APTI ijopp - Indian Journal of Pharmacy Practice

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Indian J. Pharm. Pract. 1(2), Jan-Mar, 2009ammonia was 443 ìg /dl (normal value 25-94 ìg/dl). L- normal coagulation factors-especially fibrinogen-andasparaginase toxicity was suspected. Throat swab and thrombotic cases developing by decreased Antithrombinurine cultures were negative. As cerebral venous sinus III (AT Ill) and Plasminogen or decreased fibrinogenthrombosis was suspected a MRI and Magnetic level and hemorrhagic cases developing by normal AT IIIResonance Venography (MRV) of the brain were done,(9,10)and plasminogen concentration .which revealed thrombosis of the sagittal, transverse AI-Mondhiry reported that, in two of the four patientsand straight sinuses on the right side with partial whom vincristine and prednisone treatment applied,recanalisation. Low dose subcutaneous heparin 2500 fibrinogen level decreased but Prothrombin time (PT),thI.U 8 hourly was started and continued for 10 days. The Partial thromboplastin time (PTT) and Thrombin timepatient regained normal power in the left upper limb and(11)(TT) remain in normal limits . Ramsay et al useddid not have any further convulsions. Acetyl salicylic vincristine, prednisone, and L- asparaginase in 26 ALLacid 150 mg/day orally was given for 7 to 10 days and cases. In these cases, after cessation of L-asparaginasethe patient was discharged.coagulation tests were turned to normal limits.Anterioposterior (AP) view of MRV showing absenceConsequently those coagulation abnormality were foundof filling of sagittal sinus and right transverse and (12)to be due to L-asparaginase .sigmoid sinuses is shown in picture 1. Lateral view of In the study of Miniero et al., when the patients are treatedMRV showing venous filling defects as noted above are by prednisone, vincristine and L-asparaginase, comparedshown in picture 2.with patients treated by only L-asparaginase moreDISCUSSION(13)L-asparaginase enzyme has a molecular weight ofcommon coagulopathy was observed . In the133.000 daltons and hydrolyses L- asparagine. L-previously treated ALL cases, some hemorrhagic andasparagine is synthesised by transamination of L- thrombotic complications due to L-asparaginase have(14,15,16,17)aspartic acid. In tumor cells, lacking of L-asparagine been reported .synthase, the L-asparagine can be obtained from theHemorrhagic complications due to L-asparaginase arecirculating pool of amino acids. As the L-asparaginaseseen rarely and important for morbidity, once in 2 or 3will decrease the amount of extracellular L-asparagine,days the coagulation parameters (PT,PTT, Fibrinogen,tumor cells use this amino acid which is necessary forPlasminogen,and AT III levels) must be measured andprotein synthesis. But in normal cells, this synthesis when necessary, fresh frozen plasma, AT III andmay be re-done because of enzyme existence.thrombolytic therapy must be given. However, bleedingCerebrovascular symptoms dependent on or thrombosis occurring as a direct result of changes inL-asparaginase appear in two forms; either increased or(18)coagulation factors has not been frequently reported .Table No 1: Treatment Schedule for Induction TherapyVariables Mg/m2 Dayvincristin 1.5 8,15,22,29prednisolone 60 1-28daunorubicin 30 8,15,22,29L-asparaginase 10,000 19,22,25,28,31,34,37,40methotrexate BY AGE 182
Indian J. Pharm. Pract. 1(2), Jan-Mar, 2009Figure no.1: AP view of MR Venogram showing absence of filling of Sagittal sinus andright transverse and sigmoid sinuses.Figure no.2: Lateral view of MR venogram showing venous filling defects as noted above.83
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