1
|
Johnson RJ, Mandell BF, Schlesinger N, Mount DB, Botson JK, Abdellatif AA, Rhoades R, Singh JA. Controversies and practical management of patients with gout and chronic kidney disease. Kidney Int 2024:S0085-2538(24)00473-3. [PMID: 39033815 DOI: 10.1016/j.kint.2024.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/05/2024] [Accepted: 05/28/2024] [Indexed: 07/23/2024]
Abstract
Uric acid is a toxin retained with advancing kidney disease. Clinical manifestations of hyperuricemia include gout and systemic inflammation that are associated with increased risk of cardiovascular mortality. As many as one-third of all patients with chronic kidney disease have a history of gout, yet <25% of these patients are effectively treated to target serum urate levels of ≤6 mg/dl. A major reason for ineffective management of gout and hyperuricemia is the complexity in managing these patients, with some medications contraindicated and others requiring special dosing, potential drug interactions, and other factors. Consequently, many nephrologists do not primarily manage gout despite it being a common complication of chronic kidney disease, leaving management to the primary physician or rheumatologist. We believe that kidney specialists should consider gout as a major complication of chronic kidney disease and actively manage it in their patients. Here, we present insights from nephrologists and rheumatologists for a team approach to gout management that includes the nephrologist.
Collapse
Affiliation(s)
- Richard J Johnson
- Division of Renal Diseases, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Brian F Mandell
- Department of Rheumatologic and Immunologic Disease, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland, Ohio, USA
| | - Naomi Schlesinger
- Division of Rheumatology, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - David B Mount
- Renal Divisions, Brigham and Women's Hospital and VA Boston Healthcare System, Harvard Medical School, Boston; Massachusetts, USA
| | - John K Botson
- Orthopedic Physicians Alaska, Anchorage, Alaska, USA
| | | | | | - Jasvinder A Singh
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
| |
Collapse
|
2
|
Brucato A, Cianci F, Carnovale C. Management of hyperuricemia in asymptomatic patients: A critical appraisal. Eur J Intern Med 2020; 74:8-17. [PMID: 31952982 DOI: 10.1016/j.ejim.2020.01.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/02/2020] [Accepted: 01/04/2020] [Indexed: 02/07/2023]
Abstract
While there is consensus on starting urate-lowering therapy (ULT) in cases of symptomatic hyperuricemia, the frequent condition of asymptomatic hyperuricemia (AH) remains a challenge due to differences in the findings of studies that have addressed the issue. Uric acid has anti-oxidant properties, but high levels predispose to gout and may play a role in metabolic syndrome. We systematically evaluated randomized controlled trials (RCTs) addressing ULT in patients with AH, to assess the current evidence. We found broad heterogeneity among the studies (13 RCTs), in terms of study design and population, making findings challenging to interpret and generalize; hard end-points were not assessed. Allopurinol is often prescribed for AH despite the fact that its use is not backed by conclusive evidence from prospective RCTs, nor is it recommended by the guidelines. Its potential benefits, in terms of absolute risk reduction, must be weighed against its potential for harm since it can trigger severe adverse hypersensitivity reactions, sometimes even fatal. RCTs with hard end-points are needed to assess the risk/benefit of lowering uric acid in subjects with AH, particularly as secondary prevention for cardiovascular risk and in patients with different degrees of renal disease. To date, particularly after the result from the CARES trial, preventive treatment of asymptomatic and non-severe hyperuricemia is not recommended.
Collapse
Affiliation(s)
- Antonio Brucato
- Department of biomedical and clinical sciences, Università di Milano, Fatebenefratelli Hospital, Milan, Italy
| | | | - Carla Carnovale
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, Università di Milano, Via GB Grassi 74, Milan, 20157, Italy.
