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Koning ASCAM, van der Meulen M, Schaap D, Satoer DD, Vinkers CH, van Rossum EFC, van Furth WR, Pereira AM, Meijer OC, Dekkers OM. Neuropsychiatric Adverse Effects of Synthetic Glucocorticoids: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2024; 109:e1442-e1451. [PMID: 38038629 PMCID: PMC11099480 DOI: 10.1210/clinem/dgad701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 11/16/2023] [Accepted: 11/29/2023] [Indexed: 12/02/2023]
Abstract
CONTEXT Synthetic glucocorticoids are widely used to treat patients with a broad range of diseases. While efficacious, glucocorticoids can be accompanied by neuropsychiatric adverse effects. OBJECTIVE This systematic review and meta-analysis assesses and quantifies the proportion of different neuropsychiatric adverse effects in patients using synthetic glucocorticoids. METHODS Six electronic databases were searched to identify potentially relevant studies. Randomized controlled trials, cohort studies, and cross-sectional studies assessing psychiatric side effects of glucocorticoids measured with validated questionnaires were eligible. Risk of bias was assessed with RoB 2, ROBINS-I, and AXIS appraisal tool. For proportions of neuropsychiatric outcomes, we pooled proportions, and when possible, differences in questionnaire scores between glucocorticoid users and nonusers were expressed as standardized mean differences (SMD). Data were pooled in a random-effects logistic regression model. RESULTS We included 49 studies with heterogeneity in study populations, type, dose, and duration of glucocorticoids. For glucocorticoid users, meta-analysis showed a proportion of 22% for depression (95% CI, 14%-33%), 11% for mania (2%-46%), 8% for anxiety (2%-25%), 16% for delirium (6%-36%), and 52% for behavioral changes (42%-61%). Questionnaire scores for depression (SMD of 0.80 [95% CI 0.35-1.26]), and mania (0.78 [0.14-1.42]) were higher than in controls, indicating more depressive and manic symptoms following glucocorticoid use. CONCLUSION The heterogeneity of glucocorticoid use is reflected in the available studies. Despite this heterogeneity, the proportion of neuropsychiatric adverse effects in glucocorticoid users is high. The most substantial associations with glucocorticoid use were found for depression and mania. Upon starting glucocorticoid treatment, awareness of possible psychiatric side effects is essential. More structured studies on incidence and potential pathways of neuropsychiatric side effects of prescribed glucocorticoids are clearly needed.
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Affiliation(s)
- Anne-Sophie C A M Koning
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Merel van der Meulen
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Daphne Schaap
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Djaina D Satoer
- Department of Neurosurgery, Erasmus MC—University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Christiaan H Vinkers
- Department of Psychiatry and Department of Anatomy and Neurosciences, Amsterdam University Medical Center, Location VUMC, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Academic Working Place Depression, GGZ InGeest, Oldenaller 1, 1081 HJ Amsterdam, The Netherlands
- Amsterdam Neuroscience (Mood, Anxiety, Psychosis, Stress & Sleep Program) and Amsterdam Public Health (Mental Health Program) Research Institutes, Amsterdam, The Netherlands
| | - Elisabeth F C van Rossum
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Wouter R van Furth
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospitals, Leiden and The Hague, The Netherlands
| | - Alberto M Pereira
- Department of Endocrinology and Metabolism, Amsterdam University Medical Center, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Onno C Meijer
