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Bakhsh S, Khan MA, Alshamrani M, Mufti R, Naeem A, AlMansour M, Alsaeed A, Alahmari M, Aseeri M. Effectiveness of a Single Fixed Dose of 3 mg Rasburicase for the Prevention and Management of Hyperuricemia in Tumor Lysis Syndrome in Adults With Cancer. Cureus 2024; 16:e68664. [PMID: 39376806 PMCID: PMC11456990 DOI: 10.7759/cureus.68664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2024] [Indexed: 10/09/2024] Open
Abstract
BACKGROUND Tumor lysis syndrome (TLS) is a critical and potentially fatal complication linked to specific types of cancer. Rasburicase stands as a crucial medication necessary for the prevention and treatment of hyperuricemia, a condition commonly associated with TLS. Due to a shortage of rasburicase during the COVID-19 pandemic, a fixed-dose strategy of 3 mg rasburicase was used in many adult cancer patients in our center. OBJECTIVE The objective of this study was to assess the effectiveness of a fixed dose of 3 mg rasburicase in preventing and managing hyperuricemia associated with TLS in adult cancer patients. METHODS We conducted a retrospective, observational cohort study between March 2020 and February 2022. The study included adult patients who received a fixed dose of 3 mg rasburicase. The primary outcome measure was the reduction in serum uric acid (UA) levels at 24 and 48 hours after treatment, with the aim of achieving and maintaining normal UA levels. RESULTS Seventeen patients in the treatment group and 20 patients in the prevention group were included. In the treatment group, 15 (88%) patients had normalization of serum UA, which is considered to be <7 mg/dL (median: 4.48 mg/dL) at 24 hours, and 16 (94%) patients had achieved normal UA at 48 hours (median: 2.78 mg/dL) after receiving the rasburicase dose. In the prevention group, all 20 (100%) patients achieved normal UA at 24 hours after receiving the rasburicase dose. CONCLUSION Based on these findings, a single fixed dose of 3 mg rasburicase is effective for preventing and managing hyperuricemia associated with TLS in high-risk patients.
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Affiliation(s)
- Sabirin Bakhsh
- Pharmaceutical Care Services, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Mansoor Ahmed Khan
- Pharmaceutical Care Services, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Majed Alshamrani
- Pharmaceutical Care Services, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
- Medical Affairs, Johnson & Johnson Innovative Medicine, Riyadh, SAU
| | - Roula Mufti
- Oncology, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
| | - Anjum Naeem
- Pharmaceutical Care Services, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Mubarak AlMansour
- Adult Medical Oncology, Princess Noorah Oncology Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Ahmad Alsaeed
- Adult Hematology/Bone Marrow Transplantation (BMT), Princess Noorah Oncology Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Mousa Alahmari
- Pharmaceutical Care Services, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
| | - Mohammed Aseeri
- Pharmaceutical Care Services, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, SAU
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Musleh Ud Din S, Shan K, Rehman TU, Ivanov S, Vargas-Madueno FM. Unexpected Rasburicase-Induced Hemolysis in a Patient With Normal Glucose-6-Phosphate Dehydrogenase Activity. J Med Cases 2024; 15:231-236. [PMID: 39205694 PMCID: PMC11349123 DOI: 10.14740/jmc4277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Accepted: 08/05/2024] [Indexed: 09/04/2024] Open
Abstract
Tumor lysis syndrome (TLS) presents significant challenges in oncology, primarily due to metabolic complications such as hyperuricemia, which can lead to acute kidney injury. Rasburicase, a recombinant urate oxidase, is frequently employed to manage hyperuricemia in TLS patients. However, its use is an absolute contraindication in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency due to the risk of hemolysis. In this case, the patient developed hemolytic anemia post-rasburicase administration even though she had normal G6PD activity, which was confirmed on two separate occasions, including during an acute episode and 3 months later. This case is unique as it documents hemolytic anemia induced by rasburicase in a patient without G6PD deficiency, challenging current understandings of the drug's safety profile. It suggests the need for caution and thorough screening before rasburicase use, even in patients considered low risk for G6PD deficiency. The report highlights the importance of close monitoring for adverse effects and the potential for alternative mechanisms of rasburicase-induced hemolysis.
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Affiliation(s)
- Saba Musleh Ud Din
- Department of Internal Medicine, Memorial Healthcare System, Hollywood, FL, USA
| | - Khine Shan
- Department of Hematology and Oncology, Memorial Healthcare System, Hollywood, FL, USA
| | - Tauseef Ur Rehman
- Department of Hematology and Oncology, Memorial Healthcare System, Hollywood, FL, USA
| | - Stanislav Ivanov
- Department of Hematology and Oncology, Memorial Healthcare System, Hollywood, FL, USA
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Gilmore S, Carroll M, Koselke E, Hough S. Rasburicase dose optimization for tumor lysis syndrome management in a network of community oncology practices. J Oncol Pharm Pract 2024; 30:867-872. [PMID: 37563922 DOI: 10.1177/10781552231190005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
INTRODUCTION Single, fixed-dose rasburicase administration has been evaluated as an effective strategy in the management of hyperuricemia in the hospital setting, but this has not yet been described within ambulatory community oncology practices. The objective of this study is to evaluate and optimize the dosing strategy for rasburicase in the management of tumor lysis syndrome (TLS)-associated hyperuricemia in The US Oncology Network (The Network). METHODS A network-wide guideline was revised to standardize rasburicase dosing from a previous recommended fixed doses of 4.5 or 7.5 mg to either 3 or 6 mg for outpatient rasburicase use in management and prevention of TLS. The primary outcome evaluated mean dose of rasburicase among all patients before and after guideline revision. A retrospective chart review evaluated secondary endpoints. RESULTS The primary analysis included 291 patients (128 pre-revised and 163 post-revised guideline implementation). The primary outcome, mean rasburicase dose, was reduced in the post-revision compared to the pre-revision population (mean 6.2 mg pre vs. 4.5 mg post, p < 0.00001) resulting in a reduced cost per rasburicase dose of $974. Fifty patients were included for the secondary analysis. Guideline concordance was identified in 12 (48%) and 16 patients (64%), and uric acid <8 mg/dL post-rasburicase administration occurred in 14 (56%) and 16 patients (64%) before and after guideline revision, respectively. CONCLUSIONS Guideline revision and electronic health record modification resulted in a 27% reduction in the mean rasburicase dose and a 50% reduction in repeat rasburicase dosing without a negative impact on clinical efficacy.
