Oral desensitization therapy in patients with chronic tophaceous gout

Abstract

Introduction: Allopurinol is the most popular drug for gout management. But some patients have adverse reactions for allopurinol therapy, and this limits its use. Such reactions are more common in patients with gout and chronic renal disease, probably because of accumulation of the allopurinol. Objective: To estimate effect of desensitization therapy on the patient with chronic tophous gout and a chronic kidney disease. Case: A 51-year-old male patient with a primary chronic tophous gout and urate nephropathy and chronic kidney disease stage 3. The man has a long-standing history of tophaceous gout and numerous episodes of arthritis during the past 8 years. The treatment with allopurinol was commenced with numerous attempts, but had to be discontinued due to mild rash, itching and increasing frequency of acute gouty arthritis. The patient was treated with NSAID (nimesulide), colchicines, and plasmapheresis (each every 3 months). He had a history of several years arterial hypertension and cardiac failure. The last 1–2 weeks before and at visit the patient had acute gouty arthritis in ankles, wrists, and small joints of hands and feet from both parties. Physical examination: He had large multiple tophaceous deposits over the small joints of the hands, elbows and feet (45 tophi), and he had active synovitis of the small joints of the hands and ankles. The lab result showed: anemia (Hb 97 g/l, Er 3.10 ∗ 1012), ESR 35 mm/h, serum urate was elevated 645 μmol/l, creatinine level 97 μmol/l, and urea level 8.2 mmol/l. Glomerular filtration rate (GFR) 51.2 ml/min/1.73 m2. Considering high level of uric acid, frequent gouty attacks, and lack of basic therapy after resolution of the acute gout attack, allopurinol was commenced in the standard desensitization regime (initial dosage of 50 μg, then each 3 days the dose increases and by 28-th day reaches 100 mg per day). The next visits at the 2 and 4 weeks showed good portability of allopurinol. At the control visit after 6 months, the patient accepts allopurinol 100 mg per day and he hadn't gouty attacks and mild rash with itching. Serum concentration of uric acid 430 μmol/l, GFR 63.4 ml/min/1.73 m2. Conclusion: The clinical case present shows the long-term efficacy and safety of slow oral desensitization for patient with gout and minor adverse events for previous allopurinol therapy.