Case Report: The Use of Intravenous SMOFlipid Infusion to Treat Severe Asparaginase-Induced Hypertriglyceridemia in Two Pediatric Acute Lymphoblastic Leukemia Patients

Abstract

Asparaginase-induced hypertriglyceridemia can have a spectrum of clinical presentations, from being asymptomatic to having life-threatening thrombosis or hyperviscosity syndrome. At present, there is no recommendation on routine lipid monitoring during asparaginase-containing treatment phase, nor a standardized guideline on its management. Two cases are presented here to illustrate the effects of concurrent infection on asparaginase-induced hypertriglyceridemia in patients with high-risk ALL and the use of SMOFlipid infusion as a treatment option in an acute situation.

Hypertriglyceridemia Induced By L-Asparaginase and Prednisolone in Pediatric Hemato-Oncology: A Case Report

“…Further, while rechallenging of causative drugs to avoid cumulative effects of steroids and asparaginase was given for subsequent doses after steroids was stopped [3]. Studies have also treated the extreme levels of TGs levels with Gemfibrozil 600 mg orally twice daily [2], Gemfibrozil 1200 mg orally per day followed by fish oil 3600mg/day and after 2 weeks fibrates were started [13], IV infusion of SMOFlipid at 0.5 g/kg/day [14], plasmapheresis has been proven to decrease TGs levels within few hours of administration [15]. Kimberly M Lau.et.al, mentioned about treatment recommendations available i.e, ➢ If TGs < 1000mg/dl, continue asparaginase with frequent monitoring for developing pancreatitis.…”

SOHO State of the Art Updates and Next Questions: Management of Asparaginase Toxicity in Adolescents and Young Adults with Acute Lymphoblastic Leukemia

“…Medical intervention should only be considered for patients presenting with high grade hypertriglyceridemia (> 1,000 mg/dL = 11.3 mmol/L) and toxicities 65,66 , but Asp therapy can in general be continued without dose adjustments 7,37,66 . Fibrates, such as gemfibrozil and fenofibrate, and Omega-3 has been recommended as first line in treatment of high grade hypertriglyceridemia 66,69,70 , and the latter is being tested in a randomized trial (clinicaltrials.gov: NCT04209244). More aggressive strategies such as insulin infusion, heparin infusion and plasmapheresis should only be used when an immediate decrease in triglycerides is needed, such as with severe hypertriglyceridemia-induced thrombosis 64,71 .…”