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Multiple Asparaginase Infusions Cause Increasingly Severe Acute Hyperammonemia.

Randal K Buddington1,2,3, Karyl K Buddington4, Scott C Howard1,5

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Medical Sciences (Basel, Switzerland)
|August 23, 2022
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Summary

Asparaginase treatment for leukemia can cause severe hyperammonemia, especially with later doses. This study in pigs reveals an acute ammonia spike during infusions, coinciding with infusion reactions and potentially limiting treatment.

Keywords:
asparaginasechemotherapyhyperammonemiainfusion reactionspig

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Area of Science:

  • Biochemistry
  • Pharmacology
  • Toxicology

Background:

  • Asparaginase is crucial for acute lymphoblastic leukemia (ALL) treatment.
  • Infusion reactions and hyperammonemia are known adverse effects of asparaginase.
  • The immediate post-infusion ammonia levels and their correlation with reactions remain understudied.

Purpose of the Study:

  • To investigate the acute and chronic changes in serum ammonia levels following Erwinia asparaginase infusions.
  • To examine the concurrence of hyperammonemia and infusion reactions in a preclinical model.
  • To evaluate the juvenile pig as a translational model for asparaginase-induced hyperammonemia.

Main Methods:

  • Weaned juvenile pigs received 12 infusions of Erwinia asparaginase (1250 U/kg) over 28 days.
  • Two recovery periods without asparaginase were included after the 8th and 11th doses.
  • Dense ammonia sampling was performed during and after infusions; prolonged hyperammonemia was defined as >50 µM ammonia 48 hours post-infusion.

Main Results:

  • Infusion reactions and prolonged hyperammonemia (>50 µM at 48h) emerged after the fourth dose and worsened with subsequent doses.
  • An acute hyperammonemia phase peaked within 20 minutes of infusion initiation (298 ± 62 µM), lasting less than an hour without symptoms.
  • The final infusion resulted in pronounced acute hyperammonemia (1260 ± 250 µM), coinciding with severe reactions and one mortality.

Conclusions:

  • A previously unrecognized acute hyperammonemia phase during asparaginase infusion is directly linked to infusion reactions.
  • The juvenile pig model effectively replicates both acute and chronic hyperammonemia seen in asparaginase therapy.
  • Understanding this acute hyperammonemia is critical for improving infusion protocols, mitigating reactions, and ensuring continued asparaginase use in ALL patients.