Management of hyperuricemia in adults with or at risk of tumor lysis syndrome

Conclusion

In adult patients with cancer, the risk of serious clinical consequences of TLS often is increased by the presence of renal impairment, heart disease, baseline metabolic imbalances, and multiorgan derangements. Even in adult patients without serious comorbidities, an age-related decrease in physiologic resistance (reduced pathobiologic reserve), lifestyle factors (eg, adverse chronic exposure to tobacco, alcohol, or other toxins; sedentary existence; obesity; and vitamin and macro/micronutrient deficiencies), and dependence on multiple medications (polypharmacy and an associated increased risk for drug-drug interactions) should be considered for both TLS risk assessment and therapeutic choices in TLS prophylaxis and treatment. Although TLS is most common in patients with hematologic malignancies, serious cases of TLS have been reported in patients with a large variety of solid tumors, with sometimes fatal outcomes.

Assessment of TLS risk in patients with solid tumors, who generally tend to belong to a more aged population, is more difficult than in those with hematologic malignancies. Tumor burden and the type of chemotherapy are the most important risk factors for development of TLS in association with solid tumors; however, an unexpected occurrence of acute spontaneous TLS with hyperuricemia has been observed, even in the absence of these two factors.

Hyperuricemia is a key manifestation of TLS and is associated with risks of AKI, fluid overload, heart failure, and death. Prevention of hyperuricemia in high-risk patients and its rapid reversal in those with hyperuricemia at presentation or in those with fully developed TLS are of utmost importance in the successful management of TLS in adults with cancer. Results of the recent phase III study of rasburicase in adult patients with cancer demonstrated that rasburicase is superior to allopurinol in providing rapid and effective control of PUA levels.

Acknowledgments: Editorial assistance provided by Roland Tacke, PhD, and Candace Lundin, DVM, MS, was funded by sanofi-aventis US. The authors were fully responsible for all content and editorial decisions and did not receive financial support or compensation related to the development of this article.

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