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Affiliation(s)
- Steven Gilmore
- The US Oncology Network, McKesson Specialty Health, The Woodlands, TX, USA
| | - Melissa Carroll
- The US Oncology Network, McKesson Specialty Health, The Woodlands, TX, USA
| | - Elizabeth Koselke
- The US Oncology Network, McKesson Specialty Health, The Woodlands, TX, USA
| | - Shannon Hough
- The US Oncology Network, McKesson Specialty Health, The Woodlands, TX, USA
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Kamel A, Sanders M, Dyk H, Hamilton T. A retrospective review of rasburicase utilization in pediatric and adult patients across a large health system. J Oncol Pharm Pract 2024:10781552241253214. [PMID: 38794946 DOI: 10.1177/10781552241253214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
PURPOSE This study aimed to characterize rasburicase dosing and duration. Secondary objectives included characterizing the indication of rasburicase and identifying the utilization of prophylactic therapy for tumor lysis syndrome (TLS). METHODS This retrospective review included patients 0 to 89 years old admitted between 1 January 2021 and 31 December 2021, and received at least one dose of rasburicase. Patients were excluded if they were >89 years old, pregnant, lactating, or received rasburicase outpatient. RESULTS A total of 192 patients, 176 adults and 16 pediatric patients were included in the retrospective review. Of the total population, 184 received a fixed dose of rasburicase and 8 patients received a weight-based dose (0.15 mg/kg/dose) of rasburicase. The average dose administered was 3.4 mg for fixed and 2.99 mg for weight-based dosing. Nearly half (49.5%) the patients received rasburicase for an elevated uric acid but did not meet Cairo-Bishop criteria for TLS. Only 42.2% received at least one dose of allopurinol within 5 days prior to rasburicase and 18.8% received aggressive hydration within 72 h prior to rasburicase. CONCLUSION The majority of rasburicase administered was ordered as fixed dose for a uric acid level ≥7.5 mg/dL. Most patients did not meet criteria for laboratory or clinical TLS and less than half the patients received prophylactic allopurinol and/or aggressive hydration. These study results are supported by recent literature for fixed dose rasburicase as a safe and economical dosing strategy compared to weight-based dosing.
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Affiliation(s)
| | | | - Hannah Dyk
- Banner Desert Medical Center, Mesa, AZ, USA
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Joseph A, Zafrani L. How I Treat Tumor Lysis Syndrome. Clin J Am Soc Nephrol 2023; 18:1634-1636. [PMID: 37788006 PMCID: PMC10723907 DOI: 10.2215/cjn.0000000000000331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 09/25/2023] [Indexed: 10/04/2023]
Affiliation(s)
- Adrien Joseph
- Department of medical intensive care unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris Cité, Paris, France
| | - Lara Zafrani
- Department of medical intensive care unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, University of Paris Cité, Paris, France
- INSERM U944, Saint-Louis Research Institute, University of Paris Cité, Paris, France
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Perissinotti AJ, Bishop MR, Bubalo J, Geyer MB, Goodrich A, Howard SC, Kula J, Mandayam S, Cairo MS, Pui CH. Expert consensus guidelines for the prophylaxis and management of tumor lysis syndrome in the United States: Results of a modified Delphi panel. Cancer Treat Rev 2023; 120:102603. [PMID: 37579533 DOI: 10.1016/j.ctrv.2023.102603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION Tumor lysis syndrome (TLS), which occurs spontaneously or in response to anticancer treatment, results in the release of intracellular potassium, phosphorus, and nucleic acids into the bloodstream, which results in secondary clinical complications that may be fatal. Prior TLS guidelines do not take into consideration potent novel oncologic agents or contemporary treatment paradigms with increased risk of TLS. Thus, a modified Delphi panel of experts was convened to provide an update for TLS management guidelines based upon a combination of supporting literature and practice consensus. METHODS A three-round modified Delphi process was implemented. For round 1, nine expert panelists completed a web-based questionnaire developed using published literature. In round 2, panelists were asked to reconsider their answers to questions that did not reach consensus (defined as ≥ 66% agreement among voting panelists). Round 3 was an unblinded, moderated virtual meeting to discuss any remaining questions that did not reach consensus. RESULTS Detailed recommendations are given for prophylaxis, monitoring, and management of TLS risks and complications, with hydration being a key element of TLS prophylaxis and management. Guidelines for the management of acute effects of TLS and prevention of long-term renal effects include management of hyperkalemia, hypocalcemia, hyperphosphatemia, and hyperuricemia. DISCUSSION Although the control of uric acid levels is quite effective with currently available agents, panelists emphasize the importance of monitoring and treating other dangerous electrolyte abnormalities such as hyperkalemia and hyperphosphatemia. Guidelines from this modified Delphi panel should aid clinicians in preventing and managing TLS.
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Affiliation(s)
- Anthony J Perissinotti
- University of Michigan Health - Michigan Medicine, Department of Pharmacy, Ann Arbor, MI 48109, USA
| | - Michael R Bishop
- The David and Etta Jonas Center for Cellular Therapy, University of Chicago Medicine, Chicago, IL 60637, USA
| | - Joseph Bubalo
- Department of Pharmacy/Division of Hematology and Medical Oncology, OHSU Hospital and Clinics, Pharmacy Services, Portland, OR 97239, USA
| | - Mark B Geyer
- Leukemia and Cell Therapy Services, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10021, USA
| | - Amy Goodrich
- Johns Hopkins Kimmel Cancer Center, Baltimore, MD 21231, USA
| | - Scott C Howard
- University of Tennessee Health Sciences Center, Memphis, TN 38103, USA
| | - Julianna Kula
- Rocky Mountain Cancer Centers, Greenwood Village, CO 80112, USA
| | - Sreedhar Mandayam
- Department of Nephrology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Mitchell S Cairo
- Department of Pediatrics, Cancer and Blood Diseases Center, New York Medical College, Valhalla, NY 10595, USA.
