Mortality Following Rasburicase-Induced Methemoglobinemia

Abstract

Methemoglobinemia is a rare adverse effect associated with the use of rasburicase and occurs most often in patients with G6PD deficiency. G6PD testing should not be ordered during active hemolysis or after blood transfusion because this may lead to false-negative results. Methylene blue should not be used as an antidote because it may worsen hemolytic anemia in patients with G6PD deficiency.

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

“…Our case suggests that the severity of hemolysis and methemoglobinemia does not appear to be dose dependent, as our patient received 0.03 mg/kg of rasburicase in a single dose. Similarly, the patient in one of the reported deaths 10 received two doses of 0.04 mg/kg.…”

“…Our case suggests that the severity of hemolysis and methemoglobinemia does not appear to be dose dependent, as our patient received 0.03 mg/kg of rasburicase in a single dose. Similarly, the patient in one of the reported deaths [10] received two doses of 0.04 mg/kg. Though typically well tolerated, rasburicase therapy has been associated with adverse reactions with the potential to cause significant morbidity and mortality.…”

“…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].…”

“…The majority of cases are mild and treatment consists of supportive treatment with oxygen and red blood cell transfusions. Death has occurred in two cases [10,13], one of which [10] was notable for the use of methylene blue in a patient whose G6PD status was unknown, but was suspected to be deficient. We treated our patient with double volume exchange transfusion, which has been employed in one other case with good results [6].…”

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].…”