29th December 2024

Management of TLS

TLS prophylaxis

When planning chemotherapy, it is important to consider strategies to prevent TLS in high risk patients.

All patients receiving chemotherapy should be monitored for biochemical and clinical features of TLS. Where possible, nephrotoxic drugs (such as NSAIDs and aminoglycosides) should be avoided, as well as drugs such as thiazide diuretics that increase serum uric acid levels.

In patients at high risk of TLS, there are a number of steps that may prevent TLS from developing.

1. IV hydration prior to treatment.
2. Phosphate binder to reduce serum phosphate levels, e.g. aluminium hydroxide, which binds and reduces bowel absorption of phosphate. Magnesium hydroxide is given to reduce the side effects of constipation.
3. Reduce serum uric acid levels:
   • Lower risk: allopurinol, a xanthine oxidase inhibitor, which reduces conversion of purine to uric acid. Will not reduce uric acid that has already been released by cells.
   • Higher risk: rasburicase, a recombinant urate oxidase enzyme, which converts uric acid into water-soluble allantoin, which prevents crystallisation and is more easily removed by the kidney. Contraindicated in patients with G6PD deficiency, haemolytic anaemia, methaemoglobinaemia.

Management of acute TLS

Acute TLS is an emergency and requires urgent action and close monitoring. Emergency management is as follows: