Rasburicase and Glucose 6-Phophaste Dehydrogenase: Clinical Utility in the Management of Acute Leukemia Related Hyperuricemia

Background: Rasburicase is a recombinant urate oxidase enzyme commonly used to treat hyperuricemia of malignancy especially in cases with associated renal failure and very high uric acid level. However, it is contraindicated in patients with glucose 6-phosphate dehydrogenase (G6PD) deficiency as it may lead to increased hemolysis and methemoglobinemia, and rarely anaphylactic reaction. G6PD level evaluation is indicated prior to rasburicase administration. Here we sought to analyze the incidence of toxicity, level of G6PD in association with rasburicase in patients with acute leukemia.

Methods: The Mayo Clinic database was interrogated using terms, acute leukemia, rasburicase and G6PD. Patients with acute leukemia and documented G6PD result who received rasburicase were selected. Time interval from documented G6PD report and rasburicase administration; concomitant hemoglobin level, and white blood cell count and creatinine level was collected.

Results: One hundred sixteen patients with G6PD level and/or rasburicase use were identified. Thirty eight (36%) patients (AML 27, ALL 2, MPN 3, and lymphoma 6) received rasburicase, and 33 of them have concomitant G6PD level. The median (range) age was 76 years (27-91), and male accounted for 79% (30/38). The median (range) hemoglobin (gm/dL), uric acid (gm/dL) and creatinine (gm/dL) level was 9.1 (5.6-14.7), 12 (8-27) and 1.8 (0.8-4) respectively. All patients were reported to be non-Hispanic White except one with Asian ancestry. The G6PD level was high, normal, and low in 15 (39%), 13 (34%), and 5 (13%) patients respectively. Rasburicase was given without G6PD level in 5 (13%) patients, before the result for G6PD level available in 6 (16%) patients, and 4 (11%) had low level of G6PD; and none of them develop documented side effects.

Conclusion: G6PD level is very variable at the time of diagnosis of hemological malignancies, and checking its level before rasburicase may have very limited clinical utility in certain patient groups.