| | - Ching-Hon Pui
- Departments of Oncology, Global Pediatric Medicine, and Pathology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
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Mahfooz K, Sohail H, Gvajaia A, Arif U, Grewal D, Muppidi MR, Vohra V, Tarique A, Vasavada A. Rasburicase in treating tumor lysis syndrome: An umbrella review. CANCER PATHOGENESIS AND THERAPY 2023; 1:262-271. [PMID: 38327601 PMCID: PMC10846299 DOI: 10.1016/j.cpt.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/10/2023] [Accepted: 07/16/2023] [Indexed: 02/09/2024]
Abstract
Tumor lysis syndrome (TLS) remains a debilitating cause of hospitalization and death in patients with cancer and is a significant challenge for healthcare providers despite advancements in its management. This umbrella review analyzed the results of meta-analyses on the use of rasburicase in the treatment of patients with cancer. A literature search was performed of five databases (PubMed, Google Scholar, Cochrane Library, Scopus, Global Index Medicus, and ScienceDirect) for articles with full texts available online. A measurement tool to assess systematic reviews 2 (AMSTAR 2) was used to assess the quality of the included studies, and Review Manager software was used to conduct all statistical analyses. The systematic search identified eight relevant meta-analyses, with primary analyses including outcome data that analyzed mortality, renal failure, and comparisons with allopurinol. The pooled data showed that rasburicase effectively reduced TLS development and serum uric acid levels in children and adults with malignancies. Most outcomes did not differ significantly compared with those of allopurinol. Future trials should focus on the cost-effectiveness of rasburicase compared to that of allopurinol while including high-, intermediate-, and low-risk patients. Rasburicase is safe and effective for managing patients with TLS. However, recent large-scale meta-analyses have reported conflicting results. Most meta-analyses were graded as low to critically low as per AMSTAR 2. The analysis revealed that the benefit of rasburicase did not differ significantly from that of allopurinol, which has higher cost-effectiveness and fewer side effects.
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Affiliation(s)
- Kamran Mahfooz
- Department of Internal Medicine, Lincoln Medical Center, Community Hospital, New York, 10451, USA
| | - Haris Sohail
- Department of Internal Medicine, Lincoln Medical Center, Community Hospital, New York, 10451, USA
| | - Ani Gvajaia
- Department of Internal Medicine, Lincoln Medical Center, Community Hospital, New York, 10451, USA
| | - Uroosa Arif
- Department of Internal Medicine, Lincoln Medical Center, Community Hospital, New York, 10451, USA
| | - Daisy Grewal
- Department of Internal Medicine, St. Georges University, St. Georges, Grenada
| | - Monica Reddy Muppidi
- Department of Internal Medicine, Lincoln Medical Center, Community Hospital, New York, 10451, USA
| | - Vanya Vohra
- Department of Pediatrics, St Barnabas Hospital, Bronx, NY, 10457, USA
| | - Aamir Tarique
- Department of Medicine, ESIC Medical College, Faridabad, 121001, India
| | - Advait Vasavada
- Department of Medicine, MP Shah Medical College, Jamnagar, 361008, India
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Latcha S, Shah CV. Rescue Therapies for AKI in Onconephrology: Rasburicase and Glucarpidase. Semin Nephrol 2023; 42:151342. [PMID: 37167817 DOI: 10.1016/j.semnephrol.2023.151342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Tumor lysis syndrome (TLS) and high-dose methotrexate (HD MTX) toxicity can present with potentially severe complications, including acute kidney injury, in patients with malignancy. Guidelines for using rasburicase and glucarpidase as rescue therapies for TLS and HD MTX toxicity, respectively, are widely used by clinicians intending to mitigate organ toxicity and decrease morbidity and mortality as a consequence of cancer therapy. This review discusses the pathogenesis of TLS and HD MTX-associated toxicity, to understand the mechanism of action of these therapeutic agents and to review the currently available evidence supporting their use.
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Affiliation(s)
- Sheron Latcha
- Renal Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Chintan V Shah
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida College of Medicine, Gainesville, FL
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Majumdar S, Sharma N, Sengar M, Thorat J, Nayak L, Bonda A, Bagal B, Rajendra A, Sethi A, Jain H. A phase II study to evaluate the efficacy of low-dose rasburicase (1.5mg) in adolescent and adult acute leukemia and high-grade lymphomas with tumor lysis syndrome. Leuk Lymphoma 2023; 64:628-638. [PMID: 36891578 DOI: 10.1080/10428194.2023.2167491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
The FDA recommended dose of rasburicase 0.2 mg/kg/day till the resolution of TLS or up to 5 days, might be in excess and is prohibitively expensive. The quality of evidence supporting low dose rasburicase is limited. The objective is to study the plasma uric acid response rate. This is a single center, non-randomised phase II study. Duration is 10 June 2017 till 30 July 2019. Study setting is at Adult Hematolymphoid Unit, Tata Memorial Center. Participants are patients with acute leukemia and high-grade lymphomas aged >/=18 years, with ECOG PS of 0-3, with either laboratory or clinical TLS. Rasburicase was administered at fixed-dose of 1.5 mg. The subsequent doses (1.5 mg each dose) were administered only if plasma UA levels did not decline by >50% on day 2, at the physician's discretion. We demonstrate that a low-dose rasburicase strategy leads to rapid and sustained reductions of uric acid in about 52% patients.
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Affiliation(s)
- Swaratika Majumdar
- Medical Oncology, MS Ramaiah Medical College, Rajiv Gandhi University of Health Sciences, Bangalore, India
| | - Neha Sharma
- Medical Oncology, Tata Memorial Centre, Homi Bhabha National University, Mumbai, India
| | - Manju Sengar
- Medical Oncology, MS Ramaiah Medical College, Rajiv Gandhi University of Health Sciences, Bangalore, India
| | - Jayashree Thorat
- Medical Oncology, MS Ramaiah Medical College, Rajiv Gandhi University of Health Sciences, Bangalore, India
| | - Lingaraj Nayak
- Medical Oncology, MS Ramaiah Medical College, Rajiv Gandhi University of Health Sciences, Bangalore, India
| | - Avinash Bonda
- Medical Oncology, Homi Bhabha Cancer Hospital & Research Centre, Tata Memorial Centre, Mumbai, India
| | - Bhausaheb Bagal
- Medical Oncology, MS Ramaiah Medical College, Rajiv Gandhi University of Health Sciences, Bangalore, India
| | - Akhil Rajendra
- Department of Medical Oncology, Cancer Institute WIA, Adyar, Chennai, India
| | - Amit Sethi
- Department of Electrical Engineering, Indian Institute of Bombay, Powai, India
| | - Hasmukh Jain
- Medical Oncology, MS Ramaiah Medical College, Rajiv Gandhi University of Health Sciences, Bangalore, India
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Yu L, Xie Y, Ma J, Li G, Yuan X. Rasburicase-Induced Falsely Low Measurement of Uric Acid in Tumor Lysis Syndrome: A Report of Two Cases. Cureus 2023; 15:e34435. [PMID: 36874663 PMCID: PMC9981216 DOI: 10.7759/cureus.34435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 02/01/2023] Open
Abstract
Rasburicase, a recombinant urate-oxidase enzyme, can significantly catalyze the oxidation of uric acid to allantoin. It was approved by the US Food and Drug Administration (FDA) to control blood uric acid levels in both pediatric and adult patients especially those with tumor lysis syndrome. It is quite important to realize that rasburicase can continue to be effective ex vivo and cause falsely low results if the blood sample is not contained and transported in ice water immediately. We presented two cases of falsely low measurement of blood uric acid caused by rasburicase and elaborated the proper method for collecting and transporting blood samples from patients using rasburicase.
