatitis and osteonecrosis were significantly associated with increasing asparaginase enzyme activity.
Asparaginase treatment is a mainstay in contemporary treatment of acute lymphoblastic leukemia (ALL), but substantial asparaginase-related toxicity may lead to jeopardized protocol compliance and compromises survival. We investigated the association between risk of asparaginase-associated toxicities (AspTox) and asparaginase enzyme activity (AEA) levels in 1155 children aged 1.0 to 17.9 years, diagnosed with ALL between July 2008 and March 2016, and treated according to the Nordic Society of Pediatric Hematology and Oncology (NOPHO) ALL2008 protocol. Patients with ≥2 blood samples for AEA measurement drawn 14 ± 2 days after asparaginase administration were included (6944 trough values). AEA was measurable (or >0 IU/L) in 955 patients, whereas 200 patients (17.3%) had asparaginase inactivation and few AspTox recorded. A time-dependent multiple Cox model of time to any first asparaginase-associated toxicity adjusted for sex and age was used. For patients with measurable AEA, we found a hazard ratio (HR) of 1.17 per 100 IU/L increase in median AEA (95% confidence interval [CI], 0.98-1.41; P = .09). For pancreatitis, thromboembolism, and osteonecrosis, the HRs were 1.40 (95% CI, 1.12-1.75; P = .002), 0.99 (95% CI, 0.70-1.40; P = .96), and 1.36 (95% CI, 1.04-1.77; P = .02) per 100 IU/L increase in median AEA, respectively. No significant decrease in the risk of leukemic relapse was found: HR 0.88 per 100 IU/L increase in AEA (95% CI, 0.66-1.16; P = .35). In conclusion, these results emphasize that overall AspTox and relapse are not associated with AEA levels, yet the risk of pancreatitis and osteonecrosis increases with increasing AEA levels.
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12
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Brigitha LJ, Pieters R, van der Sluis IM. How much asparaginase is needed for optimal outcome in childhood acute lymphoblastic leukaemia? A systematic review. Eur J Cancer 2021; 157:238-249. [PMID: 34536947 DOI: 10.1016/j.ejca.2021.08.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/13/2021] [Accepted: 08/13/2021] [Indexed: 10/20/2022]
Abstract
This review focuses on asparaginase, a key component of childhood acute lymphoblastic leukaemia (ALL) treatment since the 1970s. This review evaluates how much asparaginase is needed for optimal outcome in childhood ALL. We provide an overview of asparaginase dose intensity, i.e. duration of total cumulative exposure in weeks and level of exposure reflected by dose and/or asparaginase activity level, and the corresponding outcome. We systematically searched papers published between January 1990 and March 2021 in the PubMed and MEDLINE databases and included 20 papers. The level and duration of exposure were based on the pharmacokinetic profile of the drug and the assumption that trough asparaginase activity levels of ≥100 IU/L should be achieved for complete l-asparagine depletion. The statistical meta-analysis of outcomes was not performed because different outcome measures were used. The level of exposure was not associated with the outcome as long as therapeutic asparaginase activity levels of ≥100 IU/L were reached. Conflicting results were found in the randomised controlled trials, but all truncation studies showed that the duration of exposure (expressed as weeks of l-asparagine depletion) does affect the outcome; however, no clear cutoff for optimal exposure duration was determined. Optimal exposure duration will also depend on immunophenotype, (cyto)genetic subgroups, risk group stratification and backbone therapy.
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Affiliation(s)
- Leiah J Brigitha
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
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13
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Mesegué M, Alonso-Saladrigues A, Pérez-Jaume S, Comes-Escoda A, Dapena JL, Faura A, Conde N, Català A, Ruiz-Llobet A, Zapico-Muñiz E, Camós M, Rives S. Lower incidence of clinical allergy with PEG-asparaginase upfront versus the sequential use of native E. coli asparaginase followed by PEG-ASP in pediatric patients with acute lymphoblastic leukemia. Hematol Oncol 2021; 39:687-696. [PMID: 34397119 DOI: 10.1002/hon.2914] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 06/28/2021] [Accepted: 07/07/2021] [Indexed: 11/08/2022]
Abstract
Asparaginase (ASP) is an essential component for the acute lymphoblastic leukemia (ALL) treatment, but toxicities, such as allergy, frequently limit its use. Although the potentially lower PEG-ASP formulation immunogenicity, few studies with conflicting results have compared the allergy incidence between Escherichia coli-ASP and PEG-ASP in the same protocol. We aimed at comparing the allergy incidence in children receiving native E. coli-ASP versus PEG-ASP within the same clinical protocol (Spanish Society of Pediatric Hematology and Oncology ALL-SEHOP-PETHEMA 2013). One hundred and twenty-six children (1-19 years) diagnosed with ALL from 2013 to 2020 were included. Patients in group 1 received a sequential scheme of native E. coli-ASP 10,000 IU/m2 intramuscularly (IM) followed by PEG-ASP 1000 IU/m2 IM. Patients in group 2 received PEG-ASP 1000 IU/m2 IM upfront. Clinical allergy incidence was compared between both groups. Serum ASP activity (SAA) was measured in a subgroup of patients, and silent inactivation was recorded. The cumulative incidence of clinical allergy was significantly higher in group 1 (native followed by PEG-ASP) than in group 2 (PEG-ASP upfront), 24.7% versus 4.1% (p = 0.0085). Adequate ASP activity was achieved with PEG-ASP 1000 IU/m2 dose in most patients (median SAA 412.5 and 453.0 IU/L at days 7 and 14). The incidence of silent inactivation in PEG-ASP upfront patients was very low. PEG-ASP-used upfront was associated with a lower incidence of clinical allergy than that observed in the sequential use of native E. coli-ASP followed by PEG-ASP. PEG-ASP at 1000 IU/m2 was effective in achieving enough ASP activity in most patients.
