More detailed information about the symptoms, causes, and treatments of allopurinol hypersensitivity syndrome is available below. The clinical myths and pearls presented here highlight some commonly held assumptions about dress syndrome, a severe hypersensitivity drug reaction, in an effort to illuminate subtleties of managing patients with this condition. Although participation of other opportunistic viral infections has also been reported, the mechanisms by which any of these contribute to ahs are still. Allopurinol hypersensitivity syndrome ahs is a severe and sometimes life threatening adverse drug. An immune reaction to the ingestion of a drug called allopurinol.
Allopurinol hypersensitivity syndrome ahs is an idiosyncratic cellmediated hypersensitivity to allopurinol1 characterized by a diffuse morbilliform rash which can evolve into exfoliative dermatitis, eosinophilia, worsening renal function, and fever2. Successful febuxostat desensitization in a patient with. Febuxostat hypersensitivity, albeit rare, has been documented. A relationship between allopurinol hypersensitivity syndrome ahs and viral infections, especially with human herpes virus hhv6, has been suspected since the first report of ahs in 1970. Patients with chronic renal insufficiency have an increased risk of hypersensitivity reactions with allopurinol. Because allopurinol is on the world health organizations list of essential medicines and is still the main drug for treating hyperuricemia and gout, the data from this study suggest that physicians should be cautious when prescribing allopurinol to highrisk populations and should consider the potential risks of fatal hypersensitivity reactions. Identifying individuals with an increased risk of severe cutaneous adverse reactions to allopurinol based on the presence of the human leukocyte antigen hlab58. Ahs is categorized as a severe cutaneous adverse reaction scar 6. Highdose allopurinol in patients with stable angina pectoris. Serious allopurinol related adverse events for example, allopurinol. The syndrome is often characterized by fever, severe and profuse skin.
Genotyping patients who prefer not to have venipuncture done. These serious skin rashes are often preceded by influenzalike. A high index of suspicion is necessary in patients with a history of. The mainstay of treatment of these severe reactions is withdrawal of allopurinol.
Aug 14, 2019 drug rash with eosinophilia and systemic symptoms dress syndrome or drug hypersensitivity syndrome dhs has been reported in association with allopurinol use. Hypersensitivity reactions to allopurinol, a drug commonly used in the treatment of hyperuricemia, are being reported with increasing frequency. Characteristics and clinical outcomes article pdf available in the korean journal of internal medicine 304. Allopurinol desensitization with a 2 weeks modified protocol. A febuxostat desensitization protocol is a practical and realistic approach in offering treatment to those deemed not suitable to receive allopurinol and with previous documented febuxostat hypersensitivity. Over 60% of patients had received allopurinol for asymptomatic hyperuricemia.
Allopurinol use and risk of fatal hypersensitivity reactions. Allopurinol hypersensitivity syndrome symptoms, diagnosis. Here are links to possibly useful sources of information about allopurinol hypersensitivity syndrome. The annual incidence of allopurinol hypersensitivity rose statistically. Use of allopurinol for the treatment of asymptomatic hyperuricemia has also become common, due to a series of reports demonstrating. Allopurinol hypersensitivity syndrome ahs is a severe and sometimes lifethreatening adverse drug reaction. Jan 19, 20 lee hy, ariyasinghe jtn, thirumoorthy t. Recent euroscar studies demonstrated that allopurinol is the leading cause of stevensjohnson syndrome sjs and toxic epi. We describe a 61yearold male patient who was treated with allopurinol and developed fever, a skin rash, eosinophilia and severe renal and liver dysfunction. Pdf allopurinol hypersensitivity syndrome in patients. Frequently, the rash can involve ulcers of the mouth, throat, nose, genitals and conjunctivitis red and swollen eyes. Jun 15, 2010 pdf download the food and drug administration had received 11 reports of hypersensitivity reactions to febuxostat as of last month.
Describe risk factors for and clinical features of allopurinol hypersensitivity syndrome in patients with gout who are receiving allopurinol. Fatal allopurinol hypersensitivity syndrome after treatment. Sir, a relationship between allopurinol hypersensitivity syndrome ahs and viral infections, especially with human herpes virus hhv6, has been suspected since the first report of ahs in 1970 1. The syndrome includes many of the severe reactions described above, and is potentially lifethreatening and fatal. Allopurinol hypersensitivity and dress syndrome the american. Racialethnic variation and risk factors for allopurinol. Viruses may trigger allopurinol hypersensitivity syndrome. Sep 29, 2015 allopurinol is a highly effective, cheap and simple therapy for gout if dosing is adequate and patients adhere to the therapy. Beyond renal dosing to help reduce the risk of ahs, the recently discovered strong associations. Allopurinol hypersensitivity syndrome has clinical peculiarities that distinguish it from hypersensitivity syndrome caused by other drugs.