| |
Collapse
|
3
|
Sato Y, Feig DI, Stack AG, Kang DH, Lanaspa MA, Ejaz AA, Sánchez-Lozada LG, Kuwabara M, Borghi C, Johnson RJ. The case for uric acid-lowering treatment in patients with hyperuricaemia and CKD. Nat Rev Nephrol 2019; 15:767-775. [PMID: 31296965 DOI: 10.1038/s41581-019-0174-z] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2019] [Indexed: 02/07/2023]
Abstract
Hyperuricaemia is common among patients with chronic kidney disease (CKD), and increases in severity with the deterioration of kidney function. Although existing guidelines for CKD management do not recommend testing for or treatment of hyperuricaemia in the absence of a diagnosis of gout or urate nephrolithiasis, an emerging body of evidence supports a direct causal relationship between serum urate levels and the development of CKD. Here, we review randomized clinical trials that have evaluated the effect of urate-lowering therapy (ULT) on the rate of CKD progression. Among trials in which individuals in the control arm experienced progressive deterioration of kidney function (which we define as ≥4 ml/min/1.73 m² over the course of the study - typically 6 months to 2 years), treatment with ULT conferred consistent clinical benefits. In contrast, among trials where clinical progression was not observed in the control arm, treatment with ULT was ineffective, but this finding should not be used as an argument against the use of uric acid-lowering therapy. Although additional studies are needed to identify threshold values of serum urate for treatment initiation and to confirm optimal target levels, we believe that sufficient evidence exists to recommend routine measurement of serum urate levels in patients with CKD and consider initiation of ULT among those who are hyperuricaemic with evidence of deteriorating renal function, unless specific contraindications exist.
Collapse
Affiliation(s)
- Yuka Sato
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel I Feig
- Division of Pediatric Nephrology, University of Alabama, Birmingham, AL, USA
| | - Austin G Stack
- Division of Nephrology, Department of Medicine, University Hospital Limerick, Limerick, Ireland.,Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Duk-Hee Kang
- Division of Nephrology, Department of Internal Medicine, Ewha Womans University College of Medicine Ewha Medical Research Center, Seoul, South Korea
| | - Miguel A Lanaspa
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - A Ahsan Ejaz
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, Gainesville, FL, USA
| | - L Gabriela Sánchez-Lozada
- Laboratory of Renal Physiopathology, Department of Nephrology, INC Ignacio Chavez, Mexico City, Mexico
| | - Masanari Kuwabara
- Department of Cardiology and Intensive Care Unit, Toranomon Hospital, Tokyo, Japan
| | - Claudio Borghi
- Department of Medicine, University of Bologna, Bologna, Italy
| | - Richard J Johnson
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA. .,Rocky Mountain Regional VA Medical Center, Aurora, CO, USA.
| |
Collapse
|
4
|
Pharmacological urate-lowering approaches in chronic kidney disease. Eur J Med Chem 2019; 166:186-196. [PMID: 30769179 DOI: 10.1016/j.ejmech.2019.01.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/20/2019] [Accepted: 01/20/2019] [Indexed: 02/05/2023]
Abstract
Chronic kidney disease (CKD) has become a global public health issue and uric acid (UA) remains a major risk factor of CKD. As the main organ for the elimination of UA, kidney owned a group of urate transporters in tubular epithelium. Kidney disease hampered the UA excretion, and the accumulation of serum UA in return harmed the renal function. Commercially, there are three kinds of agents targeting at urate-lowering, xanthine oxidoreductase inhibitor which prevents the production of UA, uricosuric which increases the concentration of UA in urine thus decreasing serum UA level, and uricase which converts UA to allantoin resulting in the dramatic decrement of serum UA. Of note, in patients with CKD, administration of above-mentioned agents, alone or combined, needs special attention. New evidence is emerging for the efficacy of several urate-lowering drugs for the treatment of hyperuricemia in patients with CKD. Besides, loads of novel and promising drug candidates and phytochemicals are in the different phases of research and development. As of today, there is insufficient evidence to recommend the widespread use of UA-lowering therapy to prevent or slow down the progression of CKD. The review summarized the evidence and perspectives about the treatment of hyperuricemia with CKD for medicinal chemist and nephrologist.
Collapse
|
5
|
Simsek M, Opperman RCM, Mulder CJJ, Lambalk CB, de Boer NKH. The teratogenicity of allopurinol: A comprehensive review of animal and human studies. Reprod Toxicol 2018; 81:180-187. [PMID: 30125681 DOI: 10.1016/j.reprotox.2018.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/08/2018] [Accepted: 08/13/2018] [Indexed: 02/09/2023]
Abstract
Allopurinol is widely used in the management of multiple disorders including gout, kidney stones and inflammatory bowel disease. Despite of long-term experience, its safety in pregnancy has been debated due to reports on possible teratogenicity. We aimed to review the literature on the safety of allopurinol in pregnancy and offspring. In animals, allopurinol induced species-specific reproductive toxicity. In humans, a total of 53 allopurinol exposed infants were reported in the literature. Major congenital malformations were reported in two cases with a comparable pattern of multiple abnormalities. Five other infants had minor birth defects. In conclusion, the association between allopurinol and teratogenicity appears to be weak and limited to two reports with uncertain causality. However, the available data are insufficient to make a certain judgement, and as allopurinol treatment evolves, report and prospective follow-up of all exposed infants (i.e. deviant and normal cases) should be encouraged.
