Guidelines for the Management of Tumour Lysis Syndrome in Haematological and Solid Tumour Malignancies

Transcription

1 Guidelines for the Management of Tumour Lysis Syndrome in Haematological and Solid Tumour Malignancies CSPM 02 Date to be reviewed: September 2017 No of pages: 7 Author(s): Dr Yvonne Jones Author(s) title: Consultant Haematologist Responsible dept. / director: Cancer, Clinical Haematology Division/Pharmacy & Medicines Division Approved by: Chemotherapy Governance Group Date approved: 23 rd October 2015 Endorsement by: Drugs and Therapeutics Committee Date endorsed: 2 nd November 2015 Date activated (live): 1 st December 2015 Date EQIA completed: Documents to be read alongside this policy: This document MUST be read in conjunction with the following guidance: Purpose of Issue/Description of current changes: First operational: 1 st December 2015 Previously reviewed: Changes made yes/no: PROPRIETARY INFORMATION This document contains proprietary information belonging to the Betsi Cadwaladr University Health Board. Do not produce all or any part of this document without written permission from the BCUHB. Version 1 Page 1 of 7

2 SECTION CONTENTS PAGE NO 1 Introduction 3 2 Scope 3 3 General Recommendations 3 4 Management of High Risk Patients 4 5 Management of Intermediate Risk Patients 5 6 Management of Low Risk Patients 6 7 References 6 Version 1 Page 2 of 7

3 Guidelines for the management of tumour lysis syndrome in haematological and solid tumour malignancies 1. Introduction Tumour lysis syndrome is a constellation of metabolic disturbances that may follow the initiation of chemotherapy. Tumour lysis typically occurs in patients with bulky, highly proliferative, treatment responsive tumours, such as acute leukaemias and high grade lymphomas (particularly Burkitt s). Despite tumour lysis syndrome (TLS) being a rare event affecting approximately 3-6% of patients with high grade tumours, the consequences are significant with the development of hyperkalaemia, hyperphosphataemia, hypocalcaemia, hyperuricaemia and acute renal failure. The recognition of patients at risk of developing the syndrome and subsequent institution of prophylactic measures to prevent its occurrence is therefore key to the management of TLS 2. Scope This document is primarily for healthcare professionals delivering chemotherapy for patients with malignant disease, in in-patient and out-patient settings within Cancer and Clinical Haematology services, Betsi Cadwaladr University Health Board (BCUHB). 3. General Recommendations Patients due to receive chemotherapy for any haematological malignancy should be assessed for the risk of Tumour Lysis Syndrome (TLS). Any patient with a haematological diagnosis and renal impairment or is who allergic to allopurinol should be considered for rasburicase regardless of their tumour features. Patients with solid tumours such as metastatic teratomas may also be at risk and clinicians must use their discretion to identify such patients. There is no role for allopurinol in patients being treated with rasburicase as it is unnecessary and has the potential to reduce the effectiveness of rasburicase. Urinary alkalinisation is not recommended in TLS prophylaxis. Version 1 Page 3 of 7

4 4. Management of High Risk Patients The following patients should be defined as high risk; ALL/AML with a WBC>100x10⁹/L Burkitts or lymphoblastic lymphoma High grade lymphoma (diffuse large B cell lymphoma and T cell NHL) with bulky disease defined as LDH > twice the upper limit of normal or tumour bulk on CT scan (>10cm) Prophylaxis of Tumour Lysis Syndrome in High Risk Patients High risk patients should receive prophylaxis with rasburicase (unless contraindicated in the case of G6PD deficiency) along with increased hydration of 3 litres/24hours. Urine output should be measured hourly, aiming to maintain a urine output of 100ml/m 2 /hr. Although the licensed dose of rasburicase is 0.2mg/kg/day, in the absence of established clinical or laboratory TLS, prophylaxis can be achieved by administering a single fixed dose of 3mg of rasburicase. Prophylactic Dose Rasburicase 3mg in 50 ml 0.9% Sodium chloride infused over 30 minutes. Flush line with saline after rasburicase administration The flat prophylaxis dose needs to be followed by close clinical and laboratory monitoring for evidence of progressive TLS. The dose should be repeated daily until the markers of TLS have returned to normal. If TLS develops despite prophylaxis then patients should be managed with the standard dose of 0.2mg/kg/day until the markers of TLS have returned to normal. Version 1 Page 4 of 7