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Affiliation(s)
- Montserrat Mesegué
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Anna Alonso-Saladrigues
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Sara Pérez-Jaume
- Developmental Tumor Biology Laboratory, Institut de Recerca Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Ariadna Comes-Escoda
- Oncohematology Unit, Pharmacy Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - José Luís Dapena
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Anna Faura
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Nuria Conde
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Albert Català
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Anna Ruiz-Llobet
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain
| | - Edgar Zapico-Muñiz
- Biochemistry Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Mireia Camós
- Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain.,Developmental Tumor Biology Laboratory, Institut de Recerca Sant Joan de Déu Barcelona, Barcelona, Spain.,Hematology Laboratory, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Susana Rives
- Pediatric Hematology and Oncology Departments, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Leukemia and other Pediatric Hemopathies, Developmental Tumor Biology Group, Institut de Recerca Hospital Sant Joan de Déu Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
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14
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Relapse risk following truncation of pegylated asparaginase in childhood acute lymphoblastic leukemia. Blood 2021; 137:2373-2382. [PMID: 33150360 DOI: 10.1182/blood.2020006583] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/04/2020] [Indexed: 11/20/2022] Open
Abstract
Truncation of asparaginase treatment due to asparaginase-related toxicities or silent inactivation (SI) is common and may increase relapse risk in acute lymphoblastic leukemia (ALL). We investigated relapse risk following suboptimal asparaginase exposure among 1401 children aged 1 to 17 years, diagnosed with ALL between July 2008 and February 2016, treated according to the Nordic Society of Pediatric Hematology and Oncology (NOPHO) ALL2008 protocol (including extended asparaginase exposure [1000 IU/m2 intramuscularly weeks 5-33]). Patients were included with delayed entry at their last administered asparaginase treatment, or detection of SI, and followed until relapse, death, secondary malignancy, or end of follow-up (median, 5.71 years; interquartile range, 4.02-7.64). In a multiple Cox model comparing patients with (n = 358) and without (n = 1043) truncated asparaginase treatment due to clinical toxicity, the adjusted relapse-specific hazard ratio (HR; aHR) was 1.33 (95% confidence interval [CI], 0.86-2.06; P = .20). In a substudy including only patients with information on enzyme activity (n = 1115), the 7-year cumulative incidence of relapse for the 301 patients with truncation of asparaginase treatment or SI (157 hypersensitivity, 53 pancreatitis, 14 thrombosis, 31 other, 46 SI) was 11.1% (95% CI, 6.9-15.4) vs 6.7% (95% CI, 4.7-8.6) for the 814 remaining patients. The relapse-specific aHR was 1.69 (95% CI, 1.05-2.74, P=.03). The unadjusted bone marrow relapse-specific HR was 1.83 (95% CI, 1.07-3.14, P=.03) and 1.86 (95% CI, 0.90- 3.87, P=.095) for any central nervous system relapse. These results emphasize the importance of therapeutic drug monitoring and appropriate adjustment of asparaginase therapy when feasible. This trial was registered at www.clinicaltrials.gov as #NCT03987542.
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15
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Rank CU, Lynggaard LS, Als-Nielsen B, Stock W, Toft N, Nielsen OJ, Frandsen TL, Tuckuviene R, Schmiegelow K. Prophylaxis of thromboembolism during therapy with asparaginase in adults with acute lymphoblastic leukaemia. Cochrane Database Syst Rev 2020; 10:CD013399. [PMID: 33038027 PMCID: PMC9831116 DOI: 10.1002/14651858.cd013399.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The risk of venous thromboembolism is increased in adults and enhanced by asparaginase-based chemotherapy, and venous thromboembolism introduces a secondary risk of treatment delay and premature discontinuation of key anti-leukaemic agents, potentially compromising survival. Yet, the trade-off between benefits and harms of primary thromboprophylaxis in adults with acute lymphoblastic leukaemia (ALL) treated according to asparaginase-based regimens is uncertain. OBJECTIVES: The primary objectives were to assess the benefits and harms of primary thromboprophylaxis for first-time symptomatic venous thromboembolism in adults with ALL receiving asparaginase-based therapy compared with placebo or no thromboprophylaxis. The secondary objectives were to compare the benefits and harms of different groups of primary systemic thromboprophylaxis by stratifying the main results per type of drug (heparins, vitamin K antagonists, synthetic pentasaccharides, parenteral direct thrombin inhibitors, direct oral anticoagulants, and blood-derived products for antithrombin substitution). SEARCH METHODS We conducted a comprehensive literature search on 02 June 2020, with no language restrictions, including (1) electronic searches of Pubmed/MEDLINE; Embase/Ovid; Scopus/Elsevier; Web of Science Core Collection/Clarivate Analytics; and Cochrane Central Register of Controlled Trials (CENTRAL) and (2) handsearches of (i) reference lists of identified studies and related reviews; (ii) clinical trials registries (ClinicalTrials.gov registry; the International Standard Randomized Controlled Trial Number (ISRCTN) registry; the World Health Organisation's International Clinical