From the Guidelines
The most important management step prior to commencing chemotherapy in a 48-year-old man with stage 4 Burkitt's lymphoma presenting with biochemistry consistent with spontaneous tumor lysis syndrome is to administer rasburicase and hydration in an inpatient setting.
Key Management Steps
- Rasburicase administration: The dose of rasburicase should be 0.20 mg/kg/day, infused over 30 minutes, with the first dose administered at least four hours before the start of tumor-specific therapy and continued for at least 3-5 days 1.
- Hydration: Hydration should start at least 48 hours before tumor-specific therapy, with a goal of maintaining a urine output of at least 100 mL/hour in adults 1.
- Monitoring: Patients should be closely monitored for signs of tumor lysis syndrome, including electrolyte levels, uric acid levels, and renal function 1.
- Inpatient setting: Patients with high-risk tumor lysis syndrome, such as those with Burkitt's lymphoma, should be managed in an inpatient setting where they can be closely monitored and quickly transferred to an intensive care unit if necessary 1.
Important Considerations
- Concomitant allopurinol: Allopurinol should not be administered concomitantly with rasburicase, as it can interfere with the enzyme's activity 1.
- Urine alkalinization: Urine alkalinization is not recommended in patients receiving rasburicase therapy, unless other clinical conditions require it 1.
- Loop diuretics: Loop diuretics may be required to maintain adequate urine output, but should be used with caution in patients with obstructive uropathy or hypovolemia 1.
From the FDA Drug Label
The safety and efficacy of Elitek have been established only for a single course of treatment once daily for 5 days. Elitek is contraindicated in patients with G6PD deficiency because hydrogen peroxide is one of the major by-products of the conversion of uric acid to allantoin. Allopurinol tablets are indicated in: ... the management of patients with leukemia, lymphoma and malignancies who are receiving cancer therapy which causes elevations of serum and urinary uric acid levels
The most important management step prior to commencing chemotherapy in a 48-year-old man with stage 4 Burkitt's lymphoma presenting with biochemistry consistent with spontaneous tumor lysis syndrome is to screen for G6PD deficiency before administering rasburicase (Elitek) and to initiate uric acid lowering therapy, such as allopurinol or rasburicase, to prevent further complications from tumor lysis syndrome 2, 3.
- Key considerations include:
- G6PD deficiency screening to avoid hemolysis with rasburicase
- Uric acid lowering therapy to prevent further tumor lysis syndrome complications
- Monitoring for signs of hypersensitivity reactions, hemolysis, and methemoglobinemia with rasburicase administration However, the provided drug labels do not explicitly state the most important management step prior to commencing chemotherapy.
From the Research
Management of Tumor Lysis Syndrome
The most important management step prior to commencing chemotherapy in a 48-year-old man with stage 4 Burkitt's lymphoma presenting with biochemistry consistent with spontaneous tumor lysis syndrome involves:
- Aggressive hydration and diuresis to prevent acute renal failure 4
- Control of hyperuricaemia with uric-acid-lowering drugs such as rasburicase or allopurinol 5, 4, 6
- Vigilant monitoring of electrolyte abnormalities, including hyperkalemia, hyperphosphatemia, and hypocalcemia 4
Role of Rasburicase
Rasburicase has been shown to be effective in preventing tumor lysis syndrome in patients with high-risk malignancies, including Burkitt's lymphoma 5, 7, 6
- A single dose of rasburicase may be sufficient for prophylaxis in some patients 7, 6
- Rasburicase can rapidly reduce uric acid levels and prevent acute renal failure 5, 6
Prevention of Acute Renal Failure
Prevention of acute renal failure is critical in the management of tumor lysis syndrome 5, 4