Can Pharmacists Save the Day in Tumor Lysis Syndrome?

Pharmacists' guide to recognizing, preventing, and treating tumor lysis syndrome...

Overview

As a clinical pharmacist, you play a critical role in managing tumor lysis syndrome (TLS), a life-threatening metabolic imbalance caused by rapid tumor cell destruction. TLS releases potassium, phosphorus, calcium, and nucleic acids into the bloodstream, leading to hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia. These disturbances can result in acute kidney injury, cardiac arrhythmias, seizures, and, if untreated, death.

NPS-adv

Clinical practice

Focus on prevention by initiating IV hydration (e.g., 2-3 L/m²/day with isotonic fluids) before and after chemotherapy to facilitate excretion of intracellular contents and maintain urine output above 80-100 mL/hour.

Administer allopurinol at 300 mg/day (maximum 800 mg/day) to prevent uric acid formation.

If the patient is allopurinol-intolerant or has high baseline uric acid, use febuxostat (40-120 mg/day).
For rapid uric acid reduction, consider rasburicase 50 to 100 units/kg daily for 1 to 5 days IV over 30 minutes, ensuring glucose-6-phosphate dehydrogenase deficiency is excluded.

Identify high-risk patients, including those with hematologic malignancies (e.g., acute leukemias, high-grade lymphomas) or solid tumors with a high tumor burden or chemosensitivity. Monitor serum potassium, phosphorus, calcium, uric acid, and creatinine levels 2-3 times daily for the first 48-72 hours post-chemotherapy. Cardiac monitoring is essential for patients with hyperkalemia, as ECG changes (e.g., peaked T waves, widened QRS) may occur.

Manage TLS complications promptly...

For hyperkalemia, use calcium gluconate 1 g IV for cardiac stabilization, insulin with dextrose (10 units regular insulin with 25-50 g dextrose IV), or sodium bicarbonate 50 mEq IV to drive potassium into cells.
Treat hyperphosphatemia with oral phosphate binders (e.g., calcium acetate 667-1,334 mg with meals).
Correct hypocalcemia only if symptomatic, using calcium gluconate 1-2 g IV over 10-20 minutes.

Avoid nephrotoxic agents, such as NSAIDs and aminoglycosides, and ensure adequate hydration to prevent acute kidney injury. Dialysis may be required for severe hyperkalemia (> 6 mEq/L), hyperphosphatemia (> 10 mg/dl), serum uric acid > 20 mg/dl, or fluid overload unresponsive to medical therapy. Your timely intervention in preventing and managing TLS can significantly improve patient outcomes and reduce complications.

NPS-adv

References

Gupta A, Moore JA. Tumor Lysis Syndrome. JAMA Oncol. 2018 Jun 1;4(6):895. doi: 10.1001/jamaoncol.2018.0613.
Halfdanarson TR, Hogan WJ, Madsen BE. Emergencies in Hematology and Oncology. Mayo Clin Proc. 2017;92(4):609-641.
Howard SC, Jones DP, Pui CH. The tumor lysis syndrome. N Engl J Med. 2011;364(19):1844-1854.