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Affiliation(s)
- Lian Yu
- Department of Medical Laboratory, Shenzhen People's Hospital, Shenzhen, CHN
| | - Yinjing Xie
- Department of Medical Laboratory, Shenzhen People's Hospital, Shenzhen, CHN
| | - Jiangtao Ma
- Department of Medical Laboratory, Shenzhen People's Hospital, Shenzhen, CHN
| | - Guoqiang Li
- Department of Medical Laboratory, Shenzhen People's Hospital, Shenzhen, CHN
| | - Xiaopeng Yuan
- Department of Medical Laboratory, Shenzhen People's Hospital, Shenzhen, CHN
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Masamayor EMI, Besa JJV, Tan-Lim CSC, Pajes ANNI, Palileo-Villanueva LM. Effectiveness and Safety of Allopurinol, Febuxostat, and Rasburicase in the Prevention of Tumor Lysis Syndrome: A Systematic Review and Network Meta-analysis. ASIAN JOURNAL OF ONCOLOGY 2022. [DOI: 10.1055/s-0042-1750701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
AbstractAlthough prevention is vital in managing tumor lysis syndrome (TLS), no study directly compares various regimens. This study compared the effectiveness and safety of urate-lowering agents in preventing TLS. Databases were searched for randomized controlled trials involving adults with hematologic or solid malignancies on chemotherapy or cytoreductive agents given allopurinol, febuxostat, or rasburicase alone or in combination at any dose, form, or frequency published in English by December 2021. Outcomes included laboratory and clinical TLS expressed as relative risks, adverse events as described by authors, and mean serum uric acid (sUA) as mean differences of area under the curve. A network of meta-analysis and post-hoc meta-analysis based on TLS risk using a random-effects model was done using Stata 14.0 and Review Manager 5.3, respectively. Certainty of evidence was assessed using the GRADE approach. Three studies with a total of 633 participants given allopurinol, febuxostat, rasburicase, or rasburicase combined with allopurinol were included. Rasburicase is more effective than allopurinol in preventing laboratory TLS (relative risk: 0.51; 95% confidence interval [CI]: 0.32–0.81) based on moderate quality evidence. No significant differences were observed in clinical TLS. Adverse events were attributable to toxicities of chemotherapy. Rasburicase alone or in combination with allopurinol was better than allopurinol or febuxostat alone in reducing sUA level. Febuxostat is more effective than allopurinol in lowering sUA levels among patients at high-risk of TLS (mean difference −125.75; 95% CI: −223.47 to −28.02). Rasburicase may be the most effective agent in preventing laboratory TLS and maintaining low sUA levels.
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Affiliation(s)
- Ella Mae I. Masamayor
- Department of Medicine, University of the Philippines - Philippine General Hospital, Manila, Philippines
| | - John Jefferson V. Besa
- Department of Medicine, University of the Philippines - Philippine General Hospital, Manila, Philippines
| | - Carol Stephanie C. Tan-Lim
- Department of Clinical Epidemiology, College of Medicine, University of the Philippines Manila, Philippines
| | - A. Nico Nahar I. Pajes
- Section of Gastroenterology, Department of Medicine, University of the Philippines – Philippine General Hospital, Manila, Philippines
| | - Lia M. Palileo-Villanueva
- Department of Medicine, University of the Philippines - Philippine General Hospital, Manila, Philippines
- Department of Medicine, College of Medicine, University of the Philippines Manila, Philippines
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Review of Hematological and Oncological Emergencies. Adv Emerg Nurs J 2022; 44:84-102. [PMID: 35476684 DOI: 10.1097/tme.0000000000000399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with hematological malignancies, both treated and untreated, or solid tumors undergoing treatment are at risk of life-threatening complications, which may present in the emergency department (ED). Such emergencies are diverse in etiology and often require prompt treatment. Traditional complications, such as febrile neutropenia, have had recent guideline updates, which incorporate new evidence and a new validated risk stratification tool. In addition, newer approaches to treatment, such as chimeric antigen receptor (CAR) T-cell therapy, are becoming more widely available and have unique associated toxicities. This review discusses the management of the following hematological and oncological emergencies likely to be encountered in the ED: febrile neutropenia, CAR T-cell toxicities, differentiation syndrome, tumor lysis syndrome, hypercalcemia of malignancy, and hyponatremia.
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Aylan Gelen S, Sarper N, Zengin E, Azizoğlu M. Management of Hyperleukocytosis in Childhood Acute Leukemia Without Leukapheresis and Rasburicase Prophylaxis. J Pediatr Hematol Oncol 2022; 44:12-18. [PMID: 34054042 DOI: 10.1097/mph.0000000000002225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 05/04/2021] [Indexed: 11/26/2022]
Abstract
Indications of leukapheresis (LPh) and the prophylactic use of rasburicase in tumor lysis syndrome (TLS) of patients with acute leukemia with hyperleukocytosis are not clear. In this retrospective single-center pediatric study, the outcomes of patients with hyperleukocytosis were reviewed. There were 48 patients with acute lymphoblastic leukemia (ALL) and 13 patients with acute myeloblastic leukemia (AML). The treatment strategies included hyperhydration, allopurinol administration, strict monitoring, and early initiation of induction chemotherapy (CT). No patient underwent LPh because it was not available. Rasburicase was used only in 3 ALL patients with hyperuricemia when the drug was available. Laboratory and clinical TLS developed in 54.16% and 14.58% of patients with ALL, respectively. Laboratory and clinical TLS developed in 76.92% and 15.38% of patients with AML, respectively. No patient developed grade III to V TLS requiring dialysis. Thirteen patients (21.3%) had pulmonary leukostasis on admission, but recovered with CT and nasal oxygen. During the first 14 days of presentation, cerebral leukostasis/coagulopathy-related early death (ED) was 4.2% and 7.7% in patients with ALL and AML, respectively, and all of these patients had a white blood cell count ≥400,000/µL. There was also 1 infection-related death. Patients with hyperleukocytosis can be treated without LPh and liberal use of rasburicase. Renal failure is no longer a cause of ED. Intracranial hemorrhage is the main cause of ED, especially in patients already presenting with this complication. LPh may be performed in patients with leukostasis, if it is not possible to start induction CT early. When resources are limited, rasburicase should be administered in patients presenting with or developing hyperuricemia and/or renal dysfunction.
