Rasburicase‐induced methemoglobinemia in two African–American female patients: an under‐recognized and continued problem

Abstract

Rasburicase-induced methemoglobinemia is a known adverse effect of patients administered rasburicase for tumor lysis syndrome who have concomitant glucose-6-phosphate dehydrogenase deficiency. This phenomenon has been described in multiple case reports but has been limited to male patients. We present the first case series illustrating this adverse effect in two female patients where morbidity and mortality associated with rasburicase-induced methemoglobinemia were evident. Screening protocols at the reporting institutions were lacking. The prevalence of G6PD may be underestimated based on the epidemiology of sample subjects in previous studies of rasburicase. We argue that both male and female patients should be suspected of G6PD in this setting; however, more data on prevalence and cost-effectiveness are needed on screening protocols for G6PD.

Methaemoglobinaemia in a G6PD-deficient child treated with rasburicase

“…The third paediatric case was reported in 2011 in a 6-year-old Caucasian non-G6PD-deficient boy treated for ALL 13. Recently, two cases have been reported in African-American female patients 18. Patients from ethnic groups in which G6PD deficiency is highly prevalent are routinely screened for G6PD deficiency before rasburicase administration 18.…”

“…Recently, two cases have been reported in African-American female patients 18. Patients from ethnic groups in which G6PD deficiency is highly prevalent are routinely screened for G6PD deficiency before rasburicase administration 18. However, G6PD testing may be unavailable in emergency.…”

“…In patients at high risk for TLS and belonging to ethnic groups where G6PD deficiency is highly prevalent, we suggest using allopurinol as the first option,18 followed by rasburicase if testing confirms normal G6PD function. If rasburicase is used first, a close clinical monitoring is mandatory and methaemoglobinaemia should be suspected after all other potential causes of hypoxaemia have been ruled out.…”

A perfect storm: Tumor lysis syndrome with rasburicase‐induced methemoglobinemia in a G6PD deficient adult

“…Of the reported cases of rasburicase-induced methemoglobinemia, 11 of the 15 patients tested for G6PD were found deficient (73%) [8][9][10][11][12][13][14]; however, this may be an underestimate, as some patients were only tested for the condition in the acute phase of illness. G6PD deficiency is a relative contraindication for methylene blue therapy; like rasburicase, it may exacerbate methemoglobinemia and cause hemolysis [15].…”

Rasburicase‐induced methemoglobinemia: case report, literature review, and proposed treatment algorithm

“…Since the use of rasburicase began, we are aware of 15 reported cases of methemoglobinemia with or without associated hemolysis (Table 3) [2][3][4][5][6][7][8][9][10][11][12][13][14]. It was first reported in patients with G6PD deficiency [2], but has also been seen in patients without G6PD deficiency [5,8].…”