Guideline sources The following summarized guidelines for the evaluation and management of tumor lysis syndrome (TLS) are prepared by our editorial team based on guidelines from the British Society for Haematology (BSH 2015) and the Clinical Pharmacogenetics Implementation Consortium (CPIC 2014). 2 3 Calculator Calculator Pathway Cairo-Bishop criteria for clinical Cairo-Bishop criteria for laborat Tumor lys Managemen Guidelines 1. Classification and risk stratification https://web.pathway.md/diseases/recOFcb6vQyQSz1ur 1/3 6/24/23, 4:09 PM Tumor lysis syndrome Pathway Risk stratification: evaluate the risk of risk of TLS in all patients who are due to receive chemotherapy for a hematological malignancy. B 2. Medical management Intravenous fluids: Administer balanced or isotonic crystalloid solutions to maintain urine output > 100 mL/m /hour (target > 4 mL/kg/hour for infants). B Avoid adding potassium to the hydration fluid. D Urine alkalinization: avoid using urine alkalinization for the treatment of TLS. D Rasburicase: Administer rasburicase (0.2 mg/kg IV once daily) to patients with established TLS, in the absence of contraindications. B Determine the duration of treatment according to clinical response. B Allopurinol: avoid using allopurinol as a treatment for established TLS, with the exception of patients with contraindications to rasburicase. D Management of hypocalcemia: Administer a short infusion of calcium gluconate in patients with symptomatic hypocalcemia, with close monitoring of calcium levels, phosphate levels, and renal function. B Avoid treating asymptomatic hypocalcemia in patients with TLS. D 3. Inpatient care Cardiac monitoring: provide cardiac monitoring for patients with potassium levels 6 mmol/L or a 25% increase from baseline. B 4. Therapeutic procedures Dialysis: initiate RRT in patients with intractable fluid overload, hyperkalemia, hyperuricemia, hyperphosphatemia, or hypocalcemia. A Show 2 more 5. Specific circumstances Patients with G6PD deficiency: avoid withholding rasburicase based on G6PD status in patients with a normal G6PD phenotype with low or reduced risk of hemolytic anemia. D Show 4 more https://web.pathway.md/diseases/recOFcb6vQyQSz1ur 2/3 6/24/23, 4:09 PM Tumor lysis syndrome Pathway 6. Preventative measures Urinary alkalinization: avoid performing urinary alkalinization as a prophylactic measure for TLS. D Primary prophylaxis (low risk patients): monitor fluid status and laboratory results carefully in patients at low risk of TLS, and use a low threshold to initiate intravenous fluids and consider allopurinol if needed. B Primary prophylaxis (intermediate risk patients): administer allopurinol prophylaxis along with increased hydration in patients at intermediate risk of TLS, and continue prophylaxis for up to 7 days or until risk of TLS has resolved. B Primary prevention (high risk patients): offer prophylaxis with rasburicase along with increased hydration in patients at high risk of TLS. B Show 2 more 7. Follow-up and surveillance Multidisciplinary management: Manage patients with established TLS in a multidisciplinary setting including a team of hematologists, nephrologists and intensive care physicians. B Transfer patients to an intensive care/high-dependency unit, if local facilities are not available for intensive management and monitoring. B References 1. Cairo MS, Bishop M. Tumour lysis syndrome: new therapeutic strategies and classification. Br J Haematol. 2004 Oct;127 1 3 11. Open 2. Jones GL, Will A, Jackson GH et al. Guidelines for the management of tumour lysis syndrome in adults and children with haematological malignancies on behalf of the British Committee for Standards in Haematology. Br J Haematol. 2015 Jun;169 5 661 71. Open 3. Relling MV, McDonagh EM, Chang T et al. Clinical Pharmacogenetics Implementation Consortium CPIC guidelines for rasburicase therapy in the context of G6PD deficiency genotype. Clin Pharmacol Ther. 2014 Aug;96 2 169 74. Open https://web.pathway.md/diseases/recOFcb6vQyQSz1ur 3/3