Trials Registry Platform (ICTRP); and pharmaceutical manufacturers of asparaginase including Servier, Takeda, Jazz Pharmaceuticals, Ohara Pharmaceuticals, and Kyowa Pharmaceuticals), and (iii) conference proceedings (from the annual meetings of the American Society of Hematology (ASH); the European Haematology Association (EHA); the American Society of Clinical Oncology (ASCO); and the International Society on Thrombosis and Haemostasis (ISTH)). We conducted all searches from 1970 (the time of introduction of asparaginase in ALL treatment). We contacted the authors of relevant studies to identify any unpublished material, missing data, or information regarding ongoing studies. SELECTION CRITERIA Randomised controlled trials (RCTs); including quasi-randomised, controlled clinical, cross-over, and cluster-randomised trial designs) comparing any parenteral/oral preemptive anticoagulant or mechanical intervention with placebo or no thromboprophylaxis, or comparing two different pre-emptive anticoagulant interventions in adults aged at least 18 years with ALL treated according to asparaginase-based chemotherapy regimens. For the description of harms, non-randomised observational studies with a control group were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Using a standardised data collection form, two review authors independently screened and selected studies, extracted data, assessed risk of bias for each outcome using standardised tools (RoB 2.0 tool for RCTs and ROBINS-I tool for non-randomised studies) and the certainty of evidence for each outcome using the GRADE approach. Primary outcomes included first-time symptomatic venous thromboembolism, all-cause mortality, and major bleeding. Secondary outcomes included asymptomatic venous thromboembolism, venous thromboembolism-related mortality, adverse events (i.e. clinically relevant non-major bleeding and heparin-induced thrombocytopenia for trials using heparins), and quality of life. Analyses were performed according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. For non-randomised studies, we evaluated all studies (including studies judged to be at critical risk of bias in at least one of the ROBINS-I domains) in a sensitivity analysis exploring confounding. MAIN RESULTS: We identified 23 non-randomised studies that met the inclusion criteria of this review, of which 10 studies provided no outcome data for adults with ALL. We included the remaining 13 studies in the 'Risk of bias' assessment, in which we identified invalid control group definition in two studies and judged outcomes of nine studies to be at critical risk of bias in at least one of the ROBINS-I domains and outcomes of two studies at serious risk of bias. We did not assess the benefits of thromboprophylaxis, as no RCTs were included. In the main descriptive analysis of harms, we included two retrospective non-randomised studies with outcomes judged to be at serious risk of bias. One study evaluated antithrombin concentrates compared to no antithrombin concentrates. We are uncertain whether antithrombin concentrates have an effect on all-cause mortality (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.26 to 1.19 (intention-to-treat analysis); one study, 40 participants; very low certainty of evidence). We are uncertain whether antithrombin concentrates have an effect on venous thromboembolism-related mortality (RR 0.10, 95% CI 0.01 to 1.94 (intention-to-treat analysis); one study, 40 participants; very low certainty of evidence). We do not know whether antithrombin concentrates have an effect on major bleeding, clinically relevant non-major bleeding, and quality of life in adults with ALL treated with asparaginase-based chemotherapy, as data were insufficient. The remaining study (224 participants) evaluated prophylaxis with low-molecular-weight heparin versus no prophylaxis. However, this study reported insufficient data regarding harms including all-cause mortality, major bleeding, venous thromboembolism-related mortality, clinically relevant non-major bleeding, heparin-induced thrombocytopenia, and quality of life. In the sensitivity analysis of harms, exploring the effect of confounding, we also included nine non-randomised studies with outcomes judged to be at critical risk of bias primarily due to uncontrolled confounding. Three studies (179 participants) evaluated the effect of antithrombin concentrates and six studies (1224 participants) evaluated the effect of prophylaxis with different types of heparins. When analysing all-cause mortality; venous thromboembolism-related mortality; and major bleeding (studies of heparin only) including all studies with extractable outcomes for each comparison (antithrombin and low-molecular-weight heparin), we observed small study sizes; few events; wide CIs crossing the line of no effect; and substantial heterogeneity by visual inspection of the forest plots. Although the observed heterogeneity could arise through the inclusion of a small number of studies with differences in participants; interventions; and outcome assessments, the likelihood that bias due to uncontrolled confounding was the cause of heterogeneity is inevitable. Subgroup analyses were not possible due to insufficient data. AUTHORS' CONCLUSIONS: We do not know from the currently available evidence, if thromboprophylaxis used for adults with ALL treated according to asparaginase-based regimens is associated with clinically appreciable benefits and acceptable harms. The existing research on this question is solely of non-randomised design, seriously to critically confounded, and underpowered with substantial imprecision. Any estimates of effect based on the existing insufficient evidence is very uncertain and is likely to change with future research.