Collapse
Affiliation(s)
- Melek Simsek
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, AG&M Research Institute, Amsterdam, The Netherlands.
| | - Roza C M Opperman
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, AG&M Research Institute, Amsterdam, The Netherlands
| | - Chris J J Mulder
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, AG&M Research Institute, Amsterdam, The Netherlands
| | - Cornelis B Lambalk
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Reproductive Medicine, Obstetrics and Gynecology, Amsterdam, The Netherlands
| | - Nanne K H de Boer
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Gastroenterology and Hepatology, AG&M Research Institute, Amsterdam, The Netherlands
| |
Collapse
|
6
|
Ranieri L, Contero C, Peral ML, Calabuig I, Zapater P, Andres M. Impact of diuretics on the urate lowering therapy in patients with gout: analysis of an inception cohort. Arthritis Res Ther 2018; 20:53. [PMID: 29566736 PMCID: PMC5863897 DOI: 10.1186/s13075-018-1559-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 03/06/2018] [Indexed: 11/26/2022] Open
Abstract
Background Diuretics have been associated with impaired response and refractoriness in gout, but whether this effect is still present with new urate-lowering drugs (ULD) and treat-to-target strategies is unknown. The aim of the present study was to assess the impact of the diuretics on the response to ULD in patients with gout. Methods This was a retrospective analysis of an inception cohort. Participants were classified according to the type of ULD prescribed. We analysed the maximal dose of ULD (primary outcome variable), serum urate (SU) reduction, and the achievement of different SU targets (6 mg/dL, 5 mg/dL, and 4 mg/dL), according to the type of ULD prescribed and use of diuretics (loop and/or thiazide). We adjusted for confounders using multiple linear regression analysis. Results We included 245 patients: 208 treated with allopurinol (66 on diuretics, 31.7%), 35 with febuxostat (19 on diuretics, 57.6%), and 2 with benzbromarone. Significantly fewer participants in the allopurinol plus diuretics subgroup achieved SU levels of less than 5 mg/dL, but we found no other significant differences in SU targets associated with diuretics. Regarding the maximum ULD dose, a simple linear regression suggested an inverse relationship with diuretics (beta = − 0.125, p = 0.073), but this did not hold in the multivariable analysis (beta = − 0.47, p = 0.833). There was no association with febuxostat (beta = − 0.116, p = 0.514). Conclusion Diuretics do not appear to have a significant impact on managing gout. Electronic supplementary material The online version of this article (10.1186/s13075-018-1559-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Laura Ranieri
- Rheumatology Deparment, Hospital General Universitario de Alicante-ISABIAL, Pintor Baeza 12, 03010, Alicante, Spain
| | | | - Maria-Luisa Peral
- Rheumatology Deparment, Hospital General Universitario de Alicante-ISABIAL, Pintor Baeza 12, 03010, Alicante, Spain
| | - Irene Calabuig
- Rheumatology Deparment, Hospital General Universitario de Alicante-ISABIAL, Pintor Baeza 12, 03010, Alicante, Spain
| | - Pedro Zapater
- Universidad Miguel Hernández, Elche, Alicante, Spain.,Clinical Pharmacology Deparment, Hospital General Universitario de Alicante-ISABIAL, Alicante, Spain
| | - Mariano Andres
- Rheumatology Deparment, Hospital General Universitario de Alicante-ISABIAL, Pintor Baeza 12, 03010, Alicante, Spain. .,Universidad Miguel Hernández, Elche, Alicante, Spain.