5 4.2. Monitoring Uric acid levels A strict sample-handling procedure must be followed to minimise ex vivo degradation of the analyte. Blood must be collected into pre-chilled tubes containing heparin anticoagulant. Samples must be immersed in an ice/water bath. Plasma samples should immediately be prepared by centrifugation in a precooled centrifuge (4 C). Finally, plasma must be maintained in an ice/water bath and analysed for uric acid within 4 hours Management of established Tumour Lysis Syndrome In established TLS a multidisciplinary approach should be adopted with involvement of haematologists, nephrologists and intensive care physicians. In established TLS rasburicase should be given at a dose of 0.2mg/kg/day. The duration of treatment should be determined by clinical response. Treatment Dose Rasburicase 0.2mg/kg/day in 50 ml 0.9% Sodium chloride infused over 30 minutes. Flush line with saline after rasburicase administration Potassium should not be added to hydration fluids, asymptomatic hypocalcaemia should not be treated but symptomatic hypocalcaemia should be treated with a calcium gluconate infusion. Patients with potassium levels of 6 mmol/l or a 25% increase in potassium level from baseline should receive cardiac monitoring. Intractable fluid overload, hyperkalaemia, hyperuricaemia, hyperphosphataemia or hypocalcaemia are indications for renal dialysis. 5. Management of Intermediate Risk Patients Version 1 Page 5 of 7

6 Intermediate risk patients should receive up to 7 days of prophylaxis with allopurinol and increased hydration following initiation of treatment. 6. Management of Low Risk Patients Low risk patients can be managed with attention to adequate hydration and laboratory monitoring. 7. References Jones, GL., Will, A et al.(2015). Guidelines for the management of tumour lysis syndrome in adults and children with haematological malignancies on behalf of the British Committee for Standars in Haematology. British Journal of Haematology,169, Feng, X, Dong, K et al. (2013). Efficacy and cost of single dose rasburicase in prevention and treatment of adult tumour lysis syndrome: a meta-analysis. Journal of Clinical Pharmacy and Therapeutics, 38, SPC Fasturtec Members of the Chemotherapy Governance Group: Name Dr Catherine Bale Tracy Parry-Jones Sr Beryl Roberts Sr Julie Roberts Dr Carey Macdonald-Smith Manon Williams Dr Claire Fuller Jenny Stuart Dr Yvonne Jones Damian Heron Glesni Williams Mared Hughes Sr Jackie Jones Sue Walters Geraint Roberts Title Chemotherapy Lead Lead Oncology Pharmacist Nurse Clinician (Matron) Sister Heulwen Day Unit Associate Specialist in Oncology Assistant Director of Nursing Associate Specialist in Oncology Macmillan Pharmacist Consultant Haematologist Director of North Wales Cancer Network Oncology Pharmacist (East) Oncology Pharmacist (West) Interim Lead Nurse In-patient Services Audit Facilitator, Cancer Network General Manager, Cancer Division Version 1 Page 6 of 7

7 Consultation has taken place with: Name Title Date Consulted Dr Cath Bale Chemotherapy Lead John Grant, Glesni Cancer Services Pharmacists Williams, Rob Challoner Sr Julie Roberts, Sr Laura Edge, Sr Anne-Marie Humphries, Sr Wenna Hammond Chemotherapy Day Unit Nurse Managers Siwan Owen Haematology Specialist Nurse Sr Nerys Wilkes Sister Enfys Ward Sr Hope Barlow Sister Alaw Ward Dr David Watson Consultant Haematologist Dr Lally Desoysa Consultant Haematologist Dr Earnest Heartin Consultant Haematologist Sr Beryl Roberts Nurse Clinician ( Matron) Dr Jim Seale Consultant Haematologist Dr Melinda Hamilton Consultant Haematologist Linda Rees-Jones Haematology Specialist Nurse Jane Samuel Haematology Specialist Nurse Dr David Edwards Consultant Haematologist Dr Sally Evans Consultant Haematologist Dr Margaret Goodrick Consultant Haematologist Dr Caroline Usborne Palliative Care Consultant Gillian Fisher, Louise Preston-Jones, Sharon Richards Acute Oncology Nurses Version 1 Page 7 of 7