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Affiliation(s)
- Cecilie U Rank
- Department of Hematology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Line Stensig Lynggaard
- Department of Child and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Bodil Als-Nielsen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Wendy Stock
- Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Nina Toft
- Department of Hematology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ove Juul Nielsen
- Department of Hematology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Thomas Leth Frandsen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ruta Tuckuviene
- Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
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Mondelaers V, Ferster A, Uyttebroeck A, Brichard B, van der Werff Ten Bosch J, Norga K, Francotte N, Piette C, Vandemeulebroecke K, Verbeke C, Schmidt S, Benoit Y, Lammens T, De Moerloose B. Prospective, real-time monitoring of pegylated Escherichia coli and Erwinia asparaginase therapy in childhood acute lymphoblastic leukaemia and non-Hodgkin lymphoma in Belgium. Br J Haematol 2020; 190:105-114. [PMID: 32057100 DOI: 10.1111/bjh.16495] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 12/24/2019] [Indexed: 11/25/2022]
Abstract
Asparaginase (ASNase) is an important anti-leukaemic drug in the treatment of childhood acute lymphoblastic leukaemia (ALL) and non-Hodgkin lymphoma (NHL). A substantial proportion of patients develop hypersensitivity reactions with anti-ASNase neutralising antibodies, resulting in allergic reactions or silent inactivation (SI), and characterised by inactivation and rapid clearance of ASNase. We report results of a prospective, real-time therapeutic drug monitoring of pegylated Escherichia coli (PEG-)ASNase and Erwinia ASNase in children treated for ALL and NHL in Belgium. Erwinia ASNase was given as second-line after hypersensitivity to PEG-ASNase. In total, 286 children were enrolled in the PEG-ASNase cohort. Allergy was seen in 11·2% and SI in 5·2% of patients. Of the 42 patients treated with Erwinia ASNase, 7·1% experienced allergy and 2·4% SI. The median trough PEG-ASNase activity was high in all patients without hypersensitivity. After Erwinia administration significantly more day 3 samples had activities <100 IU/l (62·5% vs. 10% at day 2 (D2)). The median D2 activity was significantly higher for intramuscular (IM; 347 IU/l) than for intravenous Erwinia administrations (159 IU/l). This prospective, multicentre study shows that monitoring of ASNase activity during treatment of children with ALL and NHL is feasible and informative. Treatment with Erwinia ASNase warrants close monitoring and optimally adherence to a 2-day interval of IM administrations.
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Affiliation(s)
- Veerle Mondelaers
- Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital and Cancer Research Institute Ghent, Ghent, Belgium
| | - Alina Ferster
- Pediatric Hematology-Oncology, Hôpital Universitaire des Enfants Reine Fabiola (HUDERF-UKZKF), Brussels, Belgium
| | - Anne Uyttebroeck
- Pediatric Hematology-Oncology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Bénédicte Brichard
- Pediatric Hematology-Oncology, Cliniques Universitaires Saint-Luc (UCL), Brussels, Belgium
| | | | - Koenraad Norga
- Pediatric Hematology-Oncology, University Hospital Antwerp, Antwerp, Belgium
| | - Nadine Francotte
- Department of Pediatric Oncology, CHC- Hospital of Hope, Montegnée, Belgium
| | - Caroline Piette
- Department of Pediatric Oncology, CHR Citadelle, Liège, Belgium
| | - Katrien Vandemeulebroecke
- Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Charlotte Verbeke
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Susanne Schmidt
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Yves Benoit
- Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital and Cancer Research Institute Ghent, Ghent, Belgium
| | - Tim Lammens
- Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital and Cancer Research Institute Ghent, Ghent, Belgium
| | - Barbara De Moerloose
- Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital and Cancer Research Institute Ghent, Ghent, Belgium
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Shimizu T, Ishima Y, Ishida T. [Induction of Anti-PEG Immune Responses by PEGylation of Proteins]. YAKUGAKU ZASSHI 2020; 140:163-169. [PMID: 32009039 DOI: 10.1248/yakushi.19-00187-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Modification of proteins with polyethylene glycol (PEG) (PEGylation) is a gold standard technique that improves the solubility, pharmacokinetics, and immunogenicity of modified proteins. To date more than 10 PEGylated protein formulations have been approved, and more than 20 PEGylated drugs are entering clinical trials. PEG has been considered non-immunogenic and non-toxic, but several studies have shown that PEG acquires immunogenicity following attachment to nanoparticles. The administration of PEGylated liposomes, micelles and proteins induces the production of antibodies against PEG (anti-PEG antibodies) in animals and human subjects. Indeed, approximately 20% of healthy human subjects possess pre-existing anti-PEG antibodies prior to treatment with PEGylated therapeutics. The induced and pre-existing anti-PEG antibodies cause not only the elimination of PEGylated proteins from blood circulation, but also allergic responses via the release of anaphylatoxins. Consequently, therapeutic outcomes for PEGylated proteins are impaired. The utility of PEGylated proteins could be improved by attenuating the PEG-related immune response. On the other hand, anti-PEG immune responses might be exploited for vaccine applications. Our recent studies demonstrated that anti-PEG antibodies mediate the delivery of antigens encapsulated in PEGylated liposomes, and enhance antigen-specific immune responses. In this review, we summarize anti-PEG antibody induction by PEGylated proteins and alterations in anti-PEG IgM-mediated pharmacokinetics and pharmacodynamics. These findings extend our knowledge of PEG-related immune responses.
