Table 10 Oncologic considerations for uric acid reduction
Drug | Primary role in therapy | Dosing and administration | Monitoring, adverse events, and toxicities | Drug-drug interactions | Clinical pearls |
|---|---|---|---|---|---|
Allopurinol [144] | Prevention of hyperuricemia in TLS | Dosing PO/PT: 600–800 mg daily in one to three divided doses. IV: 200–400 mg/m2 daily Administration Initiate 1–2 days before chemotherapy | Monitoring Serum uric acid levels, BUN, SCr HLA-B*5801 testing in high-risk patients (not typically feasible in acute setting) AE/Toxicities Dermatologic toxicities Hepatotoxicity (increased alkaline phosphatase) Nephrotoxicity | 6-mercaptopurine, azathioprine, cyclophosphamide, thiazide, and loop diuretics, warfarin | • Preferred in patients with known G6PD deficiency • Does not lower existing uric acid levels • May require up to 72 h to effectively decrease uric acid levels • Does not warrant dose reductions in acute management of TLS • Caution in hypoxanthine/xanthine nephropathy |
Rasburicase | Hyperuricemia associated with malignancy | Dosing IV: 3–6 mg x 1, may repeat Administration Infuse over 30 min to avoid reaction, dose 4 h prior to chemotherapy if possible | Monitoring Serum uric acid levels AE/toxicities Anaphylaxis CI: Patients with known hemolytic anemia, methemoglobinemia, and G6PD deficiency* *due to time sensitive administration, G6PD screening should not preclude administration of rasburicase acutely | N/A | • Initiate in patients with pre-existing hyperuricemia (Uric acid >7.5 mg/dL) or high-risk patients regardless of baseline uric acid levels • Achieves target uric acid lowering in ~ 4 h in most patients • Enzymatic degradation of uric acid in blood specimen will occur if left at room temperature; collect samples on ice and assay within 4 h |