| |
Collapse
|
7
|
Khanna D, Fitzgerald JD, Khanna PP, Bae S, Singh MK, Neogi T, Pillinger MH, Merill J, Lee S, Prakash S, Kaldas M, Gogia M, Perez-Ruiz F, Taylor W, Lioté F, Choi H, Singh JA, Dalbeth N, Kaplan S, Niyyar V, Jones D, Yarows SA, Roessler B, Kerr G, King C, Levy G, Furst DE, Edwards NL, Mandell B, Schumacher HR, Robbins M, Wenger N, Terkeltaub R. 2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken) 2013. [PMID: 23024028 DOI: 10.1002/acr.21772;10.1002/acr.21772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
|
8
|
Khanna D, FitzGerald JD, Khanna PP, Bae S, Singh M, Neogi T, Pillinger MH, Merill J, Lee S, Prakash S, Kaldas M, Gogia M, Perez-Ruiz F, Taylor W, Lioté F, Choi H, Singh JA, Dalbeth N, Kaplan S, Niyyar V, Jones D, Yarows SA, Roessler B, Kerr G, King C, Levy G, Furst DE, Edwards NL, Mandell B, Schumacher HR, Robbins M, Wenger N, Terkeltaub R. 2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken) 2012; 64:1431-46. [PMID: 23024028 PMCID: PMC3683400 DOI: 10.1002/acr.21772] [Citation(s) in RCA: 1056] [Impact Index Per Article: 88.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | | | | | - Sangmee Bae
- University of California Los Angeles, Los Angeles, CA
| | | | | | | | - Joan Merill
- Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Susan Lee
- VA Healthcare System and University of California San Diego, San Diego, CA
| | | | - Marian Kaldas
- University of California Los Angeles, Los Angeles, CA
| | - Maneesh Gogia
- University of California Los Angeles, Los Angeles, CA
| | | | - Will Taylor
- University of Otago, Wellington, New Zealand
| | - Frédéric Lioté
- Université Paris Diderot, Sorbonne Paris Cité, and Hôpital Lariboisière, Paris, France
| | - Hyon Choi
- Boston University Medical Center, Boston, MA
| | - Jasvinder A. Singh
- VA Medical Center. Birmingham, Alabama and University of Alabama, Birmingham, AL
| | | | - Sanford Kaplan
- Private Practice, Oral and Maxillofacial Surgery, Beverly Hills, CA
| | | | | | | | | | - Gail Kerr
- Veterans Affairs Medical Center, Washington, DC
| | | | - Gerald Levy
- Southern California Permanente Medical Group, Downey, CA
| | | | | | | | | | - Mark Robbins
- Harvard Vanguard Medical Associates/Atrius Health, Somerville, MA
| | - Neil Wenger
- University of California Los Angeles, Los Angeles, CA
| | - Robert Terkeltaub
- VA Healthcare System and University of California San Diego, San Diego, CA
| |
Collapse
|
9
|
VOETS AJ, JOESOEF KSHEIK. Allopurinol toxicity after coronary artery bypass grafting. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/tcic.9.2.88.89] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
10
|
Ng DY, Stocker SL, Graham GG, Williams KM, Day RO. Lack of effect of hydrochlorothiazide and low-dose aspirin on the renal clearance of urate and oxypurinol after a single dose of allopurinol in normal volunteers. Eur J Clin Pharmacol 2010; 67:709-13. [PMID: 21181139 DOI: 10.1007/s00228-010-0963-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 11/23/2010] [Indexed: 11/30/2022]
Abstract
AIMS To determine whether low-dose aspirin and hydrochlorothiazide (HCTZ) affect the renal clearance of oxypurinol and/or urate. METHODS Healthy volunteers (n = 8) were treated with allopurinol (600 mg, control), and allopurinol (600 mg) co-administered with single doses of aspirin (100 mg) or HCTZ (25 mg) or a combination of the two. RESULTS Hydrochlorothiazide, low-dose aspirin or a combination of the two, when co-administered with allopurinol, did not significantly alter (P > 0.05) the renal clearance of oxypurinol or urate. In particular, aspirin and HCTZ, when taken together and with allopurinol, did not change (P > 0.05) oxypurinol fractional renal clearance (allopurinol alone: 0.217, 0.173-0.262; combined: 0.202, 0.155-0.250) or urate fractional renal clearance (allopurinol alone: 0.066, 0.032-0.099; combined: 0.058, 0.038-0.078). CONCLUSIONS A single, low-dose of aspirin or an anti-hypertensive dose of hydrochlorothiazide, when administered alone or together with allopurinol, are unlikely to alter the hypouricaemic effect of allopurinol. The effect of chronic aspirin and HCTZ dosing taken together upon the efficacy of chronic allopurinol therapy in patients with hyperuricaemia needs to be investigated.