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Affiliation(s)
- Taro Shimizu
- Institute of Biomedical Sciences, Tokushima University
| | - Yu Ishima
- Institute of Biomedical Sciences, Tokushima University
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18
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Rank CU, Wolthers BO, Grell K, Albertsen BK, Frandsen TL, Overgaard UM, Toft N, Nielsen OJ, Wehner PS, Harila-Saari A, Heyman MM, Malmros J, Abrahamsson J, Norén-Nyström U, Tomaszewska-Toporska B, Lund B, Jarvis KB, Quist-Paulsen P, Vaitkevičienė GE, Griškevičius L, Taskinen M, Wartiovaara-Kautto U, Lepik K, Punab M, Jónsson ÓG, Schmiegelow K. Asparaginase-Associated Pancreatitis in Acute Lymphoblastic Leukemia: Results From the NOPHO ALL2008 Treatment of Patients 1-45 Years of Age. J Clin Oncol 2019; 38:145-154. [PMID: 31770057 PMCID: PMC6953441 DOI: 10.1200/jco.19.02208] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Asparaginase-associated pancreatitis (AAP) is common in patients with acute lymphoblastic leukemia (ALL), but risk differences across age groups both in relation to first-time AAP and after asparaginase re-exposure have not been explored. PATIENTS AND METHODS We prospectively registered AAP (n = 168) during treatment of 2,448 consecutive ALL patients aged 1.0-45.9 years diagnosed from July 2008 to October 2018 and treated according to the Nordic Society of Pediatric Hematology and Oncology (NOPHO) ALL2008 protocol. RESULTS Compared with patients aged 1.0-9.9 years, adjusted AAP hazard ratios (HRa) were associated with higher age with almost identical HRa (1.6; 95% CI, 1.1 to 2.3; P = .02) for adolescents (10.0-17.9 years) and adults (18.0-45.9 years). The day 280 cumulative incidences of AAP were 7.0% for children (1.0-9.9 years: 95% CI, 5.4 to 8.6), 10.1% for adolescents (10.0 to 17.9 years: 95% CI, 7.0 to 13.3), and 11.0% for adults (18.0-45.9 years: 95% CI, 7.1 to 14.9; P = .03). Adolescents had increased odds of both acute (odds ratio [OR], 5.2; 95% CI, 2.1 to 13.2; P = .0005) and persisting complications (OR, 6.7; 95% CI, 2.4 to 18.4; P = .0002) compared with children (1.0-9.9 years), whereas adults had increased odds of only persisting complications (OR, 4.1; 95% CI, 1.4 to 11.8; P = .01). Fifteen of 34 asparaginase-rechallenged patients developed a second AAP. Asparaginase was truncated in 17/21 patients with AAP who subsequently developed leukemic relapse, but neither AAP nor the asparaginase truncation was associated with increased risk of relapse. CONCLUSION Older children and adults had similar AAP risk, whereas morbidity was most pronounced among adolescents. Asparaginase re-exposure should be considered only for patients with an anticipated high risk of leukemic relapse, because multiple studies strongly indicate that reduction of asparaginase treatment intensity increases the risk of relapse.
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Affiliation(s)
- Cecilie U Rank
- Rigshospitalet, Copenhagen, Denmark.,University of Copenhagen, Copenhagen, Denmark
| | | | - Kathrine Grell
- Rigshospitalet, Copenhagen, Denmark.,University of Copenhagen, Copenhagen, Denmark
| | | | | | | | - Nina Toft
- Herlev University Hospital, Herlev, Denmark
| | | | | | | | | | | | | | | | | | - Bendik Lund
- Trondheim University Hospital, Trondheim, Norway
| | - Kirsten B Jarvis
- Oslo University Hospital, Oslo, Norway.,University of Oslo, Oslo, Norway
| | | | - Goda E Vaitkevičienė
- Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Vilnius University, Vilnius, Lithuania
| | - Laimonas Griškevičius
- Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.,Vilnius University, Vilnius, Lithuania
| | | | | | | | - Mari Punab
- Tartu University Hospital, Tartu, Estonia
| | | | - Kjeld Schmiegelow
- Rigshospitalet, Copenhagen, Denmark.,University of Copenhagen, Copenhagen, Denmark
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19
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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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20
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Utke Rank C, Lynggaard LS, Toft N, Nielsen OJ, Stock W, Als-Nielsen B, Frandsen TL, Tuckuviene R, Schmiegelow K. Prophylaxis of thromboembolism during therapy with asparaginase in adults with acute lymphoblastic leukaemia. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2019. [DOI: 10.1002/14651858.cd013399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Cecilie Utke Rank
- Rigshospitalet, University Hospital of Copenhagen; Department of Hematology; Blegdamsvej 9 Copenhagen Copenhagen Denmark 2100
| | - Line Stensig Lynggaard
- Aarhus University Hospital; Department of Child and Adolescent Medicine; Palle Juul-Jensens Boulevard 99 Aarhus Denmark 8200
| | - Nina Toft
- Rigshospitalet, University Hospital of Copenhagen; Department of Hematology; Blegdamsvej 9 Copenhagen Copenhagen Denmark 2100
| | - Ove Juul Nielsen
- Rigshospitalet, University Hospital of Copenhagen; Department of Hematology; Blegdamsvej 9 Copenhagen Copenhagen Denmark 2100
| | - Wendy Stock
- University of Chicago Medicine; Department of Medicine; 900 E. 57th Street Chicago IL USA 60637
| | | | - Thomas Leth Frandsen
- Rigshospitalet, University Hospital of Copenhagen; Department of Pediatrics and Adolescent Medicine; Blegdamsvej 9 Copenhagen Denmark 2100