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Olaf M Dekkers
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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van Hulst AM, Verwaaijen EJ, van den Berg SAA, van Litsenburg RRL, Grootenhuis MA, Fiocco M, Neggers SJCMM, van den Heuvel-Eibrink MM, van den Akker ELT. Leptin Increase During Dexamethasone and Its Association With Hunger and Fat in Pediatric Acute Lymphoblastic Leukemia. J Clin Endocrinol Metab 2024; 109:631-640. [PMID: 37878899 PMCID: PMC10876409 DOI: 10.1210/clinem/dgad621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 10/13/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023]
Abstract
CONTEXT During treatment, children with acute lymphoblastic leukemia (ALL) receive high doses dexamethasone, which induce acute side effects. OBJECTIVE To determine the influence of a 5-day dexamethasone course on changes in leptin, fat mass, BMI, hunger, sleep, and fatigue and to explore associations between these changes. METHODS Pediatric ALL patients were included during maintenance treatment. Data were collected before (T1) and after (T2) a 5-day dexamethasone course (6 mg/m2/day). At both time points, BMI, fat mass (bioelectrical impedance analysis), and leptin were assessed, as well as parent-reported questionnaires regarding hunger, fatigue, and sleep problems. Changes between T1 and T2 were assessed using paired tests. Correlation coefficients were calculated to assess associations between these changes (Delta scores: T2-T1). Univariable regression models were estimated to study associations between covariates and elevated leptin. RESULTS We included 105 children, with median age 5.4 years (range, 3.0-18.8). Leptin and fat mass, as well as hunger scores, fatigue, and sleep deteriorated after 5 days of dexamethasone (P < .001), in contrast to BMI (P = .12). No correlations between delta leptin and delta fat mass, BMI, hunger, fatigue, or sleep were found. Elevated leptin on T1 was associated with older age (odds ratio [OR] 1.51; 95% CI, 1.28-1.77), higher fat mass (OR 1.19; 95% CI, 1.07-1.33), and earlier maintenance week (OR 0.96; 95% CI, 0.92-0.99). CONCLUSION Five days of high-dose dexamethasone treatment led to direct and significant changes in leptin, hunger scores, and fat mass. Since children with ALL are at increased risk for metabolic adverse events, understanding underlying mechanisms is important, and a dexamethasone-induced state of acute leptin resistance might play a role.
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Affiliation(s)
| | - Emma J Verwaaijen
- Pediatric Oncology, Princess Máxima Center, 3584 CS Utrecht, The Netherlands
| | - Sjoerd A A van den Berg
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
| | | | | | - Marta Fiocco
- Pediatric Oncology, Princess Máxima Center, 3584 CS Utrecht, The Netherlands
- Leiden University Mathematical Institute, 2333 CA Leiden, The Netherlands
- Department of Biomedical Data Science, Medical Statistics, Leiden University Medical Centre, 2333 ZA Leiden, The Netherlands
| | - Sebastian J C M M Neggers
- Pediatric Oncology, Princess Máxima Center, 3584 CS Utrecht, The Netherlands
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Marry M van den Heuvel-Eibrink
- Pediatric Oncology, Princess Máxima Center, 3584 CS Utrecht, The Netherlands
- Child Health, UMCU-Wilhelmina Children's Hospital, 3584 EA Utrecht, The Netherlands
| | - Erica L T van den Akker
- Department of Pediatric Endocrinology, Erasmus MC- Sophia Children's Hospital, 3015 CN Rotterdam, The Netherlands
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Verwaaijen EJ, van Hulst AM, Hartman A, Pieters R, Fiocco M, Pluijm SMF, van Litsenburg RRL, Grootenhuis MA, van den Akker ELT, van den Heuvel‐Eibrink MM. Physical frailty deteriorates after a 5-day dexamethasone course in children with acute lymphoblastic leukemia, results of a national prospective study. Cancer Med 2023; 12:22304-22315. [PMID: 38069550 PMCID: PMC10757098 DOI: 10.1002/cam4.6779] [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: 07/24/2023] [Revised: 11/08/2023] [Accepted: 11/21/2023] [Indexed: 12/31/2023] Open
