Evaluation and Treatment of Oncology Patients at Risk for Tumor Lysis Syndrome (TLS) — Ongoing Treatment — Clinical Pathway: Inpatient, ICU, Outpatient Specialty Care, ED

Tumor Lysis Syndrome Clinical Pathway — Inpatient, ICU

Correct Laboratory Abnormalities

Hyperuricemia

Medication Dose Considerations
Allopurinol
  • ≤ 10 yrs:
    • 10 mg/kg/day PO in 3 divided doses
  • 10 yrs and adults:
    • 600-800 mg/day PO in 2-3 divided doses
  • Max:
    • 800 mg/day
  • DOSE REDUCTION required IN RENAL IMPAIRMENT
Rasburicase
  • Children and adults:
    • 0.15-0.2 mg/kg IV x 1 dose
  • Max:
    • 6 mg/dose

Hyperphosphatemia

  • Initiate phosphorous-restricted diet
  • Do not use calcium carbonate since it may prompt formation of calcium phosphate crystals and worsen renal and other organ function, especially if the calcium phosphate product is > 60 mg2/dL2
Medication Dose Considerations
Sevelamer
  • Children:
    • 120-160 mg/kg/day PO
  • Divided 3 times a day with meals
  • Adults:
    • 800-1600 mg PO with each meal
  • Hold if NPO
Aluminum Hydroxide
  • Children:
    • 50 mg to 150 mg/kg/day in divided doses every 4-6 hrs, titrate dosage to maintain serum phosphorus within normal range
  • Adults:
    • 500-1800 mg, 3-6 times/day, between meals and at bedtime
  • Hold if NPO
  • Ensure no renal dysfunction

    Hyperkalemia

    • Stop all potassium-containing IV fluids and enteral supplementation
    • Correct respiratory acidosis if possible
    • Twelve-lead ECG
    • Treat per standard hyperkalemia algorithms, such as in Pediatric Advanced Life Support (PALS)
    • Dialysis in patients with renal insufficiency who do not respond to medical management
    Medication Dose Considerations
    Calcium Gluconate
    • Infants and children:
      • 60-100 mg calcium gluconate/kg/dose IV
    • Adults:
      • 1500-3000 mg calcium gluconate/dose IV
    • Max:
      • 3000 mg calcium gluconate/dose
    • Emergent medication for severe hyperkalemia; stabilizes myocardium in the setting of ECG changes
    • Use with caution in patients with hyperphosphatemia
    • If there are ECG changes, calcium should be given regardless of severity of hyperkalemia
      Sodium Bicarbonate
      • Children < 40 kg:
        • 1 mEq/kg/dose IV
      • Adults or > 40 kg:
        • 50 mEq/dose IV
      • Emergent medication for severe hyperkalemia
      Dextrose and Insulin
      • Children:
        • Dextrose 0.5-1 g/kg/dose (5-10 mL/kg/dose of 10% solution; 2-4 mL/kg/dose of 25% solution) IV infused over 15-30 mins followed by
          0.1 unit/kg IV regular insulin
      • Note:
        • Patients ≤ 50 kg will require an insulin dilution to create a measurable volume. Utilize the Insulin Dilution Worksheet to determine the necessary dilution of insulin
      • Adults:
        • Dextrose 25 g/dose (250 mL/dose of 10% solution; 100 mL/dose of 25% solution) IV infused over 15-30 mins followed by 10 units IV regular insulin
      • Emergent medication for severe hyperkalemia
      • To be used after treatment with IV calcium gluconate and sodium bicarbonate
      • Check glucose every hour for 4 hrs after insulin administration
      Albuterol Nebulize
      • Infants, children, and adolescents:
        • 0.3 to 0.5 mg/kg/dose administered as a rapid nebulization or via continuous nebulization
      • Adults:
        • 10 to 20 mg/dose via nebulization over 10 mins
      • Albuterol should not be used as the sole agent for treating severe hyperkalemia
      Furosemide
      • Infants and children:
        • 1-2 mg/kg/dose IV up to every 6-12 hrs
      • Adults:
        • 20-40 mg/dose IV once or twice daily
      Sodium Polystyrene Sulfonate Kayexalate
      • Enteral
      • Children:
        • 1 g/kg/dose every 6 hrs
      • Adults:
        • 5 g/dose given 1-4 times/day
      • Avoid rectal route as patient is likely functionally neutropenic

      Hypocalcemia

      • Correct hyperphosphatemia
      • Calcium supplementation should not be used unless patient is symptomatic with tetany, muscle spasm, Trousseau/Chvostek signs
      • Consider hemodialysis/continuous renal replacement therapies

      Renal Replacement Therapy Indications

      • Most patients respond to medical management of electrolyte derangements
      • Consult nephrology if indicated
        • Severe oliguria or anuria
        • Intractable fluid overload
        • Persistent hyperkalemia
        • Hyperphosphatemia-induced symptomatic hypocalcemia
        • Calcium-phosphate product ≥ 70 mg2/dL