Maintenance Treatment in Acute Lymphoblastic Leukemia: A Clinical Primer

Krishnan, Shekhar; Mahadevan, Ananya; Mungle, Tushar; Gogoi, Manash Pratim; Saha, Vaskar

doi:10.1007/s12098-023-04687-6

Indian J Pediatr

2023

DOI: 10.1007/s12098-023-04687-6

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Maintenance Treatment in Acute Lymphoblastic Leukemia: A Clinical Primer

Shekhar Krishnan

Ananya Mahadevan

Tushar Mungle

et al.

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Cited by 3 publications

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“…Instead, blood counts are used as surrogate markers of antimetabolite drug exposure, and doses are adjusted to maximum tolerated doses that maintain safe low absolute neutrophil (ANC) and platelet counts 7 . The aim is to avoid suboptimal antimetabolite dosing as this increases the risk of relapse 8–10 …”

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Hybrid Email and Outpatient Clinics to Optimize Maintenance Therapy in Acute Lymphoblastic Leukemia

Mungle,

Mahadevan,

Das

et al. 2023

Journal of Pediatric Hematology/Oncology

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Acute lymphoblastic leukemia treatment includes an outpatient (OP)-based 2-year maintenance therapy (MT). Over an 8-year period, patients were transited from only OP to a hybrid e-clinic/OP-clinic model. Electronic and patient-held medical records of acute lymphoblastic leukemia patients aged 1 to 18 years during MT were used to analyze demographics, drug doses, treatment response and cost. A survey evaluated family satisfaction with the hybrid service. Four hundred and seventy-eight children, all with at least 1 year of MT from March 13, 2014 to March 24, 2022 were grouped into 4 treatment eras, representing the transition from all OP (era 1) to the current hybrid MT practice (era 4). Cohort demographics were similar across all eras. With transition to era 4, OP visits decreased to a third (16 to 18/48 visits). Practice optimization in era 2 resulted in higher MT dose intensity in subsequent eras (era 1: median 82% [interquartile range, 63 to 97]; era 2: 93% [73 to 108]; era 3: 88% [68 to 106]; era 4: 90% [74 to 114], P<0·0001), with no differences in absolute neutrophil count or neutropenia-related toxicity (P=0.8). The hybrid service reduced MT expenses by ~50% and families (133/156, 85%) reported being very satisfied. Our experience indicates that a hybrid model is feasible, effective and less burdensome for patients and families.

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Hybrid Email and Outpatient Clinics to Optimize Maintenance Therapy in Acute Lymphoblastic Leukemia

Mungle,

Mahadevan,

Das

et al. 2023

Journal of Pediatric Hematology/Oncology

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Management Principles and Advances in Therapies of Pediatric Acute Leukemia: A Comprehensive Snapshot

Ganguly,

Ravindranath,

Bakhshi

2023

Indian J Pediatr

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Analysis toolkit for evaluation of drug titration practice in acute lymphoblastic leukemia maintenance

Mungle,

Mahadevan,

Mukhopadhyay

et al. 2024

JAMIA Open

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Objective During the 2-year maintenance treatment phase (MT) of acute lymphoblastic leukemia (ALL), personalized patient-specified titration of oral antimetabolite drug doses is required to ensure maximum tolerated systemic drug exposure. Drug titration is difficult to implement in practice and insufficient systemic drug exposure resulting from inadequate dose titration increases risk of ALL relapse. Materials and Methods We developed an open-source R-based analytical toolkit, including the allMT R package and an interactive web-based R Shiny VIATAMIN application, to evaluate antimetabolite drug titration during MT. Results Evaluation is initiated with basic visualization analysis of drug titration, in both individual patients and patient cohorts. Observations are supplemented with descriptive analyses of hematological toxicity frequency and prescriber compliance rates with protocol drug titration rules. In individual patients, visual and quantitative analyses indicate recurring potentially correctable suboptimal drug titration patterns. In patient cohorts, the toolkit enables evaluation of the impact of interventions to optimize MT drug titration. Discussion Incorporation of the toolkit in a forthcoming clinical decision support system for MT would enable real-time examination and course correction of drug titration practice. Conclusion Future versions will be enhanced to include other variables that influence drug titration practice, including clinical toxicity data and later, pharmacological markers of antimetabolite, adherence, and drug activity.

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Maintenance Treatment in Acute Lymphoblastic Leukemia: A Clinical Primer

Cited by 3 publications

References 44 publications

Hybrid Email and Outpatient Clinics to Optimize Maintenance Therapy in Acute Lymphoblastic Leukemia

Hybrid Email and Outpatient Clinics to Optimize Maintenance Therapy in Acute Lymphoblastic Leukemia

Management Principles and Advances in Therapies of Pediatric Acute Leukemia: A Comprehensive Snapshot

Analysis toolkit for evaluation of drug titration practice in acute lymphoblastic leukemia maintenance

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