Abstract
BACKGROUND Dexamethasone is important in the treatment for pediatric acute lymphoblastic leukemia (ALL) but induces muscle atrophy with negative consequences for muscle mass, muscle strength, and functional abilities. The aim of this study was to establish the effect of a dexamethasone course on sarcopenia and physical frailty in children with ALL, and to explore prognostic factors. METHODS Patients with ALL aged 3-18 years were included during maintenance therapy. Patients had a sarcopenia/frailty assessment on the first day of (T1) and on the day after (T2) a 5-day dexamethasone course. Sarcopenia was defined as low muscle strength in combination with low muscle mass. Prefrailty and frailty were defined as having two or ≥three of the following components, respectively: low muscle mass, low muscle strength, fatigue, slow walking speed, and low physical activity. Chi-squared and paired t-tests were used to assess differences between T1 and T2. Logistic regression models were estimated to explore patient- and therapy-related prognostic factors for frailty on T2. RESULTS We included 105 patients, 61% were boys. Median age was 5.3 years (range: 3-18.8). At T1, sarcopenia, prefrailty, and frailty were observed in respectively 2.8%, 23.5%, and 4.2% of patients. At T2, the amount of patients with frailty had increased to 17.7% (p = 0.002), whereas the number of patients with sarcopenia and prefrailty remained similar. Higher ASMM (odds ratio [OR]: 0.49, 95% CI: 0.28-0.83), stronger handgrip strength (OR: 0.41, 95% CI: 0.22-0.77) and more physical activity minutes per day (OR: 0.98, 95% CI: 0.96-0.99) decreased the risk of frailty at T2. Slower walking performance (OR: 2, 95% CI: 1.2-3.39) increased the risk. Fatigue levels at T1 were not associated with frailty at T2. CONCLUSION Physical frailty increased strikingly after a 5-days dexamethasone course in children with ALL. Children with poor physical state at start of the dexamethasone course were more likely to be frail after the course.
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Affiliation(s)
| | | | - Annelies Hartman
- Department of Pediatric PhysiotherapyErasmus Medical Center‐Sophia Children's HospitalRotterdamThe Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric OncologyUtrechtThe Netherlands
| | - Marta Fiocco
- Princess Máxima Center for Pediatric OncologyUtrechtThe Netherlands
- Mathematical Institute Leiden UniversityLeidenThe Netherlands
- Department of Biomedical Data Science, Section Medical StatisticsLeiden University Medical CenterLeidenThe Netherlands
| | | | | | | | - Erica L. T. van den Akker
- Department of Pediatrics, Division Pediatric Endocrinology, Obesity Center CGGErasmus Medical Center‐Sophia Children's HospitalRotterdamThe Netherlands
| | - Marry M. van den Heuvel‐Eibrink
- Princess Máxima Center for Pediatric OncologyUtrechtThe Netherlands
- Division of Child HealthWilhelmina Children's HospitalUtrechtThe Netherlands
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van Hulst AM, Grootenhuis MA, van den Akker ELT, van den Heuvel-Eibrink MM. Response to letter entitled: Re: Hydrocortisone to reduce dexamethasone-induced neurobehavioral side-effects in children with acute lymphoblastic leukaemia-results of a double-blind, randomised controlled trial with cross-over design. Eur J Cancer 2023; 191:112980. [PMID: 37574396 DOI: 10.1016/j.ejca.2023.112980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 08/15/2023]
Affiliation(s)
- Annelienke M van Hulst
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands.