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Affiliation(s)
- Sema Aylan Gelen
- Department of Pediatrics, Division of Pediatric Hematology, Kocaeli University, Kocaeli, Turkey
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Yaman S, Başcı S, Turan G, Ulu BU, Yiğenoğlu TN, Dal MS, Kızıl Çakar M, Altuntaş F. Single-Dose Rasburicase Might Be Adequate To Overcome Tumor Lysis Syndrome In Hematological Malignancies. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:e71-e76. [PMID: 34565690 DOI: 10.1016/j.clml.2021.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 08/16/2021] [Accepted: 08/25/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Tumor lysis syndrome (TLS) is a commonly observed oncological emergency that requires prompt diagnosis and treatment. Rasburicase is a recombinant urate oxidase endorsed in TLS for the treatment of hyperuricemia. The effect of single-dose 7.5 mg rasburicase at longer follow-ups was not widely investigated. PATIENTS AND METHODS Eighty-two patients included in the study with clinical TLS and laboratory TLS. The primary endpoint was the normalization of uric acid (<6mg/dL) within 24 hours of rasburicase administration, which was described as treatment success. The secondary endpoint was defined as having sustained response at the first week. The third endpoint was defined as the reaching the baseline renal function before TLS. RESULTS We found that the use of a 7.5 mg dose of rasburicase controlled uric acid in 74 of 82 (90,2%) patients at the 24th hour. In the first week, uric acid remained at normal levels in 69 of 82 (84,1%) patients. At 24 hours, the TLS risk group was the only predictor for failing uric acid normalization; at the end of the first week, no predictive factor was identified for failing uric acid normalization. CONCLUSION Rasburicase at 7.5 mg dose is an important agent for controlling laboratory and clinical TLS at 24 hours and extending its effect to the first week.
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Affiliation(s)
- Samet Yaman
- Department of Hematology and Bone Marrow Transplantation Center, Ankara Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey.
| | - Semih Başcı
- Department of Hematology and Bone Marrow Transplantation Center, Ankara Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Gökhan Turan
- Department of Internal Medicine, Ankara Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Bahar Uncu Ulu
- Department of Hematology and Bone Marrow Transplantation Center, Ankara Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Tuğçe Nur Yiğenoğlu
- Department of Hematology and Bone Marrow Transplantation Center, Ankara Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Mehmet Sinan Dal
- Department of Hematology and Bone Marrow Transplantation Center, Ankara Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Merih Kızıl Çakar
- Department of Hematology and Bone Marrow Transplantation Center, Ankara Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Fevzi Altuntaş
- Department of Hematology and Bone Marrow Transplantation Center, Ankara Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital, University of Health Sciences, Ankara, Turkey
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Hossain S, Naber M, Yacobucci MJ. A retrospective observational study of a low fixed-dose rasburicase protocol for the treatment of tumor lysis syndrome in adults. J Oncol Pharm Pract 2021; 28:1326-1331. [PMID: 34115548 DOI: 10.1177/10781552211021147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Tumor lysis syndrome is an oncologic emergency characterized by hyperuricemia. Previous studies have demonstrated that a fixed-dose strategy of rasburicase is as effective as the FDA approved weight-based dose. Albany Medical Center employs rasburicase 1.5 mg in patients with a uric acid (UA) between 8 and 12 mg/dL and 3 mg for UA above12 mg/dL.We aimed to evaluate the UA lowering effectiveness and provider adherence to the institutional protocol, as well as the cost-efficiency of this dosing strategy. METHODS This is a single center, retrospective, cohort study. The electronic medical record was used to identify patients receiving rasburicase and to collect baseline demographic and laboratory data. The fixed-dose strategies of rasburicase 1.5 mg and 3 mg were compared in their degree of UA reduction and clinical outcomes. Cost-savings of fixed-dosing was compared to the FDA-approved weight-based dose. RESULTS Mean UA reduction in the 1.5 mg group (n = 49) from baseline to 24 hours was 2.88 ± 0.88 mg/dL (p < 0.0001) and 4.83 ± 1.39 mg/dL (p < 0.0001) in the 3 mg group (n = 105). A subgroup analysis of patients who received per protocol initial doses of rasburicase showed a mean reduction in UA from baseline to 24 hours of 2.83 ± 0.62 mg/dL in the 1.5 mg group (n = 42) and 6.12 ± 1.87 mg/dL in the 3 mg group (n = 42). Using a low fixed-dose approach resulted in a cost-savings of $138,077.30 annually. CONCLUSION Low fixed-dose rasburicase was an effective treatment, with a dose of 1.5 mg being sufficient to reach a goal UA of less than 8 mg/dL for serum UA levels below 12 mg/dL, while a 3 mg dose is appropriate for levels above 12 mg/dL. Cost analysis indicates this strategy is more cost-efficient than the FDA-approved weight-based dose.
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Affiliation(s)
- Shahrier Hossain
- Department of Pharmacy, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Martha Naber
- Department of Pharmacy, Albany Medical Center Hospital, Albany, NY, USA
| | - Matthew J Yacobucci
- Department of Pharmacy, Albany Medical Center Hospital, Albany, NY, USA.,Department of Pharmacy Practice, Albany College of Pharmacy and Health Sciences, Albany, NY, USA
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Vachhani P, Baron J, Freyer CW, Miller A, Wetzler M, Thompson JE, Griffiths EA, Wang ES. A phase 2 trial of single low doses of rasburicase for treatment of hyperuricemia in adult patients with acute leukemia. Leuk Res 2021; 107:106588. [PMID: 33957371 DOI: 10.1016/j.leukres.2021.106588] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/22/2021] [Accepted: 03/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rasburicase can markedly and rapidly decrease uric acid (UA) levels, thereby preventing and treating tumor lysis syndrome. However, rasburicase is expensive, especially when used as per the manufacturer's recommended dosage of 0.2 mg/kg/day for up to 5 days. Numerous reports have shown that lower, and even single doses are effective in lowering UA levels but prospective randomized studies comparing low doses have not been performed. OBJECTIVES To prospectively determine the efficacy and safety of two single low doses of rasburicase in adult patients (pts) with acute leukemia and elevated plasma UA. METHODS Eligible pts aged ≥ 18 years old with acute leukemia and UA ≥ 7.5 mg/dL were randomized to receive an initial single dose of rasburicase 1.5 mg (Arm A) or 3 mg (Arm B) on day 1 in an unblinded fashion. All pts received allopurinol 300 mg daily on days 1-6. RESULTS Twenty-four pts (median age 69 years; 14 males and 10 females) were enrolled in this phase 2 study (12 on each arm). Twenty pts had acute myeloid leukemia while 3 had acute lymphoblastic leukemia, and 1 had acute promyelocytic leukemia. Median initial UA level was 9.8 mg/dL. Eighty-three percent of pts in both arms achieved UA < 7.5 mg/dL by 24 h after therapy. Five pts (21 %; 2 from Arm A and 3 from Arm B) required additional doses of rasburicase. The majority (23/24) of pts achieved UA goals after 1-2 doses of rasburicase. None had worsening renal function. Both doses were well tolerated, and no treatment related adverse events were reported. CONCLUSIONS Single doses of rasburicase (as low as 1.5-3 mg) used in addition to allopurinol were well tolerated and highly efficacious (83 % response rate) in decreasing UA levels within 24 h of administration in adult acute leukemia pts with hyperuricemia.
