1. First-Line Therapies

First-line pharmacotherapy for oncologic emergencies is driven by the underlying mechanism, the urgency of the clinical situation, and patient-specific risk factors. In tumor lysis syndrome (TLS), urate-lowering therapy with rasburicase or allopurinol is paramount. In malignant spinal cord compression (MSCC), high-dose dexamethasone is initiated to reduce vasogenic edema and preserve neurologic function.

1.1 Rasburicase vs. Allopurinol in Tumor Lysis Syndrome

TLS is a life-threatening emergency characterized by hyperuricemia, hyperkalemia, hyperphosphatemia, and secondary hypocalcemia, often leading to acute kidney injury. The choice of urate-lowering agent depends on the risk of TLS and the presence of established hyperuricemia.

Key Considerations

• Mechanism of Action: Rasburicase, a recombinant urate oxidase, rapidly converts existing uric acid into allantoin, which is 5–10 times more soluble. Allopurinol is a xanthine oxidase inhibitor that prevents the formation of new uric acid but has no effect on pre-existing levels.
• Indications: Rasburicase is preferred for patients with high-risk TLS (e.g., bulky lymphoma, acute leukemias with WBC >100,000/µL) or established, severe hyperuricemia (>8 mg/dL). Allopurinol is used for prophylaxis in patients with low-to-intermediate risk.
• Dosing: Rasburicase is dosed at 0.1–0.2 mg/kg IV once daily for 1–7 days. Allopurinol is typically given at 300–600 mg PO daily, with a 50% dose reduction for CrCl <60 mL/min.
• Contraindications: Rasburicase is contraindicated in patients with G6PD deficiency due to the risk of severe hemolysis and methemoglobinemia. Allopurinol should be used with caution in patients with a history of hypersensitivity syndrome.

1.2 Corticosteroids in Malignant Spinal Cord Compression

MSCC is a neurologic emergency presenting with back pain, motor weakness, sensory changes, and/or bladder/bowel dysfunction. High-dose dexamethasone is a critical first step to reduce cord edema and preserve neurologic function while awaiting definitive therapy like radiation or surgery.

Key Considerations

• Mechanism of Action: Dexamethasone, a potent glucocorticoid, reduces vasogenic edema around the spinal cord by downregulating VEGF and proinflammatory cytokines and stabilizing capillary membranes.
• Indications: Administer immediately in any patient with suspected or confirmed MSCC who has neurologic deficits or severe, progressive pain.
• Dosing Strategy: An initial 10 mg IV bolus is standard, followed by a maintenance dose of 6–10 mg IV every 6 hours. The dose should be tapered over 1–2 weeks once definitive treatment is complete to prevent adrenal insufficiency.
• Monitoring: Frequent neurologic exams (every 4 hours initially), blood glucose monitoring (every 6-8 hours), and daily surveillance for signs of infection or GI bleeding are essential.

2. Pharmacologic Framework

A structured framework ensures rational selection, dosing, monitoring, and adjustment of pharmacotherapy in oncologic emergencies. This systematic approach helps standardize care and minimize adverse events.

3. Second-Line and Adjunctive Pharmacotherapies

Adjunctive agents are selected based on initial response, specific metabolic derangements, patient comorbidities, and institutional guidelines. These therapies often target aspects of the emergency not fully addressed by first-line agents.

4. Dose Adjustments for Organ Dysfunction

Organ impairment, particularly renal and hepatic dysfunction, is common in critically ill cancer patients and markedly alters drug clearance. Dosing must be tailored using functional data and drug-specific properties.

4.1 Renal Impairment and Replacement Therapy

• Rasburicase: As a large protein molecule, it is not significantly removed by dialysis. Standard dosing is appropriate for patients on any form of renal replacement therapy (RRT).
• Allopurinol: The active metabolite, oxypurinol, is cleared by the kidneys and is dialyzable. The initial dose should be reduced in renal impairment, and a supplemental dose may be required after a dialysis session.

4.2 Hepatic Impairment Modifications

• Dexamethasone: It undergoes hepatic metabolism via CYP3A4. In severe hepatic impairment, clearance may be reduced, increasing the risk of toxicity. Dose adjustments should be guided by clinical effect and toxicity monitoring rather than a preset formula.
• Rasburicase: No dose adjustment is required for hepatic impairment.

5. Route of Administration and Delivery

Selecting the optimal route ensures prompt and reliable drug delivery, which is critical in an emergency setting.

• Rasburicase: Available for IV administration only. It should be reconstituted with the provided diluent (do not use other diluents) and administered immediately or within 4 hours if refrigerated and protected from light.
• Allopurinol: The oral route is preferred. An IV formulation is available and should be used for patients with GI intolerance or malabsorption.
• Dexamethasone: IV administration is required for acute MSCC to ensure rapid onset. A rapid IV push is acceptable for emergent neurologic compromise. Once the patient is clinically stable and can tolerate oral intake, a transition to an equivalent oral dose is appropriate.

6. Monitoring and Pharmacoeconomic Analysis

Structured monitoring schedules are crucial for assessing efficacy and detecting toxicity early. Pharmacoeconomic evaluation helps guide high-value care decisions, balancing drug acquisition costs with clinical outcomes.

Pharmacoeconomic Considerations

• Rasburicase: While it has a high acquisition cost, studies suggest it can be cost-effective by reducing the need for renal replacement therapy, shortening ICU length of stay, and preventing long-term renal damage compared to allopurinol in high-risk patients.
• Dexamethasone: This is a low-cost, high-impact intervention. Its ability to preserve neurologic function significantly reduces the long-term costs associated with rehabilitation, skilled nursing care, and loss of independence.