Successful Extended Allopurinol Desensitization in an Elderly Patient With Chronic Kidney Disease and Febuxostat Intolerance

Effective management of gout in patients with chronic kidney disease (CKD) is frequently complicated by medication intolerance. Although allopurinol remains the preferred first-line urate-lowering therapy, cutaneous hypersensitivity reactions often necessitate drug discontinuation. Febuxostat is commonly used as an alternative, but intolerance or adverse effects may limit its use in certain patients. We describe a therapeutic solution for a patient who failed both standard agents. An 82-year-old woman with CKD and tophaceous gout presented with a benign maculopapular eruption following allopurinol initiation. After discontinuation of the drug, febuxostat was initiated, but this trial was aborted due to idiosyncratic symptomatic hypotension (94/64 mmHg). With no other oral options available, the patient underwent a conservative, 28-day oral allopurinol desensitization protocol under corticosteroid coverage. She successfully completed the desensitization and was titrated to a maintenance dose of 150 mg daily, achieving target serum uric acid levels without recurrence of skin manifestations. This case illustrates that a prolonged "start low, go slow" desensitization protocol can be safely employed in elderly patients with CKD who have experienced benign cutaneous reactions to allopurinol. This approach is particularly valuable when alternative agents like febuxostat are contraindicated or poorly tolerated, ensuring that patients are not left without effective treatment for progressive gout.