From the Guidelines
Hyperuricemia in oncology patients with cancer is a significant concern that requires prompt monitoring and treatment, especially during chemotherapy, to prevent tumor lysis syndrome and its associated morbidity and mortality. The management of hyperuricemia in cancer patients involves a combination of hydration, medication, and close monitoring of uric acid levels.
- Hydration is crucial, with a target of 2-3 liters of fluid daily to promote uric acid excretion.
- The first-line medication for treatment is allopurinol, typically started at 100mg daily and increased as needed to 300-600mg daily based on uric acid levels and kidney function 1.
- For acute management or in patients who cannot tolerate allopurinol, rasburicase (Elitek) at 0.2mg/kg IV for 1-5 days provides rapid reduction of uric acid 1.
- Febuxostat (Uloric) at 40-80mg daily is an alternative for those with allopurinol hypersensitivity. Elevated uric acid in cancer patients often results from tumor lysis syndrome, where rapid destruction of cancer cells releases intracellular contents including purines, which metabolize to uric acid.
- This commonly occurs during treatment of high-turnover malignancies like leukemias and lymphomas.
- Untreated hyperuricemia can lead to acute kidney injury, gout, and urinary tract obstruction, potentially interrupting cancer treatment and worsening outcomes. Prophylactic treatment with rasburicase or allopurinol should begin 24-48 hours before chemotherapy in high-risk patients and continue for 5-7 days after, as recommended by the consensus conference on the management of tumor lysis syndrome 1.
From the FDA Drug Label
Hyperuricemia may be primary, as in gout, or secondary to diseases such as acute and chronic leukemia, polycythemia vera, multiple myeloma, and psoriasis It may occur with the use of diuretic agents, during renal dialysis, in the presence of renal damage, during starvation or reducing diets, and in the treatment of neoplastic disease where rapid resolution of tissue masses may occur.
The significance of hyperuricemia in oncology patients with cancer is that it may occur secondary to the disease itself, such as in acute and chronic leukemia, or as a result of treatment of neoplastic disease where rapid resolution of tissue masses may occur. Hyperuricemia can lead to complications such as urate precipitation and nephropathy, making it essential to manage and monitor uric acid levels in these patients 2. Key points to consider include:
- Hyperuricemia can be a consequence of cancer treatment
- It can lead to complications such as nephropathy
- Management of uric acid levels is crucial in oncology patients with hyperuricemia.
From the Research
Significance of Hyperuricemia in Oncology Patients
- Hyperuricemia is a significant concern in oncology patients with cancer, particularly those at risk of tumor lysis syndrome (TLS) 3, 4, 5, 6.
- TLS can lead to acute renal failure, necessitating dialysis, and hyperuricemia is a key contributor to this complication 4, 5.
- The management of hyperuricemia is crucial to prevent and treat TLS, and several treatment options are available, including allopurinol, rasburicase, and febuxostat 3, 4, 5, 7.
Treatment Options for Hyperuricemia
- Allopurinol has been the standard agent for managing hyperuricemia, but it often fails to prevent and treat TLS effectively 3.
- 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 3, 4, 5, 6.
- Febuxostat, a potent non-purine xanthine oxidase inhibitor, has been demonstrated to be non-inferior to allopurinol in preventing hyperuricemia in patients with malignant tumors receiving chemotherapy 7.
Benefits and Limitations of Rasburicase
- Rasburicase has a rapid onset of action and can lower pre-existing elevated uric acid levels, making it an effective alternative to allopurinol 3, 4.
- Rasburicase can reverse renal insufficiency and reduce the need for dialysis in patients with TLS 4, 5.
- However, the cost of rasburicase is a significant limitation, and its use should be judiciously chosen to prevent TLS in high-risk patients with cancer 4, 6.