| | - Ruta Tuckuviene
- Aalborg University Hospital; Department of Pediatrics; Hobrovej 18-22 Aalborg Denmark 9100
| | - Kjeld Schmiegelow
- Rigshospitalet, University Hospital of Copenhagen; Department of Pediatrics and Adolescent Medicine; Blegdamsvej 9 Copenhagen Denmark 2100
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21
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Albertsen BK, Grell K, Abrahamsson J, Lund B, Vettenranta K, Jónsson ÓG, Frandsen TL, Wolthers BO, Heyman M, Schmiegelow K. Intermittent Versus Continuous PEG-Asparaginase to Reduce Asparaginase-Associated Toxicities: A NOPHO ALL2008 Randomized Study. J Clin Oncol 2019; 37:1638-1646. [DOI: 10.1200/jco.18.01877] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Asparaginase is an essential drug in childhood acute lymphoblastic leukemia (ALL) therapy and is frequently given for months to obtain continuous asparagine depletion. We randomly assigned patients to continuous versus intermittent pegylated-asparaginase (PEG-asp) treatment, hypothesizing there would be decreased toxicity with unchanged efficacy. METHODS Children (median age, 4.2 years) treated for non–high-risk ALL according to the Nordic Society for Pediatric Hematology and Oncology ALL2008 protocol received five intramuscular PEG-asp injections (1,000 IU/m2) every two weeks and were then randomly assigned to additional three doses (6-week intervals [experimental arm], n = 309) versus 10 doses (2-week intervals [standard arm], n = 316). The primary end point was noninferior (6% margin) disease-free survival. Toxicity reduction was a secondary end point. Occurrence of asparaginase-associated hypersensitivity, pancreatitis, osteonecrosis, and thromboembolism were prospectively registered. RESULTS After a median follow-up of 4.1 years, the 5-year disease-free survival was 92.2% (95% CI, 88.6 to 95.8) and 90.8% (95% CI, 87.0 to 94.6) in the experimental and standard arms, respectively. The 3-year cumulative incidence of any first asparaginase-associated toxicity (hypersensitivity [n = 13]; osteonecrosis [n = 29]; pancreatitis [n = 24]; thromboembolism [n = 17]) was 9.3% in the experimental arm and 18.1% in the standard arm ( P = .001). Asparaginase-associated toxicity reduction was confirmed in sex- and risk-group–adjusted Cox regression analysis stratified by age (≥ 10 and < 10 years; hazard ratio, 0.48; P = .001). The experimental arm had the lowest incidences of all four toxicities, reaching significance for pancreatitis (6-month risk, 5.8% v 1.3%; P = .002). CONCLUSION The excellent cure rates and reduced toxicity risk support the use of intermittent PEG-asp therapy after the first 10 weeks in future childhood ALL trials that apply prolonged PEG-asp therapy.
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Affiliation(s)
| | - Kathrine Grell
- University of Copenhagen, Copenhagen, Denmark,
- Rigshospitalet, Copenhagen, Denmark
| | | | - Bendik Lund
- Trondheim University Hospital, Trondheim, Norway
| | | | | | | | | | - Mats Heyman
- Karolinska University Hospital, Stockholm, Sweden
| | - Kjeld Schmiegelow
- University of Copenhagen, Copenhagen, Denmark,
- Rigshospitalet, Copenhagen, Denmark
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22
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Karol SE, Janke LJ, Panetta JC, Ramsey LB, Cai X, Payton MA, Jenkins DA, Evans WE, Relling MV. Asparaginase combined with discontinuous dexamethasone improves antileukemic efficacy without increasing osteonecrosis in preclinical models. PLoS One 2019; 14:e0216328. [PMID: 31059548 PMCID: PMC6502315 DOI: 10.1371/journal.pone.0216328] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 04/19/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Combination therapy for acute lymphoblastic leukemia (ALL) is highly effective but results in significant toxicity including osteonecrosis. Asparaginase is known to potentiate both the antileukemic and osteonecrosis-inducing effects of dexamethasone. The schedule of dexamethasone alters osteonecrosis risk. However, the effects of the interaction with asparaginase are unknown when dexamethasone is given on a discontinuous schedule. Methods Using the murine model of osteonecrosis, we compared the frequency of osteonecrosis in mice receiving discontinuous dexamethasone (3.5 days/ week) with mice receiving asparaginase and discontinuous dexamethasone. We then tested the effect on antileukemic efficacy using six pediatric ALL xenografts. Results The addition of asparaginase to discontinuous dexamethasone did not alter the rate of osteonecrosis compared to dexamethasone alone (7/35 in dexamethasone with asparaginase combination vs. 10/36 in dexamethasone alone, p = 0.62) despite increasing steady-state plasma dexamethasone levels (103.9 nM vs. 33.4 nM, p = 9.2x10-7). Combination therapy with asparaginase and dexamethasone demonstrated synergistic antileukemic effects across all six xenografts studied. Conclusions When discontinuous dexamethasone was given, its anti-leukemic activity synergized with asparaginase but the osteonecrosis-worsening effects of asparaginase (above dexamethasone alone) were not observed. Thus, there is a favorable drug interaction (unchanged toxicity, synergistic efficacy) between discontinuous dexamethasone and asparaginase.
