From the Guidelines
The treatment for tumor lysis syndrome (TLS) should prioritize aggressive hydration, electrolyte management, and uric acid reduction, with rasburicase being the preferred option for high-risk patients, as recommended by the most recent guidelines 1.
Key Components of TLS Treatment
- Aggressive hydration with intravenous fluids at 3 L/m² per day to maintain high urine output and dilute circulating metabolites
- Electrolyte management, including:
- Hyperkalemia: calcium gluconate, insulin with glucose, sodium bicarbonate, or potassium binders
- Hyperphosphatemia: phosphate binders like aluminum hydroxide or sevelamer
- Hypocalcemia: treatment only if symptomatic
- Uric acid management:
- Allopurinol (100-300 mg orally every 8 hours) to prevent new uric acid formation
- Rasburicase (0.1-0.2 mg/kg IV as a single dose) to rapidly reduce existing uric acid levels, preferred for high-risk patients
Important Considerations
- Urinary alkalinization with sodium bicarbonate is no longer recommended 1
- Renal replacement therapy may be necessary in severe cases with acute kidney injury
- Prevention is crucial in high-risk patients with aggressive malignancies, particularly during chemotherapy initiation
High-Risk Patient Management
- Patients with a high risk of developing TLS (WBC >100 × 10^9/L, high tumor burden) should receive increased hydration and rasburicase prophylaxis 1
- Intractable fluid overload, hyperkalemia, hyperuricemia, hyperphosphatemia, or hypocalcemia are indications for renal dialysis 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.
Clinical TLS occurred in 3% of Elitek-treated patients, 3% of Elitek/allopurinol-treated patients, and 4% of allopurinol-treated patients.
The treatment for Tumor Lysis Syndrome (TLS) includes the use of rasburicase (Elitek), which can be administered alone or in combination with allopurinol. The dose of rasburicase is 0.2 mg/kg/day as a 30-minute infusion once daily. Allopurinol is administered orally at a dose of 300 mg once a day. The choice of treatment may depend on the individual patient's risk factors and laboratory parameters. Key considerations in the treatment of TLS include:
- Monitoring of laboratory parameters: hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia
- Renal function: monitoring for renal failure/injury, need for renal dialysis, and serum creatinine increase
- Cardiac monitoring: monitoring for arrhythmia or seizure 2
From the Research
Treatment Overview
The treatment for tumor lysis syndrome (TLS) involves a combination of strategies to manage the condition and prevent further complications.
- Intravenous hydration to maintain urine flow is a crucial step in the management of TLS 3.
- Medications targeting hyperuricemia, such as rasburicase and allopurinol, are also essential in the treatment of TLS 3, 4, 5, 6, 7.
Management of Hyperuricemia
Hyperuricemia is a key component of TLS, and its management is critical to preventing further complications.
- Rasburicase, a recombinant urate oxidase, has been shown to be effective in reducing uric acid levels and preventing uric acid accumulation in patients with hematologic malignancies 5, 6, 7.
- Allopurinol is also used to manage hyperuricemia, but it may not be as effective as rasburicase in some cases 4, 6.
Renal Replacement Therapy
In severe cases of TLS, renal replacement therapy may be required to manage the condition.
- Hemodialysis has been used in some cases to manage TLS, particularly in patients with severe renal impairment 4.
Prophylaxis
Prophylaxis with allopurinol and rasburicase is recommended in patients who are at an increased risk for TLS.