Tumor lysis syndrome (TLS) prophylaxis recommendations based on TLS risk

Low risk disease (LRD)	Intermediate risk disease (IRD)	High risk disease (HRD)
Most solid tumors	Rare, highly chemotherapy-sensitive solid tumors (eg, neuroblastoma, germ cell tumor, small-cell lung cancer) with bulky or advanced stage disease	N/A
MM	Plasma cell leukemia	N/A
CML	N/A	N/A
Indolent NHL	N/A	N/A
HL	N/A	N/A
CLL and WBC <50 x 10⁹/L treated only with alkylating agents	CLL treated with fludarabine, rituximab, or lenalidomide, or venetoclax and lymph node ≥5 cm or absolute lymphocyte count ≥25 x 10⁹/L, and/or those with high WBC ≥50 x 10⁹/L	CLL treated with venetoclax and lymph node ≥10 cm, or lymph node ≥5 cm and absolute lymphocyte count ≥25 x 10⁹/L and elevated baseline uric acid.
AML and WBC <25 x 10⁹/L and LDH <2 x ULN	AML with WBC 25 to 100 x 10⁹/L	AML and WBC ≥100 x 10⁹/L
AML and WBC <25 x 10⁹/L and LDH <2 x ULN	AML and WBC <25 x 10⁹/L and LDH ≥2 x ULN	AML and WBC ≥100 x 10⁹/L
Adult intermediate grade NHL and LDH within normal limits	Adult T cell leukemia/lymphoma, diffuse large B-cell, transformed, and mantle cell lymphomas with LDH > ULN, non-bulky	Adult T cell leukemia/lymphoma, diffuse large B-cell, transformed, and mantle cell lymphomas with bulky disease and LDH ≥2 x ULN
Adult ALCL	Childhood ALCL stage III/IV	N/A
N/A	Childhood intermediate grade NHL stage III/IV with LDH <2 x ULN	Stage III/IV childhood diffuse large B-cell lymphoma with LDH ≥2 x ULN
N/A	ALL and WBC <100 x 10⁹/L and LDH <2 x ULN	Burkitt's leukemia
N/A	ALL and WBC <100 x 10⁹/L and LDH <2 x ULN	Other ALL and WBC ≥100 x 10⁹/L and/or LDH ≥2 x ULN
N/A	Burkitt lymphoma and LDH <2 x ULN	Burkitt lymphoma stage III/IV and/or LDH ≥2 x ULN
N/A	Lymphoblastic lymphoma stage I/II and LDH <2 x ULN	Lymphoblastic lymphoma stage III/IV and/or LDH ≥2 x ULN
N/A	N/A	Intermediate risk disease with renal dysfunction and/or renal involvement
N/A	N/A	Intermediate risk disease with uric acid, potassium, and/or phosphate > ULN
Prophylaxis recommendations
Monitoring	Monitoring	Monitoring
Hydration	Hydration	Hydration
±Allopurinol	Allopurinol	Rasburicase*

N/A: not applicable; MM: multiple myeloma; CML: chronic myeloid leukemia; NHL: non-Hodgkin lymphoma; HL: Hodgkin lymphoma; CLL: chronic lymphoid leukemia; WBC: white blood cell count; AML: acute myeloid leukemia; LDH: lactate dehydrogenase; ULN: upper limit of normal; ALCL: anaplastic large cell lymphoma; ALL: acute lymphoblastic leukemia.
* Contraindicated in patients with a history consistent with glucose-6 phosphate dehydrogenase (G6PD) deficiency. In these patients, rasburicase should be substituted with allopurinol.

Cairo MS, Coiffier B, Reiter A. Recommendations for the evaluation of risk and prophylaxis of tumour lysis syndrome (TLS) in adults and children with malignant diseases: an expert TLS panel consensus. Br J Haematol 2010; 149:578. Copyright © 2010. Modified with permission of Blackwell Publishing Inc.

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Tumor lysis syndrome (TLS) prophylaxis recommendations based on TLS risk