From the Guidelines
Hyperuricemia in pediatric patients should be approached with rasburicase as the primary treatment for tumor lysis syndrome, given its ability to rapidly degrade uric acid and prevent complications. The management of hyperuricemia in pediatric patients requires careful consideration of the underlying cause, as it may be asymptomatic or indicate serious conditions like tumor lysis syndrome, inborn errors of metabolism, or renal disease. Initial management involves identifying and treating the underlying cause while monitoring serum uric acid levels. For asymptomatic hyperuricemia without complications, lifestyle modifications are recommended, including increased fluid intake, reduced consumption of purine-rich foods (red meat, seafood, organ meats), and limiting fructose-containing beverages.
For symptomatic hyperuricemia or gout, allopurinol is the primary medication, typically started at 100-200 mg/day (or 10 mg/kg/day) and adjusted based on response, with a maximum of 600 mg/day 1. For acute gout attacks, NSAIDs like naproxen or ibuprofen can be used at age-appropriate doses. In tumor lysis syndrome, aggressive hydration (2-3 L/m²/day) and rasburicase (0.1-0.2 mg/kg as a single dose) are indicated, as rasburicase has been shown to be more effective than allopurinol in reducing uric acid levels and preventing complications 1. Febuxostat may be considered in older adolescents (10-40 mg daily) if allopurinol is not tolerated.
Some key points to consider in the management of hyperuricemia in pediatric patients include:
- The importance of aggressive hydration in preventing tumor lysis syndrome
- The use of rasburicase as the primary treatment for tumor lysis syndrome, given its ability to rapidly degrade uric acid and prevent complications
- The role of allopurinol in the management of symptomatic hyperuricemia or gout
- The need for regular monitoring of uric acid levels, renal function, and liver enzymes during treatment
- The goal of maintaining serum uric acid below 6 mg/dL to prevent complications like gouty arthritis, nephrolithiasis, and nephropathy.
Overall, the management of hyperuricemia in pediatric patients requires a comprehensive approach that takes into account the underlying cause, the severity of symptoms, and the potential risks and benefits of different treatment options. By prioritizing the use of rasburicase in tumor lysis syndrome and allopurinol in symptomatic hyperuricemia or gout, and by emphasizing the importance of lifestyle modifications and regular monitoring, clinicians can help to improve outcomes and reduce the risk of complications in pediatric patients with hyperuricemia.
From the FDA Drug Label
Children, 6 to 10 years of age, with secondary hyperuricemia associated with malignancies may be given 300 mg allopurinol tablets daily while those under 6 years are generally given 150 mg daily. The approach to hyperuricemia in pediatric patients involves administering allopurinol at a dose of:
- 300 mg daily for children 6 to 10 years of age
- 150 mg daily for children under 6 years of age 2
From the Research
Approach to Hyperuricemia in Pediatrics
Hyperuricemia is a condition characterized by elevated levels of uric acid in the blood. In pediatric patients, hyperuricemia can be caused by various factors, including genetic and environmental factors 3, 4.
Causes and Risk Factors
The causes of hyperuricemia in children include:
- Chronic conditions such as Down syndrome, metabolic or genetic disease, and congenital heart disease 4
- Acute conditions such as gastroenteritis, bronchial asthma, malignant disorders, and drug side effects 4
- Obesity, which is a major cause of hyperuricemia in otherwise healthy children and adolescents 4, 5
- Connective tissue disorders and inherited metabolic disorders 5
Diagnosis and Management
The diagnosis of hyperuricemia is based on serum uric acid levels, which increase gradually with age until adolescence 4. Management of hyperuricemia in pediatric patients includes:
- Lifestyle intervention, such as dietary changes and increased physical activity 4
- Urate-lowering therapy, such as allopurinol and febuxostat, which can be effective in reducing serum uric acid levels 6, 7
- Monitoring of urine sediment analysis and musculoskeletal ultrasound to guide treatment decisions 6
Treatment Considerations
The treatment of asymptomatic hyperuricemia in pediatric patients is not well established, and current guidelines do not recommend routine treatment 6. However, urate-lowering therapy may be considered in patients with certain conditions, such as chronic kidney disease 7. The choice of urate-lowering agent, such as allopurinol or febuxostat, depends on various factors, including the patient's renal function and other medical conditions 7.
Special Considerations
In pediatric patients with hyperuricemia, it is essential to consider the potential risks and benefits of treatment, as well as the individual patient's needs and circumstances 5, 6. Regular monitoring of serum uric acid levels, renal function, and other relevant parameters is crucial to guide treatment decisions and prevent long-term complications associated with hyperuricemia 3, 5.