title: Substituting dexamethasone for prednisone complicates remission induction in children with acute lymphoblastic leukemia.
abstract: BACKGROUND
  The authors report the occurrence of fatal or near-fatal sepsis in 16 of 38 children with newly diagnosed acute lymphoblastic leukemia (ALL) treated with a new induction regimen that differed from its predecessor by the substitution of dexamethasone for prednisone.
  
  
  METHODS
  The frequency of septic deaths among 38 children who received multiagent remission induction therapy, including dexamethasone (6 mg/m(2)) daily for 28 days (pilot protocol 91-01P), was compared with the frequency of septic deaths among children previously treated (protocol 87-01) and subsequently treated (protocol 91-01) in consecutive Dana-Farber Cancer Institute (DFCI) ALL trials with induction therapy that included 21 and 28 days of prednisone (40 mg/m(2)), respectively. Except for dexamethasone in protocol 91-01P, the remission induction agents used were identical in substance to those used in protocol 87-01. Protocol 91-01, the successor 91-01P, was also similar, with the exception of the deletion of a single dose of L-asparaginase.
  
  
  RESULTS
  Sixteen of the 38 children (42%) treated on the DFCI 91-01P had documented gram positive or gram negative sepsis (17 episodes) during remission induction, including 4 toxic deaths (11%). In contrast, there were 4 induction deaths among 369 children (1%) treated on protocol 87-01 (P = 0.0035) and 1 induction death among 377 children (<1%) treated on protocol 91-01 (P = 0.0003).
  
  
  CONCLUSIONS
  Substitution of dexamethasone for prednisone or methylprednisolone in an otherwise intensive conventional induction regimen for previously untreated children with ALL resulted in an alarmingly high incidence of septic episodes and toxic deaths. Awareness of this complication, considering that the substitution has no apparent benefit in the efficacy of remission induction, argues against its routine use in intensive induction regimens for children with ALL.
authors.affiliation: Maine Children's Cancer Program, The Barbara Bush Children's Hospital at Maine Medical Center, Scarborough, ME 04074-9308, USA.
authors.forename: C A
authors.initials: CA
authors.lastname: Hurwitz
authors.forename: L B
authors.initials: LB
authors.lastname: Silverman
authors.forename: M A
authors.initials: MA
authors.lastname: Schorin
authors.forename: L A
authors.initials: LA
authors.lastname: Clavell
authors.forename: V K
authors.initials: VK
authors.lastname: Dalton
authors.forename: K M
authors.initials: KM
authors.lastname: Glick
authors.forename: R D
authors.initials: RD
authors.lastname: Gelber
authors.forename: S E
authors.initials: SE
authors.lastname: Sallan
mesh_terms: D018931:Antineoplastic Agents, Hormonal / Q000008:administration & dosage / Q000009:adverse effects*; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D002648:Child; D002675:Child, Preschool; D003907:Dexamethasone / Q000008:administration & dosage / Q000009:adverse effects*; D017809:Fatal Outcome; D005260:Female; D016905:Gram-Negative Bacterial Infections / Q000139:chemically induced / Q000401:mortality; D016908:Gram-Positive Bacterial Infections / Q000139:chemically induced / Q000401:mortality; D006801:Humans; D008297:Male; D008775:Methylprednisolone / Q000008:administration & dosage*; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000188:drug therapy*; D011241:Prednisone / Q000008:administration & dosage*; D018805:Sepsis / Q000139:chemically induced* / Q000401:mortality
chemical_list: D018931:Antineoplastic Agents, Hormonal; D003907:Dexamethasone; D011241:Prednisone; D008775:Methylprednisolone