Nutritional Complications Following PEG-Asparaginase Administration in Pediatric Patients with ALL

Background: Acute lymphoblastic leukemia (ALL) is the most common childhood malignancy in the United States. Lymphoblastic lymphoma (LL) is less common than ALL in the pediatric population but is often treated with ALL protocols. Polyethylene glycol (PEG) L-asparaginase, a mainstay chemotherapeutic to treat pediatric ALL, can cause a myriad of nutritional complications, including acute pancreatitis, hyperglycemia, hypertriglyceridemia, and exocrine pancreatic insufficiency. However, these complications and the appropriate treatments for them have not been well described in the literature. Case Information: Two pediatric patients with ALL and one pediatric patient with LL, who all received PEG-Asparaginase, faced adverse events leading to nutritional complications. The first patient, a 17-year-old-male diagnosed with ALL, experienced blood clotting issues, acute pancreatitis, hyperglycemia, and exocrine pancreatic insufficiency (EPI). The patient was managed with insulin and a low fat diet; however, due to severe weight loss and loose, oily stools, a fecal elastase was ordered and confirmed EPI. Therefore, the patient was transitioned to enteral nutrition (EN) and treated with pancreatic enzyme replacement therapy. The second patient, a 6-year-old female diagnosed with LL and on ALL chemotherapy protocol, experienced acute pancreatitis, constipation, and vomiting. Based on new recommendations developed by the team in treating pediatric oncologic patients with acute pancreatitis and the patient's poor oral intake, she was managed with a proactive EN feeding protocol. This was well tolerated by the patient, and she did not experience any additional episodes of acute pancreatitis. The third patient, a 7-year-old female diagnosed with ALL, experienced hypertriglyceridemia (>5200 mg/dL). Further complications of hyponatremia (presumed to be partially pseudohyponatremia related to hypertriglyceridemia), weight loss, and excessive stooling warranted the need for EN. The patient was initially fed with a very low fat (and subsequently high in carbohydrate) formula but was later switched to a more balanced peptide-based formula with a high ratio of medium chain triglycerides and lower carbohydrate content. Conclusions: In this case series, three patients' courses were detailed following the nutritional difficulties they faced after PEG L-asparaginase administration. Although further studies are needed, this series sheds light on potential nutritional complications and interventions.