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Affiliation(s)
- Seth E. Karol
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
- * E-mail:
| | - Laura J. Janke
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - John C. Panetta
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Laura B. Ramsey
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Xiangjun Cai
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Monique A. Payton
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - David A. Jenkins
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - William E. Evans
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
| | - Mary V. Relling
- Department of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States of America
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23
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Albertsen BK, Harila-Saari A, Jahnukainen K, Lähteenmäki P, Riikonen P, Möttönen M, Lausen B. Asparaginase treatment in infants with acute lymphoblastic leukemia; pharmacokinetics and asparaginase hypersensitivity in Interfant-06. Leuk Lymphoma 2019; 60:1469-1475. [PMID: 30632847 DOI: 10.1080/10428194.2018.1538507] [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: 10/27/2022]
Abstract
Acute lymphoblastic leukemia (ALL) is a rare disease in infants. Asparaginase is an essential part of the treatment, and there Acute is a need to evaluate the efficiency and safety of this drug in this age group. We evaluated the pharmacokinetics of intramuscularly administered native E. coli asparaginase (Asparaginase Medac®) and PEG-asparaginase (Oncaspar®) as well as hypersensitivity reactions during treatment in Interfant-06 ( www.clinicaltrials.gov : NCT01025804). All patients without hypersensitivity had sufficiently high enzyme activity levels during treatment with both preparations. Patients with hypersensitivity reactions during treatment, characterized by the presence of either or not of clinical symptoms and no measurable enzyme activity, received ineffective therapy. For optimization of the bad prognosis in infant ALL, therapeutic drug monitoring should be performed for identification of patients who should be switched to a different asparaginase preparation because of inactivation of the drug.
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Affiliation(s)
| | - Arja Harila-Saari
- b Department of Women's and Children's Health , Uppsala University , Sweden
| | - Kirsi Jahnukainen
- c Children's Hospital , University of Helsinki and Helsinki University Central Hospital , Helsinki , Finland
| | - Päivi Lähteenmäki
- d Department of Pediatrics and Adolescent Medicine , Turku University Hospital and Turku University , Turku , Finland
| | - Pekka Riikonen
- e Department of Pediatrics , Kuopio University Hospital , Kuopio , Finland
| | - Merja Möttönen
- f PEDEGO Research Center and Medical Research Center Oulu , University of Oulu , and Department of Children and Adolescents , Oulu University Hospital , Oulu , Finland
| | - Birgitte Lausen
- g Department of Pediatrics and Adolescent Medicine , University Hospital Rigshospitalet , Copenhagen , Denmark
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24
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Guo L, Geng X, Liu L, Miao Y, Lin Z, Yu M, Fu Y, Liu L, Li B, Luo Y. Quality, bioactivity study, and preclinical acute toxicity, safety pharmacology evaluation of PEGylated recombinant human endostatin (M 2 ES). J Biochem Mol Toxicol 2018; 33:e22257. [PMID: 30536793 DOI: 10.1002/jbt.22257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 09/18/2018] [Accepted: 10/02/2018] [Indexed: 12/28/2022]
Abstract
Endostar, a potent endogenous antiangiogenic factor, is wildly used in clinics. However, it was easily degraded by enzymes and rapidly cleared by the kidneys. To overcome these shortcomings, PEGylated recombinant human endostatin was developed. In this study, the purity of M2 ES was evaluated by silver stain and reversed-phase high-performance liquid chromatography. Ultraviolet spectrum was used to examine the structural of M2 ES and endostar. The bioactivity and antitumor efficacy of M2 ES were evaluated using an in vitro endothelial cell migration model and athymic nude mouse xenograft model of a heterogeneous lung adenocarcinoma, respectively. A preclinical study was performed to evaluate the acute toxicity and safety pharmacology in rhesus monkeys. The purity of M2 ES was more than 98%; PEG modification has no effect on endostatin structure. Compared with the control group, M2 ES dramatically retards endothelial cell migration and tumor growth. After intravenous (IV) infusions of M2 ES at a dose level of three and 75 mg/kg in rhesus monkeys, there was no observable serious adverse event in both acute toxicity and safety pharmacology study. On the basis of the quality and bioactivity study data of M2 ES and the absence of serious side effect in rhesus monkeys, M2 ES was authorized to initiate a phase I clinical trial.
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Affiliation(s)
- Lifang Guo
- Pharmacy Department of Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.,National Engineering Laboratory for Anti-Tumor Protein Therapeutics, School of Life Sciences, Tsinghua University, Beijing, China
| | - Xingchao Geng
- National Center for Safety Evaluation of Drugs, National Institute for Food and Drug Control, Beijing, China
| | - Li Liu
- National Center for Safety Evaluation of Drugs, National Institute for Food and Drug Control, Beijing, China
| | - Yufa Miao
- National Center for Safety Evaluation of Drugs, National Institute for Food and Drug Control, Beijing, China
| | - Zhi Lin
- National Center for Safety Evaluation of Drugs, National Institute for Food and Drug Control, Beijing, China
| | - Min Yu
- National Center for Safety Evaluation of Drugs, National Institute for Food and Drug Control, Beijing, China
| | - Yan Fu
- National Engineering Laboratory for Anti-Tumor Protein Therapeutics, School of Life Sciences, Tsinghua University, Beijing, China
| | - Lihong Liu
- Pharmacy Department of Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Bo Li
- National Center for Safety Evaluation of Drugs, National Institute for Food and Drug Control, Beijing, China
