A 55-year-old man with bulky stage III Burkitt lymphoma is scheduled to begin chemotherapy. Baseline creatinine is 1.1 mg/dL, uric acid 7.8 mg/dL, potassium 4.0 mEq/L, phosphate 3.5 mg/dL. He is assessed as high risk for tumour lysis syndrome. Which agent should be given before chemotherapy to prevent urate nephropathy?

• A Allopurinol 300 mg daily
• B Febuxostat 80 mg daily
• C Sodium bicarbonate infusion to alkalinise the urine
• D Rasburicase intravenously ✓

Explanation

Burkitt lymphoma with high tumour burden is high risk for tumour lysis syndrome, and guidelines recommend rasburicase, a recombinant urate oxidase that converts uric acid to the soluble metabolite allantoin, for prophylaxis in this group. Allopurinol and febuxostat only block new uric acid formation and do not lower pre-existing urate, making them adequate for low-risk patients only. Urinary alkalinisation is no longer recommended because it promotes calcium phosphate deposition.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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