Collapse
Affiliation(s)
- Daniel Y Ng
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Xavier Level 2, Darlinghurst, NSW 2010, Australia
| | | | | | | | | |
Collapse
|
11
|
de Vries JX, Voss A, Ittensohn A, Walter-Sack I, Löffler W, Landthaler R, Zöllner N. Interaction of allopurinol and hydrochlorothiazide during prolonged oral administration of both drugs in normal subjects. II. Kinetics of allopurinol, oxipurinol, and hydrochlorothiazide. THE CLINICAL INVESTIGATOR 1994; 72:1076-81. [PMID: 7711419 DOI: 10.1007/bf00577759] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The kinetics of allopurinol and hydrochlorothiazide were investigated in seven healthy male subjects during prolonged coadministration of two drugs. Subjects were maintained on an isoenergetic, purine-free formula diet with RNA supplementation for 24 days. Allopurinol (300 mg) was given orally on days 1-24. Hydrochlorothiazide (50 mg daily) was added to days 11-21. On day 43 a single oral dose of 50 mg hydrochlorothiazide was administered. Plasma concentration-time profiles of allopurinol and its main metabolite oxipurinol were obtained on days 1, 10, and 21; hydrochlorothiazide profiles were assessed on days 21 and 43. In addition, 24-h plasma concentrations of oxipurinol were measured repetitively, and 24 h urine samples were collected for the determination of allopurinol, oxipurinol, and hydrochlorothiazide. For oxipurinol, mean Cmax was not altered on hydrochlorothiazide treatment (13.8 +/- 1.4 micrograms/ml and 14.7 +/- 2.6 micrograms/ml, respectively); mean AUC0-24 was 259 and 290 micrograms h-1 ml-1, respectively. The small difference in AUC0-24 values does not explain the increase in plasma uric acid concentration during hydrochlorothiazide treatment, nor do the variations in allopurinol and hydrochlorothiazide kinetics.
Collapse
Affiliation(s)
- J X de Vries
- Abteilung Klinische Pharmakologie, Universität Heidelberg, Germany
| | | | | | | | | | | | | |
Collapse
|
12
|
Löffler W, Landthaler R, de Vries JX, Walter-Sack I, Ittensohn A, Voss A, Zöllner N. Interaction of allopurinol and hydrochlorothiazide during prolonged oral administration of both drugs in normal subjects. I. Uric acid kinetics. THE CLINICAL INVESTIGATOR 1994; 72:1071-5. [PMID: 7711418 DOI: 10.1007/bf00577758] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The interaction of allopurinol (300 mg/day) and hydrochlorothiazide (50 mg/day) was studied in seven healthy male volunteers during prolonged coadministration of the two drugs using defined dietary conditions. A formula diet was administered with the allopurinol throughout the 24-day study, while hydrochlorothiazide was added during days 11-21. After the addition of hydrochlorothiazide both plasma uric acid and plasma oxipurinol rose for 6 days--24% and 30%, respectively, compared to steady-state levels during allopurinol alone (P < 0.01 each). In neither substance were variations in renal excretion significant. By the end of combined treatment (day 21), the changes induced by hydrochlorothiazide had already been reversed to a considerable extent. It is concluded that both in normal individuals and in patients with normal renal clearance of uric acid the effect of hydrochlorothiazide on the plasma concentration and renal excretion of oxipurinol is small. When taking both drugs, there is no increased risk during long-term treatment, and a risk is even questionable during the first days.
Collapse
Affiliation(s)
- W Löffler
- Medizinische Poliklinik, Universität München, Germany
| | | | | | | | | | | | | |
Collapse
|
13
|
Abstract
OBJECTIVE To review the pathophysiology, pathology, and clinical findings of allopurinol hypersensitivity syndrome (AHS), an infrequent but life-threatening adverse effect of allopurinol therapy. DATA SOURCES A MEDLINE search (key terms hepatitis, interstitial nephritis, severe hypersensitivity, severe toxicity, vasculitis, toxic epidermal necrolysis, Lyell's syndrome, erythema multiforme, and Stevens-Johnson syndrome) was used to identify cases reported in the literature through the end of 1990. STUDY SELECTION All cases evaluated met Singer and Wallace's diagnostic criteria for AHS. DATA EXTRACTION We extracted data from 101 cases of AHS reported in the literature. The following information, when available, was analyzed: (1) patient data (age, gender, medical history), (2) treatment data (daily dosage of allopurinol, duration of treatment, indications, concomitant medications, and (3) adverse-event data. DATA SYNTHESIS Patients were mostly middle-aged men with hypertension and/or renal failure receiving excessive doses of allopurinol primarily for asymptomatic hyperuricemia. Cutaneous rash and fever were the most common clinical findings. CONCLUSIONS Although the pathophysiologic pathway leading to the development of AHS is unknown, it probably involves an immunologic mechanism following allopurinol accumulation in patients with poor renal function. Our findings suggest that the accepted diagnostic criteria for AHS may be too broad, and we recommend the application of more restrictive criteria. There is no effective treatment for AHS. The use of allopurinol only for accepted indications and in dosages adjusted for a patient's renal function may be the only means of minimizing the incidence of AHS.
Collapse
Affiliation(s)
- F Arellano
- Clinical Pharmacology Service, Hospital Marqués de Valdecilla, Santander, Spain
| | | |
Collapse
|