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1. Hypersensitivity reactions
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It is advisable to pre-medicate every administration of Peg-ASP to reduce incidence and/or severity of hypersensitivity reactions
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In case of known grade 3–4 allergic reaction, further administrations of Peg-ASP are contraindicated and substitution with the Erwinia chrysanthemi formulation is indicated
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In case of a clinically manifested hypersensitivity reaction, ASP activity should be measured to promptly identify any possible inactivation of the medication
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2. Hepatic toxicity
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BMI > 30 and pre-existing hepatic steatosis require a reduction in the dosage of Peg-ASP
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Development of grade 3–4 toxicity does not contraindicate subsequent administrations of Peg-ASP when grade toxicity ≤2
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L-carnitine is suggested in the event of hyperbilirubinemia
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Concomitant therapy (chemotherapy, antibiotics, antifungals, steroids, other) plays a decisive role in increasing the risk of hepatotoxicity during Peg-ASP therapy
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3. Metabolic toxicity
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Hyperglycaemia should be corrected with insulin therapy and it is not an indication to discontinue or delay subsequent PegAsp administrations
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Hypoalbuminemia should be corrected
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4. Hemorrhagic/thrombotic toxicity
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Laboratory alterations of the hemocoagulative parameters in the absence of clinical signs of thrombosis or bleeding do not necessitate discontinuation or delay of Peg-ASP
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It is advisable to correct hypofibrinogenemia with cryoprecipitate
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Replenishment of AT is advisable to maintain levels consistently above 60%
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5. Peg asparaginase-associated pancreatitis
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CTCAE grade 2 asymptomatic pancreatitis, once resolved, does not contraindicate subsequent administration of Peg-ASP
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Development of symptomatic pancreatitis or asymptomatic with CTCAE grade 3–4 amylase/lipase elevation contraindicates subsequent administrations even with a different ASP formulation
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