| | - Martha A Grootenhuis
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | | | - Marry M van den Heuvel-Eibrink
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA Utrecht, the Netherlands
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van Hulst AM, van den Akker ELT, Verwaaijen EJ, Fiocco M, Rensen N, van Litsenburg RRL, Pluijm SMF, Zwaan CM, van Santen HM, Pieters R, Evers AWM, Grootenhuis MA, van den Heuvel-Eibrink MM. Hydrocortisone to reduce dexamethasone-induced neurobehavioral side-effects in children with acute lymphoblastic leukaemia-results of a double-blind, randomised controlled trial with cross-over design. Eur J Cancer 2023; 187:124-133. [PMID: 37149961 DOI: 10.1016/j.ejca.2023.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/29/2023] [Indexed: 05/09/2023]
Abstract
BACKGROUND Dexamethasone is a cornerstone of paediatric acute lymphoblastic leukaemia (ALL) treatment, although it can induce serious side-effects. Our previous study suggests that children who suffer most from neurobehavioural side-effects might benefit from physiological hydrocortisone in addition to dexamethasone treatment. This study aimed to validate this finding. METHODS Our phase three, double-blind, randomised controlled trial with cross-over design included ALL patients (3-18 years) during medium-risk maintenance therapy in a national tertiary hospital between 17th May 2018 and 5th August 2020. A baseline measurement before and after a 5-day dexamethasone course was performed, whereafter 52 patients with clinically relevant neurobehavioural problems were randomised to receive an intervention during four subsequent dexamethasone courses. The intervention consisted of two courses hydrocortisone (physiological dose 10 mg/m2/d in circadian rhythm), followed by two courses placebo, or vice versa. Neurobehavioural problems were assessed before and after each course using the parent-reported Strengths and Difficulties Questionnaire (SDQ) as primary end-point. Secondary end-points were sleep problems, health-related quality of life (HRQoL), hunger feeling, and parental stress, measured with questionnaires and actigraphy. A generalised mixed model was estimated to study the intervention effect. RESULTS The median age was 5.5 years (range 3.0-18.8) and 61.5% were boys. The SDQ filled in by 51 primary caregivers showed no difference between hydrocortisone and placebo in reducing dexamethasone-induced neurobehavioral problems (estimated effect -2.05 (95% confidence interval (CI) -6.00-1.90). Also, no benefit from hydrocortisone compared to placebo was found for reducing sleep problems, hunger, parental stress or improving HRQoL. CONCLUSIONS Hydrocortisone, when compared to placebo, had no additional effect in reducing clinically relevant dexamethasone-induced neurobehavioural problems. Therefore, hydrocortisone is not advised as standard of care for children with ALL who experience dexamethasone-induced neurobehavioural problems. TRIAL REGISTRATION Netherlands Trial Register NTR6695/NL6507 (https://trialsearch.who.int/) and EudraCT 2017-002738-22 (https://eudract.ema.europa.eu/).
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Affiliation(s)
- Annelienke M van Hulst
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands.
| | | | - Emma J Verwaaijen
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Marta Fiocco
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Mathematical Institute, Leiden University, Rapenburg 70, 2311 EZ Leiden, the Netherlands; Department of Biomedical Data Science, section Medical Statistics, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Niki Rensen
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | | | - Saskia M F Pluijm
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - C Michel Zwaan
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Hanneke M van Santen
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA Utrecht, the Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Andrea W M Evers
- Institute of Psychology, Rapenburg 70, 2311 EZ Leiden, the Netherlands
| | - Martha A Grootenhuis
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands
| | - Marry M van den Heuvel-Eibrink
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS Utrecht, the Netherlands; Wilhelmina Children's Hospital, Lundlaan 6, 3584 EA Utrecht, the Netherlands
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van Hulst AM, Grootenhuis MA, Verwaaijen EJ, van Litsenburg RR, Li L, van Zelst BD, Broer L, Pluijm SM, Pieters R, Fiocco M, van den Akker EL, van den Heuvel-Eibrink MM. Unraveling Dexamethasone-Induced Neurobehavioral and Sleep Problems in Children With ALL: Which Determinants Are Important? JCO Precis Oncol 2023; 7:e2200678. [PMID: 37343203 PMCID: PMC10309531 DOI: 10.1200/po.22.00678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 04/14/2023] [Accepted: 04/24/2023] [Indexed: 06/23/2023] Open
Abstract
