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4006 Pharmacokinetics and Immunogenicity of the First Doses of Peg-Asparaginase -an Alltogether Pilot Study

Program: Oral and Poster Abstracts
Session: 612. Acute Lymphoblastic Leukemias: Clinical and Epidemiological: Poster III
Hematology Disease Topics & Pathways:
Research, Clinical Research, drug development, Therapies, Adverse Events
Monday, December 12, 2022, 6:00 PM-8:00 PM

Merete Eybye Dam, MD1*, Maddalena Centanni2*, Lena Friberg2*, Mats Karlsson2*, Line Stensig Lynggaard, MD, PhD3*, Inga M. Johannsdottir, MD4*, Hilde Skuterud Wik, MD, PhD4*, Mats Heyman5, Johan Malmros, MD, PhD6*, Helene Hallböök, MD, PhD7*, Goda Elizabeta Vaitkeviciene, MD, PhD8*, Laimonas Griskevicius, MD, PhD9*, Ólafur Gísli Jónsson, MD, PhD10*, Ulrik Malthe Overgaard, MD11*, Kjeld Schmiegelow, MD, DMSc12 and Birgitte Klug Albertsen, MD, PhD3*

1Children and Adolescent Health, Aarhus University Hospital, Aarhus N, Denmark
2Department of Pharmacy, Uppsala University, Uppsala, Sweden
3Children and Adolescent Health, Aarhus University Hospital, Aarhus, Denmark
4Oslo University Hospital, Oslo, Norway
5Karolinska University Hospital, Stockholm, Sweden
6Karolinska Institutet, Stockholm, SWE
7Department of Hematology, Uppsala University Hospital, Uppsala, Sweden
8Center of Pediatric Oncology and Hematology, Children's hospital, affiliation of Vilnius University Hospital Santaros Klinikos and Vilnius University, Vilnius, Lithuania
9Department of Hematology, Oncology and Transfusion Medicine Center, Vilnius University Hospital Santaros Klinikos, Vilnius University, Vilnius, Lithuania
10Department of Pediatrics, Landspitali, University Hospital, Reykjavik, Iceland
11Department of Hematology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
12Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark

Background and aim

PEG-asparaginase is an indispensable part of the multiagent treatment of acute lymphoblastic leukemia (ALL). However, PEG-asparaginase treatment comes with substantial toxicity leading to discontinuation of therapy, which increases the risk of relapse. The most common toxicity is hypersensitivity, defined as either clinical allergy (13-15%) or silent inactivation (4-10%) both associated with increased clearance and inactivation of PEG-asparaginase. Asparaginase enzyme activity (AEA) measurements are widely used as Therapeutic Drug Monitoring (TDM).

TDM is commonly used to distinguish true allergy associated with inactivation of asparaginase from allergy like reactions where PEG-asparaginase treatment can be continued. TDM is included in most contemporary protocols. Pharmacokinetic (PK) analyses are essential in detecting inactivation of PEG-asparaginase and optimizing PEG-asparaginase treatment. However, TDM evaluated in PK analyses has never been shown reliable to predict hypersensitivity.

Therefore, we aimed to investigate the possibility to identify PK parameters to predict hypersensitivity before the allergic reaction occurred.


Patients with ALL aged 1-45 years treated according to the ALLTogether Pilot Protocol from December 2018 to December 2021 in the Nordic and Baltic countries were eligible. A total of 2,228 AEA samples from 219 pediatric and 43 adult patients were analyzed real-time for AEA.

A transit compartment model to characterize the PK of PEG-asparaginase was developed, representing increased clearance over time. AEA was represented by the sum of all compartments.


Inactivation of PEG-asparaginase was identified in 44 of 256 patients (17.2%); 9 patients with silent inactivation (20.5%), 12 patients with mild allergy (27.3%) and 23 patients with severe allergy (52.3%). Hypersensitivity mainly occurred after 4th (n=22 (50%)) or 5th (n=6 (13.6%)) dose.

A 10-compartmental transit model that allowed an exponential increase in clearance over time described the AEA-time profile best. The model divided patients into stable or exponentially increasing clearance over time. All patients with inactivation of PEG-asparaginase demonstrated an increased clearance over time. Patients with clinical symptoms demonstrated the most prominent increase.


PK analysis of AEA enables early identification of increased clearance, which opens new possibilities to predict inactivation of PEG-asparaginase and provides ability to intervene before inactivation of PEG-asparaginase occurs. PK analysis of AEA in addition holds the possibility to reduce the dose of PEG-asparaginase in order to minimize the risk of toxicity while continuously maintaining AEA in the therapeutic range.

Disclosures: Friberg: Pharmetheus AB: Consultancy, Current holder of stock options in a privately-held company. Karlsson: Servier, Roche, Bayer, Merck: Research Funding. Heyman: Amgen: Consultancy, Research Funding; Servier: Research Funding; Pfizer: Research Funding; NovaLab: Research Funding; Swedish Childhood Cancer FundFoundation: Current Employment, Research Funding. Griskevicius: Miltenyi Biomedicine: Membership on an entity's Board of Directors or advisory committees. Schmiegelow: Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novo Nordisk: Research Funding; Amgen: Speakers Bureau; Medscape: Speakers Bureau; Servier: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Illumina: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Albertsen: Jazz: Membership on an entity's Board of Directors or advisory committees; Servier: Speakers Bureau; Erytech Pharma: Membership on an entity's Board of Directors or advisory committees, Other: Financial support to investigator initiated Phase II study.

*signifies non-member of ASH