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Affiliation(s)
- Pankit Vachhani
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA.
| | - Jeffrey Baron
- Department of Pharmacy, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Craig W Freyer
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Austin Miller
- Department of Biostatistics & Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Meir Wetzler
- Section of Leukemia, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - James E Thompson
- Section of Leukemia, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Elizabeth A Griffiths
- Section of Leukemia, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Eunice S Wang
- Section of Leukemia, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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17
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Gupta G, Seth T, Garg V, Juneja R, Mahapatra M, Datta SK, Upadhyay AD, Saxena R. Efficacy of Single Low-Dose Rasburicase in Management of Tumor Lysis Syndrome in Leukemia and Lymphoma Patients. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2021; 21:e99-e104. [PMID: 33039358 DOI: 10.1016/j.clml.2020.08.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/28/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Tumor lysis syndrome (TLS) is a metabolic emergency in hematology patients. The recommended dose of rasburicase for the management of TLS is 0.2 mg/kg per day for 5 days, which is cost prohibitive for many patients. We sought to determine the efficacy of single low-dose rasburicase in the prevention and treatment of hyperuricemia in TLS. PATIENTS AND METHODS We planned a prospective study for the safety and efficacy of fixed (weight based) dose of rasburicase to manage TLS. Patients diagnosed with leukemia/lymphoma with laboratory or clinically confirmed TLS or presence of ≥ 2 high-risk factors and serum uric acid > 7.5 mg/dL were included. The primary endpoint was uric acid normalization (< 7.5 mg/dL) within 24 hours of rasburicase administration. RESULTS Fifty-five patients were recruited for this study. Pediatric patients (< 18 years) accounted for 43.6% of cases. Rasburicase was provided prophylactically to 43 patients (78.2%) and for treating TLS to 12 (21.8%). Mean ± standard deviation serum uric acid at baseline and 24 hours was 9.2 ± 1.8 mg/dL and 3.2 ± 2.1 mg/dL, respectively. There was significant reduction in the serum uric acid and creatinine (P < .001) within 24 hours of rasburicase administration. The response was maintained up to 72 hours. A single dose of rasburicase was effective in 94.5% of patients. Single low-dose rasburicase led to 95% direct cost savings compared to the recommended dose. CONCLUSION Single-dose rasburicase with frequent laboratory monitoring is effective in the management of TLS and offers significant cost reductions.
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Affiliation(s)
- Gopila Gupta
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India.
| | - Tulika Seth
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India
| | - Vikas Garg
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Richa Juneja
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India
| | - Manoranjan Mahapatra
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India
| | - Sudip Kumar Datta
- Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Datt Upadhyay
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Renu Saxena
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India
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Hogg R. "Disproportionate" hyperuricemia in children with hemolytic uremic syndrome (HUS): should we regard this as a "medical emergency"? Pediatr Nephrol 2020; 35:2205-2210. [PMID: 32720140 DOI: 10.1007/s00467-020-04713-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/08/2020] [Indexed: 11/26/2022]
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19
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Matuszkiewicz-Rowinska J, Malyszko J. Prevention and Treatment of Tumor Lysis Syndrome in the Era of Onco-Nephrology Progress. Kidney Blood Press Res 2020; 45:645-660. [DOI: 10.1159/000509934] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/04/2020] [Indexed: 11/19/2022] Open
Abstract
Background: Tumor lysis syndrome (TLS) is an oncologic emergency due to a rapid break down of malignant cells usually induced by cytotoxic therapy, with hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and serious clinical consequences such as acute renal injury, cardiac arrhythmia, hypotension, and death. Rapidly expanding knowledge of cancer immune evasion mechanisms and host-tumor interactions has significantly changed our therapeutic strategies in hemato-oncology what resulted in the expanding spectrum of neoplasms with a risk of TLS. Summary: Since clinical TLS is a life-threatening condition, identifying patients with risk factors for TLS development and implementation of adequate preventive measures remains the most critical component of its medical management. In general, these consist of vigilant laboratory and clinical monitoring, vigorous IV hydration, urate-lowering therapy, avoidance of exogenous potassium, use of phosphate binders, and – in high-risk cases – considering cytoreduction before the start of the aggressive agent or a gradual escalation of its dose. Key Messages: In patients with a high risk of TLS, cytotoxic chemotherapy should be given in the facility with ready access to dialysis and a treatment plan discussed with the nephrology team. In the case of hyperkalemia, severe hyperphosphatemia or acidosis, and fluid overload unresponsive to diuretic therapy, the early renal replacement therapy (RRT) should be considered. One must remember that in TLS, the threshold for RRT initiation may be lower than in other clinical situations since the process of cell breakdown is ongoing, and rapid increases in serum electrolytes cannot be predicted.
