TLS Flashcards
Treatment of TLS
Telemetry q6h BMP (monitor creatinine) + phosphate + serum uric acid Rasburicase 0.2 mg/kg daily Monitor Tbili and Hgb for hemolytic anemia (G6PD)
Labs consistent with TLS
hyperkalemia + hypocalcemia + hyperuricemia + elevated BUN
TLS prophylaxis
Aggressive IVF (1/4NS at ?) until tumor burden resolved
Monitor for anasarca
Baseline serum uric acid level
Risk stratify (low, intermediate, high)
IF intermediate risk → allopurinol q8h
IF high risk → rasburicase 0.2 mg/kg daily x 5-7 days, renally dosed
High risk tumor lysis diseases
1) Acute leukemias w/ large leukemic phases (AML, Adult T cell ALL)
2) High grade lymphomas – Burkitt, diffuse large B-cell, transformed, and mantle cell lymphomas with bulky disease and LDH ≥2 x ULN
3) Other ALL and WBC ≥100 x 109/L and/or LDH ≥2 x ULN
4) Lymphoblastic lymphoma stage III/IV and/or LDH ≥2 x ULN
TLS RF’s
1) Large tumor burden (bulky disease)
2) Aggressive tumors that grow quickly and are rapidly dividing (stage III/IV disease)
3) elevated LDH at baseline
4) decreased renal function
Major sequela of TLS
renal injury from uric acid and calcium phosphate crystal deposition in the renal tubules
Major adverse effect of rasburicase to know about
Tachyphylaxis (this is why you should be hesitant about giving it unless uric acid is very high)
rasburicase mechanism
- recombinant urate oxidase
- clears uric acid
Lymphomas that are high risk for TLS
Burkitt’s + DLBCL
Targeted therapies with a higher risk of TLS
- Venetoclax
- Obinutuzumab
- Dinaciclib
- Alvocidib
Risk stratification categories in TLS
- low risk disease
- intermediate risk disease
- high risk disease
Low risk disease prophylaxis
allopurinol is optional
Intermediate risk disease prophylaxis
allopurinol required
High risk disease prophylaxis
rasburicase
Conditions at high risk for TLS
1) Burkitt lymphoma stage III or IV
2) Adult T cell leukemia
3) DLBCL and mantle cell lymphoma with bulky disease and LDH greater than 2x ULN
4) AML and WBC greater than 100 x 10 to the 9th
