A major obstacle to the treatment of
hyperuricemia in patients allergic to
allopurinol is the limited availability of suitable, equally effective, alternative,
urate-lowering drugs. Conventional uricosuric drugs, including
probenecid and
sulfinpyrazone, are recommended for
allopurinol- intolerant patients with
gout and "underexcretion"
hyperuricemia who have normal renal function and no history of
nephrolithiasis. Therapeutic options in those in whom traditional uricosuric drugs are contraindicated, ineffective, or poorly tolerated include slow oral desensitization to
allopurinol and cautious administration of
oxipurinol.
Allopurinol desensitization is useful particularly in those who have failed other treatment modalities. If available (as in Europe, South Africa, and Japan),
benzbromarone may be tried in patients with
gout and mild-to-moderate
renal insufficiency. Recombinant
urate oxidase can be used in the short-term prophylaxis and treatment of
chemotherapy- associated
hyperuricemia in patients with lymphoproliferative and
myeloproliferative disorders.
Hyperuricemia and
gout occur with increased frequency in
cyclosporine-treated allograft transplant recipients. The management of
gout in these patients is complicated by two main factors:
cyclosporine-induced renal impairment, and interactions with medications used to preserve the allograft.