PURPOSE Dexamethasone, the preferred corticosteroid in most treatment protocols for pediatric acute lymphoblastic leukemia (ALL), can induce undesirable side effects. Neurobehavioral and sleep problems are frequently reported, but the interpatient variability is high. We therefore aimed to identify determinants for parent-reported dexamethasone-induced neurobehavioral and sleep problems in pediatric ALL. METHODS Our prospective study included patients with medium-risk ALL and their parents during maintenance treatment. Patients were assessed before and after one 5-day dexamethasone course. Primary end points were parent-reported dexamethasone-induced neurobehavioral and sleep problems, measured with the Strengths and Difficulties Questionnaire and Sleep Disturbance Scale for Children, respectively. Analyzed determinants included patient and parent demographics, disease and treatment characteristics, parenting stress (Parenting Stress Index and Distress Thermometer for Parents), dexamethasone pharmacokinetics, and genetic variation (candidate single-nucleotide polymorphisms rs41423247 and rs4918). Statistically significant determinants identified in univariable logistic regression analyses were incorporated in a multivariable model. RESULTS We included 105 patients: median age was 5.4 years (range, 3.0-18.8) and 61% were boys. Clinically relevant dexamethasone-induced neurobehavioral and sleep problems were reported by parents in 70 (67%) and 61 (59%) patients, respectively. In our multivariable regression models, we identified parenting stress as a significant determinant for parent-reported neurobehavioral (odds ratio [OR], 1.16; 95% CI, 1.07 to 1.26) and sleep problems (OR, 1.06; 95% CI, 1.02 to 1.10). Furthermore, parents who experienced more stress before start of a dexamethasone course reported more sleep problems in their child (OR, 1.16; 95% CI, 1.02 to 1.32). CONCLUSION We identified parenting stress, and not dexamethasone pharmacokinetics, genetic variation, patient/parent demographics, or disease/treatment characteristics, as a significant determinant for parent-reported dexamethasone-induced neurobehavioral and sleep problems. Parenting stress may be a modifiable target to reduce these problems.
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Affiliation(s)
| | | | | | | | - Letao Li
- Department of Hospital Pharmacy, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Bertrand D. van Zelst
- Division of Endocrinology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Linda Broer
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Rob Pieters
- Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
| | - Marta Fiocco
- Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
- Mathematical Institute, Leiden University, Leiden, the Netherlands
- Department of Biomedical Data Science, Medical Statistics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Erica L.T. van den Akker
- Department of Pediatric Endocrinology, Erasmus MC- Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marry M. van den Heuvel-Eibrink
- Pediatric Oncology, Princess Máxima Center, Utrecht, the Netherlands
- Child Health, UMCU-Wilhelmina Children's Hospital, Utrecht, the Netherlands
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Thastrup M, Duguid A, Mirian C, Schmiegelow K, Halsey C. Central nervous system involvement in childhood acute lymphoblastic leukemia: challenges and solutions. Leukemia 2022; 36:2751-2768. [PMID: 36266325 PMCID: PMC9712093 DOI: 10.1038/s41375-022-01714-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 09/17/2022] [Accepted: 09/22/2022] [Indexed: 11/10/2022]
Abstract
Delivery of effective anti-leukemic agents to the central nervous system (CNS) is considered essential for cure of childhood acute lymphoblastic leukemia. Current CNS-directed therapy comprises systemic therapy with good CNS-penetration accompanied by repeated intrathecal treatments up to 26 times over 2-3 years. This approach prevents most CNS relapses, but is associated with significant short and long term neurotoxicity. Despite this burdensome therapy, there have been no new drugs licensed for CNS-leukemia since the 1960s, when very limited anti-leukemic agents were available and there was no mechanistic understanding of leukemia survival in the CNS. Another major barrier to improved treatment is that we cannot accurately identify children at risk of CNS relapse, or monitor response to treatment, due to a lack of sensitive biomarkers. A paradigm shift in treating the CNS is needed. The challenges are clear - we cannot measure CNS leukemic load, trials have been unable to establish the most effective CNS treatment regimens, and non-toxic approaches for relapsed, refractory, or intolerant patients are lacking. In this review we discuss these challenges and highlight research advances aiming to provide solutions. Unlocking the potential of risk-adapted non-toxic CNS-directed therapy requires; (1) discovery of robust diagnostic, prognostic and response biomarkers for CNS-leukemia, (2) identification of novel therapeutic targets combined with associated investment in drug development and early-phase trials and (3) engineering of immunotherapies to overcome the unique challenges of the CNS microenvironment. Fortunately, research into CNS-ALL is now making progress in addressing these unmet needs: biomarkers, such as CSF-flow cytometry, are now being tested in prospective trials, novel drugs are being tested in Phase I/II trials, and immunotherapies are increasingly available to patients with CNS relapses. The future is hopeful for improved management of the CNS over the next decade.