An unusual case of allopurinol hypersensitivity syndrome potentiated by intravitreal bevacizumab. The allopurinol hypersensitivity syndrome sciencedirect. Allopurinol is metabolized to oxypurinol which is also an inhibitor of xanthine oxidase. The risk of allopurinol hypersensitivity syndrome can be diminished by avoiding this medication in highrisk patients who test positive for the hlab5801 allele. Allopurinol hypersensitivity syndrome ahs was first reported by lang 4 in 1979, and diagnostic criteria were established in 1986 5. Hlab5801 testing to prevent allopurinol hypersensitivity syndrome. Allopurinol is a rare but well known cause of acute liver injury that has features of a hypersensitivity reaction and can be severe and even fatal. Jun 29, 2015 furthermore, febuxostat appears to induce hypersensitivity syndrome less frequently than allopurinol, and is well tolerated by most ahs patients 34,36. Pdf viruses may trigger allopurinol hypersensitivity syndrome. Sep 15, 2005 allopurinol hypersensitivity syndrome has clinical peculiarities that distinguish it from hypersensitivity syndrome caused by other drugs. Allopurinol is a xanthine oxidase inhibitor and a widely used medication for gout. Sep 15, 2019 allopurinol inhibits xanthine oxidase, the enzyme responsible for the conversion of hypoxanthine to xanthine to uric acid. As with all treatments, a balance has to be struck between benefit and risk and monitoring might need to be developed to minimise risk so that benefit can be maximised. Drug reaction with eosinophilia and systemic symptoms.
Gout treatment dosage affects risk for hypersensitivity syndrome. Serious adverse reactions associated with allopurinol, while rare, are feared owing to the high. An unusual case of allopurinol hypersensitivity syndrome. However, the best way to gauge overall risk from a drug is to calculate the. Symptoms of allopurinol hypersensitivity syndrome including 6 medical symptoms and signs of allopurinol hypersensitivity syndrome, alternative diagnoses, misdiagnosis, and correct diagnosis for allopurinol hypersensitivity syndrome signs or allopurinol hypersensitivity syndrome symptoms. We agree entirely that allopurinol can cause hypersensitivity responses, including rarely stevensjohnson syndrome and toxic epidermal necrolysis. Allopurinol hypersensitivity syndrome in patients with hematological malignancies. Allopurinol hypersensitivity syndrome in patients with. B5801 screening in severe allopurinol hypersensitivity syndrome. Allopurinol was approved by the us food and drug administration in 1966 for treating gout and remains a cornerstone of the treatment of uric acid. Allopurinol hypersensitivity syndrome singapore medical journal.
Dosage adjustment might have reduced the occurrence or severity of the rash. Describe the effect of the starting dose of allopurinol on the risk for allopurinol hypersensitivity syndrome in patients with gout. Allopurinol is the predominant, firstline uratelowering drug uld worldwide for the treatment of gout. Allopurinol hypersensitivity syndrome in patients with hematological. A hypersensitivity reaction hsr is an important, but rareuncommon adverse event associated with the use of allopurinol,1 the most commonly used uratelowering therapy ult for the treatment of gout. Among the 11 cases, there were 2 anaphylactic reactions, 1 case of angioedema, 2 of stevensjohnson syndrome, and 6 of rashesallergies, the agency revealed in response to a request. Hlab5801 testing to prevent allopurinol hypersensitivity. Gout medication treatment patterns and adherence to standards of care from a. Hypersensitivity reactions with allopurinol and febuxostat. Article information, pdf download for allopurinol hypersensitivity syndrome. Allopurinol hypersensitivity syndrome typically occurs in persons with preexisting kidney failure 119 weeks to months after allopurinol is begun, the patient develops a morbilliform eruption. Oct 22, 2014 allopurinol is an effective uratelowering drug that is well tolerated by the majority of patients. Allopurinol is the leading choice of uratelowering therapy for gout 95% of treated cases. Allopurinol is the most commonly prescribed uratelowering therapy for the management of gout.
Pdf allopurinol, an analog of hypoxanthine has been worldwide used for the treatment of. The janus faces of allopurinolallopurinol hypersensitivity syndrome. Although ahs is rare, the number of patients with gout requiring allopurinol is high, and there are sufficient overall cases of ahs to warrant consideration of preventive measures. Although allopurinol hypersensitivity syndrome, a severe cutaneous adverse. Discontinuation of allopurinol did achieve the ultimate goal of palliative care, which was to make the patient as comfortable as possible. Hallmarks of this hypersensitivity syndrome include a prolonged illness initially manifested by fever, a prominent cutaneous reaction, eosinophilia, hepatic abnormalities, and acute renal failure. Historical risk factors for ahs include renal insufficiency and diuretic use3, and because the syndrome can prove fatal. Rasburicase is a potent recombinant form of urate oxidase, which can metabolize uric acid to the more highly soluble compound allantoin. Prescribing allopurinol only when clearly indicated and at the appropriate starting dose will also reduce the burden of adverse consequences from allopurinol. How to prevent allopurinol hypersensitivity reactions.
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