Pharmacokinetic dose adjustment of Erwinia asparaginase in protocol II of the paediatric ALL/NHL‐BFM treatment protocols

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Abstract
Native forms of asparaginase stem from different biological sources. Previously reported data from children treated with ErwinaseTM showed significantly lower trough levels and pharmacokinetic dose intensity than after E. coli‐derived preparations. Hence, schedule optimization was initiated to achieve relevant serum activities. 21 children on reinduction therapy received Erwinase on Mondays, Wednesdays and Fridays for 3 weeks (9 × 20 000 IU/m2 i.v.) instead of 4 × 10 000 IU/m2 of E. coli asparaginase (twice weekly for 2 weeks). Asparaginase trough activities were measured as the primary parameter, targeting 100–200 IU/l after 2 d and >50 IU/l after 3 d. Concurrently, asparagine trough concentrations were monitored. The mean trough activity was 156 ± 99 IU/l, with 2/108 samples showing no detectable activity. Regarding trough levels per individual (three or more measurements/patient), means ranged from 52 ± 29 to 276 ± 114 IU/l (20 patients, 106 samples), with nine, six, and five children inside, below, and above the target range, respectively. The mean 3 d trough activity was 50 ± 39 IU/l (20 patients, 51 samples). In 11 of these samples no activity was measurable. Mean trough activities calculated per individual ranged from < 20–84 ± 30 IU/l (14 patients, 42 samples) with seven children below the target limit of 50 IU/l and asparagine concentrations < 0.2–1.5 μm. We concluded that an increased dose of 9 × 20 000 IU/m2 of Erwinia asparaginase within 3 weeks resulted in a pharmacokinetic dose intensity comparable to former observations made with 4 × 10 000 IU/m2 of the E. coli product CrasnitinTM which is no longer marketed. High interindividual variability and the phenomenon of ‘silent’ inactivation necessitate monitoring wherever possible.