60 year old man presented with chronic renal failure and hyperurecemia but he developed allergy to allopurinol.
Serum creat.= 2.6 mg/dL
Serum uric acid= 9.4 mg/dL
What will be you plan of management?
I am not sure about your patient EGFR
Febuxostat is good alternative
See the link
http://rheumatology.oxfordjournals.org/content/48/suppl_2/ii15.full
As this patient has a low eGFR (25ml/min) it is unlikely that uricosuric drugs would be helpful. Does he require an ARB, losartan may have some uricosuric effect. febuxostat is a xanthine oxidase inhibitor. It may produce similar allergy to allopurinot. i may thus be tried, but with caution. The major question is, is he symptomatic as a result of his hyperuricemia. If not I would possibly not treat the hyperuricemia, but watch closely.
hyperuricimia in this case might be due to catabolic state, try improving nutritional condition and calory intake, moreover febuxa can also be used.
once the caloric intake is improved, cell breakdown will decrease and hence uric acid will also start coming towards normal. In cachexic states anabolic steroids can also be used .
We use febuxostat in patients having allergy to allopurinol who needs to decrease serum uric acid.
1.stop drugs which can cause hyperurecemia，such as lasix，aspirine
2.alkalization of urine and take more water if no edema
3.if no effect after 1and 2，use febuxostat
You didn't mention if your patient has symptoms like gout. If so you have to think about pseudo-gout too. So you have to look for Ca x Phosphate. If doubts remain that allergy to allopurinol is present you may test for HL-A B*5801.
Another approach: If the patient is obese he has to reduce his intake of carbohydrates strictly, since it is likely that his polyol-pathway is activated and he generates fructose by himself. Intake and degradation of fructose are the most common causes of hyperuricemia since the pool of ATP intracellularly is reduced rapidly and purins are broken down.
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