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20
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Balestracci A, Meni Battaglia L, Martin SM, Toledo I. Rasburicase in hemolytic uremic syndrome related to Shiga toxin-producing Escherichia coli: a report of nine cases. Pediatr Nephrol 2020; 35:1133-1137. [PMID: 32152725 DOI: 10.1007/s00467-020-04528-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 01/30/2020] [Accepted: 02/28/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hyperuricemia might induce additional renal damage in children with hemolytic uremic syndrome related to Shiga toxin-producing Escherichia coli (STEC-HUS). A few case reports have shown rasburicase to be effective in decreasing serum uric acid (UA) and improving renal function. However, there is only one report on the use of rasburicase in a child with STEC-HUS, which shows satisfactory results. We describe here the safety and efficacy of rasburicase in nine additional cases. CASE-DIAGNOSIS/TREATMENT Data from 9 children (5 females, median age 2 years) who received rasburicase were reviewed. At admission, 6 were dehydrated and 3 euvolemic. Dehydrated patients received saline solution and afterwards, as well as for those initially euvolemic, we aimed to keep a neutral fluid balance. Despite this, urine output did not increase. Baseline creatinine was 3.35 mg/dL (1.47-9.1) and UA 11.4 mg/dL (8.3-19.2). A single dose of rasburicase (0.2 mg/kg) was given 6-8 h after admission, which reduced UA levels to 1.8 mg/dL (0.3-5, p = 0.009) on the next day. However, renal parameters worsen and dialysis had to be initiated. Then, while still on dialysis, a UA rebound occurred in all cases reaching a peak of 8.9 mg/dL (4.5-13.8). Just after a steady increase in urine output, a sustained decline in UA levels concomitantly occurred with an improvement in renal function. At discharge, all patients reached normal UA levels. No side effects were recorded. CONCLUSIONS Administration of rasburicase in children with STEC-HUS was safe but failed to provide any significant benefit despite fall in serum UA levels.
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Affiliation(s)
- Alejandro Balestracci
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Buenos Aires, Argentina.
| | - Luciana Meni Battaglia
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Buenos Aires, Argentina
| | - Sandra Mariel Martin
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Buenos Aires, Argentina
| | - Ismael Toledo
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Montes de Oca 40, CP 1270, Buenos Aires, Argentina
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Otani N, Ouchi M, Kudo H, Tsuruoka S, Hisatome I, Anzai N. Recent approaches to gout drug discovery: an update. Expert Opin Drug Discov 2020; 15:943-954. [PMID: 32329387 DOI: 10.1080/17460441.2020.1755251] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Inflammation induced by urate deposition in joints causes gout. Healthy individuals maintain serum levels of urate by balancing urate production/excretion, whereas a production/excretion imbalance increases urate levels. Hyperuricemia is diagnosed when the serum urate level is continuously above 7 mg/dl as the solubility limit, and urate accumulates in the kidneys and joints. Because hyperuricemia increases the risk of gout, therapies aim to eliminate urate deposition to prevent gouty arthritis and kidney injury. AREAS COVERED This review discusses the mechanism underlying hyperuricemia with respect to urate production and urate transport, along with urate-lowering therapeutics, including urate synthesis inhibitors, uricolytic enzymes, and uricosuric agents. The authors asses published data on relevant commercial therapy development projects and clinical trials. EXPERT OPINION Available treatment options for hyperuricemia are limited. Allopurinol, a urate synthesis inhibitor, is generally administered at a reduced dosage to patients with renal impairment. Some URAT1 inhibitors have an unfavorable side effect profile. A promising strategy for treatment is the use of uricosuric agents that inhibit transporters (e.g. URAT1, URATv1/GLUT9, OAT10) which reabsorb urate from the urine.
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Affiliation(s)
- Naoyuki Otani
- Department of Clinical Pharmacology and Therapeutics, Oita University Faculty of Medicine , Oita, Japan
| | - Motoshi Ouchi
- Department of Pharmacology and Toxicology, Dokkyo Medical University School of Medicine , Tochigi, Japan
| | - Hideo Kudo
- Department of Clinical Pharmacology and Therapeutics, Oita University Faculty of Medicine , Oita, Japan
| | | | - Ichiro Hisatome
- Department of Genetic Medicine and Regenerative Therapeutics, Tottori University Graduate School of Medical Science , Tottori, Japan
| | - Naohiko Anzai
- Department of Pharmacology, Chiba University Graduate School of Medicine , Chiba, Japan
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22
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Personett HA, Barreto EF, McCullough KB, Dierkhising R, Leung N, Habermann TM. Impact of early rasburicase on incidence of clinical tumor lysis syndrome in lymphoma. Leuk Lymphoma 2019; 60:2271-2277. [PMID: 31223041 DOI: 10.1080/10428194.2019.1574000] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Early administration of rasburicase to enhance uric acid (UA) elimination has been adopted without robust evidence in support of its impact on clinical outcomes in tumor lysis syndrome (TLS), specifically, the prevention of acute kidney injury (AKI). This was a retrospective cohort study of adult lymphoma patients at intermediate or high risk for TLS. Excluded patients had AKI or were on dialysis at hospital admission. The incidence of new AKI in the setting of TLS was described along with predictors of its development, including early rasburicase use. In 383 included patients, the incidence of new-onset AKI during hospitalization was 6%. Predictors included age, history of renal or cardiovascular disease, and UA >8 mg/dL. Rasburicase use did not significantly impact the risk of developing AKI (HR 2.3; p = .11). The UA level at the time of administration did not modify the effect of rasburicase on prevention of AKI (p = .36 for the interaction term).
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Affiliation(s)
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic , Rochester , MN , USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | | | - Ross Dierkhising
- Division of Biomedical Statistics and Informatics, Mayo Clinic , Rochester , MN , USA
| | - Nelson Leung
- Division of Nephrology and Hypertension and Division of Hematology, Mayo Clinic , Rochester , MN , USA.,Division of Hematology, Mayo Clinic , Rochester , MN , USA
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Eng S, Lee CS, Ahn S, Sharma A. A retrospective analysis of tumor lysis syndrome management in a quaternary care hospital. J Oncol Pharm Pract 2019; 26:338-344. [PMID: 31088218 DOI: 10.1177/1078155219846949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Due to an increased use of rasburicase, the study's purpose was to evaluate both the management of tumor lysis syndrome and the utilization of rasburicase in the hospital system. Additionally, the efficacy of flat dose rasburicase in lowering uric acid levels was evaluated. Based on the study's findings, the investigators will evaluate the usefulness of implementing a tumor lysis syndrome order set. METHODS This study evaluated patients from January 2013 through December 2016 for the rasburicase dose and the tumor lysis syndrome therapy administered. RESULTS Overall, 251 patients were included: prophylactic rasburicase group (n = 125) vs. treatment rasburicase group (n = 126) and of rasburicase 3 mg (R3) group (n = 168) vs. 6 mg (R6) group (n = 83). The prophylactic rasburicase vs. treatment rasburicase group had a significantly lower rate of receiving a xanthine oxidase inhibitor (48.0% vs. 64.3%, p = 0.009), a phosphate binder (6.4% vs. 17.5%, p = 0.007) and an additional dose of rasburicase (20.8% vs. 41.3%, p = 0.001). Intravenous hydration was neither significantly different between the rasburicase groups (p = 0.399) nor between the two rasburicase dosing groups (p = 0.874). Between the rasburicase dosing groups, there was no significant difference in the rate of receiving a xanthine oxidase inhibitor (p = 0.521) or a phosphate binder (p = 0.390). R6 patients had a significantly greater reduction in uric acid change compared to R3 patients (median = -7.9 (-10.1, -5.5) vs. -4.3 (-6.0, -2.7), p < 0.0001). There was no significant difference in uric acid change between the prophylactic rasburicase and treatment rasburicase groups (p = 0.875). CONCLUSION The study's findings justified the need to implement a tumor lysis syndrome order set. In the study population, utilizing a flat dosing method was effective for hyperuricemia.
