What is the treatment for tumor lysis syndrome?

From the Guidelines

The treatment for tumor lysis syndrome should focus on aggressive hydration, electrolyte management, and prevention of renal complications, with rasburicase being the preferred option for high-risk patients, as it rapidly reduces existing uric acid levels, allowing for prompt continuation of chemotherapy 1.

Key Components of Treatment

• Aggressive hydration with intravenous fluids at 2-3 L/m²/day to maintain high urine output (100-200 mL/hour) and flush out uric acid and phosphate
• Rasburicase (0.1-0.2 mg/kg IV as a single dose) for rapid reduction of existing uric acid levels in high-risk patients
• Allopurinol (100-300 mg orally every 8 hours) for prevention of uric acid formation in low-risk patients
• Electrolyte management, including:
  • Hyperkalemia: calcium gluconate, insulin with glucose, sodium bicarbonate, or potassium binders
  • Hyperphosphatemia: phosphate binders like aluminum hydroxide (300-600 mg orally with meals)
  • Hypocalcemia: treatment only if symptomatic

Prevention and Monitoring

• Prevention is crucial in high-risk patients (those with high-grade lymphomas, acute leukemias, or bulky disease) by starting prophylactic measures 24-48 hours before chemotherapy 1
• Close monitoring of patients at risk of tumor lysis syndrome, with ready access to intensive care unit facilities if clinical condition deteriorates 1

Severe Cases

• Hemodialysis may be necessary for severe cases with acute kidney injury 1

From the FDA Drug Label

Tumor Lysis Syndrome (TLS) Clinical TLS was defined by changes in at least two or more laboratory parameters for hyperuricemia, hyperkalemia, hyperphosphatemia and hypocalcemia and at least one of the following events occurring within 7 days of treatment: renal failure/injury, need for renal dialysis, and/or serum creatinine increase >1.5 ULN, arrhythmia or seizure. The treatment for Tumor Lysis Syndrome (TLS) includes the use of rasburicase (IV), which is administered at a dose of 0.2 mg/kg/day as a 30-minute infusion once daily.

• The response rate in patients treated with rasburicase was significantly greater than in those treated with allopurinol.
• Clinical TLS occurred in 3% of rasburicase-treated patients, 3% of rasburicase/allopurinol-treated patients, and 4% of allopurinol-treated patients 2.

From the Research

Treatment Overview

The treatment for tumor lysis syndrome (TLS) involves several key components, including:

• Aggressive hydration to maintain urine flow and prevent acute renal failure 3, 4, 5, 6, 7
• Control of hyperuricemia using medications such as allopurinol and rasburicase 3, 4, 5, 6, 7
• Management of electrolyte abnormalities, including hyperkalemia, hyperphosphatemia, and hypocalcemia 3, 4, 5, 6, 7

Medications

Medications used to treat TLS include:

• Rasburicase, a recombinant urate oxidase that converts uric acid to allantoin, a more soluble byproduct that can be safely eliminated by the kidneys 3, 5, 6, 7
• Allopurinol, a xanthine oxidase inhibitor that reduces uric acid production 3, 4, 5, 6, 7
• Sodium polystyrene sulfonate, hypertonic glucose and insulin, loop diuretics, and bicarbonate to manage hyperkalemia 5
• Phosphate binders such as aluminum hydroxide and aluminum carbonate to manage hyperphosphatemia 5
• Calcium gluconate to manage hypocalcemia 5

Renal Replacement Therapy

In severe cases of TLS, renal replacement therapy may be required to manage acute renal failure and electrolyte abnormalities 5, 6, 7

Prevention

Prevention of TLS is crucial, and includes:

• Identifying patients at risk for TLS, such as those with high-grade lymphomas and acute lymphoblastic leukemia 4
• Aggressive hydration and monitoring of electrolyte abnormalities 3, 4, 5, 6, 7
• Use of rasburicase and allopurinol to prevent hyperuricemia 3, 4, 5, 6, 7