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Baek G, Kim M, Lee M, O'Connor S, Held L, van der Laan L, Cassaday RD. Retrospective review of the toxicities and change in dosing patterns for pegaspargase in patients with acute lymphoblastic leukemia/lymphoma and T-cell lymphoma. J Oncol Pharm Pract 2024:10781552241246104. [PMID: 38613330 DOI: 10.1177/10781552241246104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
INTRODUCTION Pegaspargase (PEG) is a key component of standard regimens for acute lymphoblastic leukemia/lymphoma (ALL) and extranodal natural killer/T-cell lymphoma (NKTCL). Emerging evidence suggests an opportunity to decrease incidence of PEG-associated toxicities with dose capping, but evidence is limited. This study aims to evaluate whether a significant difference in PEG-associated toxicities related to dosing strategy exists and to identify patient-specific or regimen-specific factors for PEG-related toxicity. METHODS A retrospective analysis of PEG-associated toxicities was completed in adult patients with ALL or NKTCL who received PEG within Cancer and Leukemia Group B (CALGB) 10403 or modified dexamethasone, methotrexate, ifosfamide, L-asparaginase, etoposide (mSMILE) regimens at the UW Medical Center/Fred Hutchinson Cancer Center. PEG-associated toxicities that occurred through 8 weeks after PEG doses were noted. RESULTS Twenty-eight patients received dose-capped PEG, and 29 received noncapped PEG. Fewer all-grade and grade 3/4 toxicities were observed in the dose-capped cohort. Grade 3/4 toxicities observed were hepatotoxicity, hyperglycemia, hypersensitivity, and hypertriglyceridemia. In addition, fewer grade 3/4 pancreatitis and thrombosis events occurred in the dose-capped cohort. Hypertriglyceridemia and hepatotoxicity were associated with the highest cumulative incidence proportions among all toxicities. CONCLUSION Dose capping of PEG was associated with a similar or later median onset for most toxicities, a less heterogeneic toxicity profile, and a lower recurrence of most toxicities upon PEG rechallenge compared to the non-dose-capped cohort. Standardizing PEG dose capping in the CALGB 10403 and mSMILE regimens may translate to improved tolerance compared to a historical standard of no dose capping PEG.
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Affiliation(s)
- Grace Baek
- Department of Pharmacy, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Pharmacy, UW Medicine, Seattle, WA, USA
| | - Miryoung Kim
- Department of Pharmacy, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Pharmacy, UW Medicine, Seattle, WA, USA
| | - Madison Lee
- Department of Pharmacy, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Pharmacy, UW Medicine, Seattle, WA, USA
| | - Shan O'Connor
- Department of Pharmacy, UW Medicine, Seattle, WA, USA
| | - Lauren Held
- Department of Pharmacy, UW Medicine, Seattle, WA, USA
| | - Lars van der Laan
- Department of Statistics, University of Washington, Seattle, WA, USA
| | - Ryan D Cassaday
- Division of Hematology, University of Washington School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
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2
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Koschade SE, Stratmann JA, Steffen B, Shaid S, Finkelmeier F, Serve H, Miesbach W, Brandts CH, Ballo O. Early-onset venous thromboembolisms in newly diagnosed non-promyelocytic acute myeloid leukemia patients undergoing intensive induction chemotherapy. Eur J Haematol 2023; 110:426-434. [PMID: 36573351 DOI: 10.1111/ejh.13920] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/18/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVES AND METHODS Venous thromboembolic (VTE) events are emerging as frequent complications in acute myeloid leukemia (AML); however, there is insufficient data regarding epidemiology, risk factors, and impact on outcomes. The optimal approach to balance risks of thrombosis and hemorrhage remains unclear. This retrospective single-center study in AML patients undergoing induction chemotherapy between 2007 and 2018 assessed incidence, risk factors, features, and outcomes of early-onset VTE. RESULTS 423 patients (median age 59 years) were enrolled. VTE was diagnosed in 31 patients (7.3%) within 3 months of admission. The median time to VTE was 3 days. Non-central venous catheter (CVC)-related VTE occurred in 19 patients (61%). Main risk factor for VTE was leukocytosis at admission, independent of platelet counts/INR. Four patients (13%) exhibited VTE recurrence. No deaths directly related to VTE or major bleeding events associated with platelet-adjusted anticoagulation in patients with VTE were recorded. There was no clear impact of VTE on 1-year overall survival; however, non-CVC-related VTE may be associated with adverse outcomes. CONCLUSIONS Early-onset VTE is a common complication in newly diagnosed AML patients admitted for induction chemotherapy. Leukocytosis is an independent VTE risk factor. The potentially adverse impact of non-CVC-related VTE merits further study.
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Affiliation(s)
- Sebastian E Koschade
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Jan A Stratmann
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Björn Steffen
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Shabnam Shaid
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Fabian Finkelmeier
- Department of Medicine, Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Hubert Serve
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Wolfgang Miesbach
- Department of Medicine, Haemostaseology and Haemophilia Treatment Center, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany.,Institute of Transfusion Medicine, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Christian H Brandts
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany.,University Cancer Center Frankfurt (UCT), University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Olivier Ballo
- Department of Medicine, Hematology/Oncology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
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3
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Chen Y, Buhlinger K, Perissinotti AJ, Schepers AJ, Benitez L, Auten J, Chen SL, Bixby DL, Burke PW, Pettit KM, Marini BL. Solving coagulation conundrums: comparing prophylaxis strategies in adult patients receiving PEG-asparaginase. Leuk Lymphoma 2022; 63:2663-2670. [DOI: 10.1080/10428194.2022.2087066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- YeeAnn Chen
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Kaitlyn Buhlinger
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Anthony J. Perissinotti
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Allison J. Schepers
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Lydia Benitez
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Jessica Auten
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Sheh-Li Chen
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Dale L. Bixby
- Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Patrick W. Burke
- Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Kristen M. Pettit
- Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Bernard L. Marini
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
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4
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Rees MJ, Wu S, Mokoonlall M, Dix CHK, Bryant CE, D'Rozario J, Schwarer A, Grigg A, Tiong IS. The real-world tolerability and efficacy of asparaginase in adults aged 40 years and older with Philadelphia-negative acute lymphoblastic leukemia. Leuk Lymphoma 2021; 62:2531-2534. [PMID: 33899667 DOI: 10.1080/10428194.2021.1919666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Matthew J Rees
- Department of Clinical Haematology, Austin Health, Melbourne, Australia
| | - Simon Wu
- Department of Clinical Haematology, Eastern Health, Melbourne, Australia
| | - Mridula Mokoonlall
- Department of Clinical Haematology, Canberra Hospital, Canberra, Australia
| | - Caroline H K Dix
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Christian E Bryant
- Institute of Haematology, Royal Prince Alfred Hospital, Sydney, Australia
| | - James D'Rozario
- Department of Clinical Haematology, Canberra Hospital, Canberra, Australia
| | - Anthony Schwarer
- Department of Clinical Haematology, Austin Health, Melbourne, Australia.,Department of Clinical Haematology, Eastern Health, Melbourne, Australia
| | - Andrew Grigg
- Department of Clinical Haematology, Austin Health, Melbourne, Australia
| | - Ing Soo Tiong
- Department of Clinical Haematology, Austin Health, Melbourne, Australia
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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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