From the Guidelines
Elevated uric acid levels in lymphoma patients should be managed with aggressive hydration and rasburicase (0.1-0.2 mg/kg IV) to prevent tumor lysis syndrome (TLS) and acute kidney injury, as supported by the guidelines for the management of pediatric and adult tumor lysis syndrome 1.
Pathogenesis and Clinical Consequences
Uric acid levels are a significant concern in lymphoma patients due to the rapid cell turnover and breakdown of purines from rapidly dividing cancer cells, leading to hyperuricemia 1. This can result in the precipitation of uric acid in the renal tubules, causing renal insufficiency or failure.
Management and Prevention
Management includes preventive measures with:
- Aggressive hydration (2-3 liters/day)
- Allopurinol (300-600 mg daily) started 2-3 days before chemotherapy
- Rasburicase (0.1-0.2 mg/kg IV) for high-risk patients or those with established TLS, as it works rapidly to convert uric acid to allantoin, which is more soluble and easily excreted 1 For ongoing monitoring, uric acid levels should be checked regularly during treatment, especially in the first 48-72 hours after chemotherapy begins.
Key Considerations
- Alkalinization of urine is no longer routinely recommended as it may promote calcium phosphate precipitation
- Patients with lymphoma should maintain adequate hydration and follow a low-purine diet to help manage uric acid levels throughout their treatment course
- Early intervention is crucial as untreated hyperuricemia can lead to acute kidney injury, which may complicate lymphoma treatment
- Rasburicase treatment has been shown to be well tolerated, with no increase in creatinine levels and no patients requiring dialysis in a study of patients with aggressive NHL 1
From the FDA Drug Label
Elitek is indicated for the initial management of plasma uric acid levels in pediatric and adult patients with leukemia, lymphoma, and solid tumor malignancies who are receiving anticancer therapy expected to result in tumor lysis and subsequent elevation of plasma uric acid The answer to the question about uric acid in lymphoma is that rasburicase (Elitek) is indicated for the initial management of plasma uric acid levels in patients with lymphoma who are receiving anticancer therapy expected to result in tumor lysis and subsequent elevation of plasma uric acid 2, 2.
- Key points:
- Indication: initial management of plasma uric acid levels
- Patient population: pediatric and adult patients with lymphoma
- Concomitant therapy: anticancer therapy expected to result in tumor lysis and subsequent elevation of plasma uric acid
From the Research
Uric Acid in Lymphoma
- Uric acid levels are a significant concern in patients with lymphoma, particularly those at risk of tumor lysis syndrome (TLS) 3, 4, 5, 6, 7
- TLS is a life-threatening oncological emergency characterized by elevated uric acid, hyperphosphatemia, hypocalcemia, hyperkalemia, and renal failure 4, 5, 6, 7
- 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, including lymphoma 3, 5, 6
- Febuxostat, a new xanthine oxidase inhibitor, has also been evaluated for its efficacy in controlling serum uric acid levels in cancer patients at risk of TLS, including those with lymphoma 4, 7
- Studies have demonstrated that both rasburicase and febuxostat can effectively reduce uric acid levels and improve renal function in patients with lymphoma at risk of TLS 3, 4, 5, 6, 7
Management of Hyperuricemia
- Rasburicase has been shown to be effective in reducing uric acid levels and preventing uric acid accumulation in patients with hematologic malignancies, including lymphoma 3, 5, 6
- Febuxostat has also been evaluated for its efficacy in controlling serum uric acid levels in cancer patients at risk of TLS, including those with lymphoma 4, 7
- The use of rasburicase and febuxostat has been associated with improved renal function and reduced risk of TLS in patients with lymphoma 3, 4, 5, 6, 7
- Prophylaxis with allopurinol and rasburicase is recommended in all patients who are at an increased risk for tumor lysis syndrome 5
Treatment Outcomes
- Studies have demonstrated that the use of rasburicase and febuxostat can effectively reduce uric acid levels and improve renal function in patients with lymphoma at risk of TLS 3, 4, 5, 6, 7
- The response to treatment with rasburicase and febuxostat has been maintained up to 72 hours in some studies 3
- Single-dose rasburicase has been shown to be effective in 94.5% of patients, with significant cost savings compared to the recommended dose 3