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Affiliation(s)
- Stephen Eng
- PGY1 Pharmacy Resident, Hackensack University Medical Center, Hackensack, USA
| | - Chung-Shien Lee
- Department of Clinical Health Professions, College of Pharmacy and Health Sciences, St. John's University, Queens, USA.,Division of Medical Oncology and Hematology Northwell Health Cancer Institute Donald & Barbara Zucker School of Medicine at Hofstra/Northwell Lake Success, NY
| | - Seungjun Ahn
- Biostatistics Unit, Feinstein Institute for Medical Research, Manhasset, USA
| | - Amy Sharma
- Division of Medical Oncology and Hematology Northwell Health Cancer Institute Donald & Barbara Zucker School of Medicine at Hofstra/Northwell Lake Success, NY
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24
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Abstract
Tumor lysis syndrome is a constellation of metabolic derangements seen when tumor cells die and release their intracellular contents into the systemic circulation. Hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia may lead to severe organ dysfunction and even death. Tumor lysis syndrome is classically considered a complication of successful cancer treatment, but it can also occur in untreated malignancies characterized by rapid proliferation. In this review, we cover the types of cancers and chemo- and immunotherapies associated with tumor lysis syndrome, the mechanisms by which severe metabolic derangements can develop, and the available treatments.
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Affiliation(s)
- Krishna Sury
- Section of Nephrology, Department of Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA
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25
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Kahts MF, Davidson A, Van Eyssen A, Nourse P, McCulloch M, Hendricks M. A cost comparison of rasburicase versus dialysis in the management of children with acute leukaemia and lymphoma at a South African centre. SOUTH AFRICAN JOURNAL OF ONCOLOGY 2018. [DOI: 10.4102/sajo.v2i0.50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background: Tumour lysis syndrome is a common complication of haematological malignancies and has historically been managed with hyperhydration, urine alkalinisation and allopurinol with renal dialysis reserved for patients in acute renal failure. Rasburicase has been shown to drastically reduce the need for dialysis; however, its use is limited in developing countries owing to its cost and availability.Aim: This retrospective analysis aimed to compare the cost to state per patient of rasburicase compared to dialysis in the management and prevention of tumour lysis syndrome in paediatric patients presenting with haematological malignancies admitted to Red Cross War Memorial Children’s Hospital (RCWMCH).Setting: Red Cross War Memorial Children’s Hospital.Methods: Patients from two consecutive 35 month periods, before and after the availability of rasburicase at RCWMCH, were grouped according to treatment modality, and the cumulative costs of hospitalisation, dialysis and drug administration were compared.Results: The groups were comparable in mean age and gender. The mean total length of hospital stay was 10.04 days shorter for the rasburicase group than the dialysis group with the average cost per patient in the rasburicase group being R40 989.64 lower than the dialysis group.Conclusion: The use of rasburicase results in a significant per patient cost saving when compared to dialysis, which often requires intensive care admission, and results in extended hospitalisation. The study supports the continued use of rasburicase as an essential adjunct in the management and prevention of tumour lysis syndrome, reaffirming its use as a cost-effective and efficient drug.
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26
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Akande M, Audino AN, Tobias JD. Rasburicase-induced Hemolytic Anemia in an Adolescent With Unknown Glucose-6-Phosphate Dehydrogenase Deficiency. J Pediatr Pharmacol Ther 2017; 22:471-475. [PMID: 29290749 DOI: 10.5863/1551-6776-22.6.471] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Rasburicase, used in the prevention and treatment of tumor lysis syndrome (TLS), may cause hemolytic anemia and methemoglobinemia in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Although routine screening for G6PD deficiency has been recommended, given the turnaround time for test results and the urgency to treat TLS, such screening may not be feasible. We report a case of rasburicase-induced hemolytic anemia without methemoglobinemia in an adolescent with T-cell lymphoblastic lymphoma, TLS, and previously unrecognized G6PD deficiency. Previous reports of hemolytic anemia with rasburicase are reviewed, mechanisms discussed, and preventative strategies presented.
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Affiliation(s)
- Manzilat Akande
- Division of Pediatric Critical Care Medicine (MA), Nationwide Children's Hospital, Columbus, Ohio, Department of Pediatrics (MA, ANA), The Ohio State University College of Medicine, Columbus, Ohio, Division of Pediatric Hematology/Oncology/BMT (ANA), Nationwide Children's Hospital, Columbus Ohio, Department of Anesthesiology & Pain Medicine (JTD), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology & Pain Medicine (JTD), The Ohio State University College of Medicine, Columbus, Ohio
| | - Anthony N Audino
- Division of Pediatric Critical Care Medicine (MA), Nationwide Children's Hospital, Columbus, Ohio, Department of Pediatrics (MA, ANA), The Ohio State University College of Medicine, Columbus, Ohio, Division of Pediatric Hematology/Oncology/BMT (ANA), Nationwide Children's Hospital, Columbus Ohio, Department of Anesthesiology & Pain Medicine (JTD), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology & Pain Medicine (JTD), The Ohio State University College of Medicine, Columbus, Ohio
| | - Joseph D Tobias
- Division of Pediatric Critical Care Medicine (MA), Nationwide Children's Hospital, Columbus, Ohio, Department of Pediatrics (MA, ANA), The Ohio State University College of Medicine, Columbus, Ohio, Division of Pediatric Hematology/Oncology/BMT (ANA), Nationwide Children's Hospital, Columbus Ohio, Department of Anesthesiology & Pain Medicine (JTD), Nationwide Children's Hospital, Columbus, Ohio, and Department of Anesthesiology & Pain Medicine (JTD), The Ohio State University College of Medicine, Columbus, Ohio
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