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Affiliation(s)
- Maria Thastrup
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Alasdair Duguid
- Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, UK
| | - Christian Mirian
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Protein Research, Proteomics Program, Faculty of Health and Medical Sciences, 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 Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christina Halsey
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
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Verwaaijen EJ, van Hulst A, Fiocco M, Hartman A, Grootenhuis M, Pluijm S, Pieters R, van den Akker E, van den Heuvel-Eibrink MM. Dexamethasone-induced sarcopenia and physical frailty in children with acute lymphoblastic leukemia: Protocol for a prospective cohort study (Preprint). JMIR Res Protoc 2021; 11:e33517. [PMID: 35403603 PMCID: PMC9039819 DOI: 10.2196/33517] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/24/2022] [Accepted: 02/07/2022] [Indexed: 12/24/2022] Open
Abstract
Background During treatment for pediatric acute lymphoblastic leukemia (ALL), children receive high doses of dexamethasone for its apoptotic effect on leukemia cells; however, muscle atrophy is a well-known serious side effect. Muscle atrophy (loss of muscle mass) accompanied by a decreased muscle strength may lead to a generalized impaired skeletal muscle state called sarcopenia. Loss of muscle mass is also an indicator of physical frailty, which is defined as a state of increased vulnerability that is characterized by co-occurrence of low muscle mass, muscle weakness, fatigue, slow walking speed, and low physical activity. Both sarcopenia and physical frailty are related to an increased risk of infections, hospitalizations, and decreased survival in children with chronic diseases. Objective This study aims to (1) estimate the occurrence of sarcopenia and physical frailty in children during ALL maintenance therapy, (2) evaluate the effect of administering dexamethasone, and (3) explore determinants associated with these outcomes. Methods This prospective study is being pursued within the framework of the DexaDays-2 study: a randomized controlled trial on neurobehavioral side effects in pediatric patients with ALL. A total of 105 children (3-18 years) undergoing ALL maintenance treatment at the Princess Máxima Center for Pediatric Oncology are included in this study. Sarcopenia/frailty assessments are performed before and just after a 5-day dexamethasone course. A subset of 50 children participating in the DexaDays-2 trial because of severe dexamethasone-induced neurobehavioral problems were assessed at 3 additional timepoints. The sarcopenia/frailty assessment consists of bioimpedance analysis (skeletal muscle mass [SMM]), handheld dynamometry (handgrip strength), Pediatric Quality of Life Inventory Multidimensional Fatigue Scale (fatigue), Timed Up and Go Test (TUG; walking speed), and physical activity questionnaires. To evaluate potential change in sarcopenia/frailty components after a 5-day dexamethasone administration, a paired Student t test or Mann-Whitney U test will be used. Because of the presence of repeated measurements, generalized linear mixed models will be used to estimate the effect of dexamethasone on sarcopenia and frailty outcomes. Multivariable regression models will be estimated to investigate associations between the assessment scores and patient and treatment-related factors. Results Patient accrual started in 2018 and was finalized in spring 2021. From autumn 2021 onward final data analyses will be performed. Conclusions This first study combining parameters of sarcopenia and physical frailty is of importance because these conditions can seriously complicate continuation of ALL therapy, independence in physical functioning, reaching motor milestones, and participating in daily life activities. The results will provide knowledge about these complications, the association between dexamethasone treatment and muscle loss and other components of frailty, and therefore insights into the severity of this side effect. By exploring potential determinants that may be associated with sarcopenia and physical frailty, we may be able to identify children at risk at an earlier stage and provide timely interventions. International Registered Report Identifier (IRRID) DERR1-10.2196/33517
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Affiliation(s)
| | | | - Marta Fiocco
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Annelies Hartman
- Department of Pediatric Physiotherapy, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
| | | | - Saskia Pluijm
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Erica van den Akker
- Department of Endocrinology, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands
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