| | - Yongzhang Luo
- National Engineering Laboratory for Anti-Tumor Protein Therapeutics, School of Life Sciences, Tsinghua University, Beijing, China
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25
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Højfeldt SG, Wolthers BO, Tulstrup M, Abrahamsson J, Gupta R, Harila-Saari A, Heyman M, Henriksen LT, Jónsson ÒG, Lähteenmäki PM, Lund B, Pruunsild K, Vaitkeviciene G, Schmiegelow K, Albertsen BK. Genetic predisposition to PEG-asparaginase hypersensitivity in children treated according to NOPHO ALL2008. Br J Haematol 2018; 184:405-417. [PMID: 30450575 DOI: 10.1111/bjh.15660] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 09/03/2018] [Indexed: 01/01/2023]
Abstract
Asparaginase is essential in childhood acute lymphoblastic leukaemia (ALL) treatment, however hypersensitivity reactions to pegylated asparaginase (PEG-asparaginase) hampers anti-neoplastic efficacy. Patients with PEG-asparaginase hypersensitivity have been shown to possess zero asparaginase enzyme activity. Using this measurement to define the phenotype, we investigated genetic predisposition to PEG-asparaginase hypersensitivity in a genome-wide association study (GWAS). From July 2008 to March 2016, 1494 children were treated on the Nordic Society of Paediatric Haematology and Oncology ALL2008 protocol. Cases were defined by clinical hypersensitivity and no enzyme activity, controls had enzyme activity ≥ 100 iu/l and no hypersensitivity symptoms. PEG-asparaginase hypersensitivity was reported in 13·8% (206/1494) of patients. Fifty-nine cases and 772 controls fulfilled GWAS inclusion criteria. The CNOT3 variant rs73062673 on 19q13.42, was associated with PEG-asparaginase allergy (P = 4·68 × 10-8 ). We further identified two signals on chromosome 6 in relation to HLA-DQA1 (P = 9·37 × 10-6 ) and TAP2 (P = 1·59 × 10-5 ). This study associated variants in CNOT3 and in the human leucocyte antigen (HLA) region with PEG-asparaginase hypersensitivity, suggesting that not only genetic variations in the HLA region, but also regulation of these genes are of importance in the biology of this toxicity. Furthermore, our study emphasizes the importance of using asparaginase enzyme activity measurements to identify PEG-asparaginase hypersensitivity.
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Affiliation(s)
- Sofie G Højfeldt
- Child and Adolescent Health, Aarhus University Hospital, Aarhus, Denmark
| | - Benjamin O Wolthers
- Department of Paediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Morten Tulstrup
- Department of Paediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jonas Abrahamsson
- Department of Paediatrics, Institution for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ramneek Gupta
- Department of Bio- and Health Informatics, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Arja Harila-Saari
- Department of Women's and Children's health, Uppsala University, Uppsala, Sweden
| | - Mats Heyman
- Department of Women's and Children's health, Childhood Cancer Research Unit, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Louise T Henriksen
- Child and Adolescent Health, Aarhus University Hospital, Aarhus, Denmark
| | - Òlafur G Jónsson
- Children's Hospital, Landspitali University Hospital, Reykjavik, Iceland
| | - Päivi M Lähteenmäki
- Department of Paediatric and Adolescent Medicine, Turku University Hospital and Turku University, Turku, Finland
| | - Bendik Lund
- Department of Paediatrics, St. Olavs Hospital, Trondheim, Norway
| | - Kaie Pruunsild
- Department of Oncology and Haematology, University Children's Hospital, Tallinn, Estonia
| | - Goda Vaitkeviciene
- Clinic of Children's Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
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26
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Thromboembolism in acute lymphoblastic leukemia: results of NOPHO ALL2008 protocol treatment in patients aged 1 to 45 years. Blood 2018; 131:2475-2484. [PMID: 29661787 DOI: 10.1182/blood-2018-01-827949] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 03/30/2018] [Indexed: 01/19/2023] Open
Abstract
Thromboembolism frequently occurs during acute lymphoblastic leukemia (ALL) therapy. We prospectively registered thromboembolic events during the treatment of 1772 consecutive Nordic/Baltic patients with ALL aged 1 to 45 years who were treated according to the Nordic Society of Pediatric Hematology and Oncology ALL2008 protocol (July 2008-April 2017). The 2.5-year cumulative incidence of thromboembolism (N = 137) was 7.9% (95% confidence interval [CI], 6.6-9.1); it was higher in patients aged at least 10 years (P < .0001). Adjusted hazard ratios (HRas) were associated with greater age (range, 10.0-17.9 years: HRa, 4.9 [95% CI, 3.1-7.8; P < .0001]; 18.0-45.9 years: HRa, 6.06 [95% CI, 3.65-10.1; P < .0001]) and mediastinal mass at ALL diagnosis (HRa, 2.1; 95% CI, 1.0-4.3; P = .04). In a multiple absolute risk regression model addressing 3 thromboembolism risk factors, age at least 10 years had the largest absolute risk ratio (RRage, 4.7 [95% CI, 3.1-7.1]; RRenlarged lymph nodes, 2.0 [95% CI, 1.2-3.1]; RRmediastinal mass, 1.6 [95% CI, 1.0-2.6]). Patients aged 18.0 to 45.9 years had an increased hazard of pulmonary embolism (HRa, 11.6; 95% CI, 4.02-33.7; P < .0001), and patients aged 10.0 to 17.9 years had an increased hazard of cerebral sinus venous thrombosis (HRa, 3.3; 95% CI, 1.5-7.3; P = .003) compared with children younger than 10.0 years. Asparaginase was truncated in 38/128 patients with thromboembolism, whereas thromboembolism diagnosis was unassociated with increased hazard of relapse (P = .6). Five deaths were attributable to thromboembolism, and patients younger than 18.0 years with thromboembolism had increased hazard of dying compared with same-aged patients without thromboembolism (both P ≤ .01). In conclusion, patients aged at least 10 years could be candidates for preemptive antithrombotic prophylaxis. However, the predictive value of age 10 years or older, enlarged lymph nodes, and mediastinal mass remain to be validated in another cohort.
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