L-Asparaginase and Steroids-associated Hypertriglyceridemia Successfully Treated With Plasmapheresis in a Child With Acute Lymphoblastic Leukemia

Abstract

L-Asparaginase is an effective drug in childhood acute lymphoblastic leukemia (ALL) and it has become an important component of most childhood ALL regimens with administration in induction, intensification, and maintenance phases of treatment. L-Asparaginase is associated with side effects occurring either in a dose or time-dependent fashion or as hypersensitivity reactions. Some well-known toxicities in asparaginase-containing regimens are hypersensitivity/allergy and thromboembolic events. When asparaginase and steroids are used together, mild hyperlipemia is reasonably common. As some published studies show, this abnormality is often underdiagnosed. Hyperlipemia rarely constitutes a clinical problem; however, when triglyceride elevation is greater than 1000 mg/dL, the risk of pancreatitis is increased. We report the case of a young female presenting with acute severe hypertriglyceridemia (9250 mg/dL) during intensification phase of ALL, with neurologic symptoms but without the development of pancreatitis. She was successfully managed with 1 single run of plasmapheresis.

Non-infectious chemotherapy-associated acute toxicities during childhood acute lymphoblastic leukemia therapy

“…The most common preventive measures in cases of hypertriglyceridemia are dietary restrictions (very limited effect), fibrates, insulin infusions, heparin infusions, and in extreme cases plasmapheresis, but there are no data to support that any of these interventions reduces the risk of hypertriglyceridemia-associated toxicities 83, 185– 189 . In adults with non-malignant disorders, hypertriglyceridemia (above 10 times the UNL) has been associated with an increased risk of acute pancreatitis 185, 188, 190 , but so far this has not been replicated in children with ALL 191 .…”

Severe hypertriglyceridaemia during therapy for childhood acute lymphoblastic leukaemia

“…There are no clear recommendations on screening patients for hypertriglyceridemia or for continuing asparaginase, steroids or their combination during severe hypertriglyceridemia [13, 14]. Occasionally, life-threatening emergencies have warranted plasmapheresis [15]. However, for asymptomatic patients or in those with milder symptoms, therapy has ranged from observation and dietary modification alone, [13] to steroid omission, [14] or pharmacotherapy with omega-3 fatty acids (FA), [16] fibrates, [12] statins, [17] heparin [12] or insulin [18].…”

Asparaginase‐associated pancreatitis is not predicted by hypertriglyceridemia or pancreatic enzyme levels in children with acute lymphoblastic leukemia

“…Furthermore, the association is only evident during delayed intensification. Dexamethasone is known to affect triglyceride levels when given as monotherapy . Therefore, it is unclear whether the association we describe between triglyceride levels and pancreatic amylase is a natural consequence of dexamethasone treatment, or if the fluctuations in triglyceride and pancreas‐amylase levels are indeed associated.…”