Levocarnitine and vitamin B complex for the treatment of pegaspargase-induced hepatotoxicity: A case report and review of the literature

Abstract

Asparaginase is a chemotherapeutic agent that is commonly used in combination with other medications for the treatment of acute lymphoblastic leukemia. An adverse effect of asparaginase includes hepatotoxicity, which can lead to severe liver failure and death. Several reports have documented successful treatment of asparaginase-induced hepatotoxicity using levocarnitine (l-carnitine) and vitamin B complex. Herein, we report a patient with acute lymphoblastic leukemia that experienced acute liver injury following pegaspargase administration. Our patient was successfully treated with l-carnitine and vitamin B complex for 8 days and achieved recovery of hepatic function. Furthermore, we review the current literature and provide a recommendation on a regimen that can be used as an option for the treatment of asparaginase-induced hepatic injury.

Optimizing the use of the hyperCVAD regimen: Clinical vignettes and practical management

“…Although toxicities associated with pegaspargase may be more significant during induction chemotherapy, it is prudent to be mindful of these toxicities, which occur more frequently in adult patients . Avoiding concomitant hepatotoxic medications and using ursodiol, vitamin B, and levocarnitine in patients who develop or are at higher risk of hepatotoxicity may be considered …”

“…Hepatotoxicity associated with pegaspargase can be severe and preclude anticipated chemotherapy. The use of vitamin B complex in combination with levocarnitine at doses of 50‐150 mg/kg/day has been shown to mitigate this toxicity and is currently being studied as a means to shorten the severity and duration of hepatotoxicity in patients receiving pegaspargase . Consensus guidelines for management of additional asparaginase‐associated toxicities should also be referenced .…”

“…25 Avoiding concomitant hepatotoxic medications and using ursodiol, vitamin B, and levocarnitine in patients who develop or are at higher risk of hepatotoxicity may be considered. [26][27][28][29] Maintenance therapy for patients with T cell ALL is also modified to incorporate nelarabine and asparaginase courses during maintenance as early intensification in months 6 and 7, in addition to the delayed intensification courses in months 18 and 19, as mentioned above. In patients with bulky mediastinal disease, a repeat positron emission tomography/computed tomography (PET-CT) examination is preferred at the completion of the 10 intensive courses.…”

“…The use of vitamin B complex in combination with levocarnitine at doses of 50-150 mg/kg/day has been shown to mitigate this toxicity and is currently being studied as a means to shorten the severity and duration of hepatotoxicity in patients receiving pegaspargase. [26][27][28][29] Consensus guidelines for management of additional asparaginase-associated toxicities should also be referenced. 25,49 Patients receiving mini-HCVD plus inotuzumab should avoid concomitant hepatotoxic medications, including azole antifungals, with inotuzumab.…”

Role and Location of L-Carnitine in Cytoprotection and Correction of Metabolic Processes in Patients With Metabolic Syndrome

“…В нескольких клинических исследованиях было зафиксировано успешное лечение гепатотоксичности, вызванной аспарагиназой и другими цитостатиками при использовании L-карнитина [84]. Описаны позитивные эффекты L-карнитина у пациентов с циррозом печени [85].…”