Allopurinol Risk Assessment

[ColonelForbin]

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Question for other PCP’s, Rheumatologists, or other Allopurinol prescribers. Lexicomp recommends screening not only persons of certain Asian ancestry, but also all African Americans for the HLA-B*5801 allele prior to starting Allopurinol given the higher prevalence of the allele in these populations and the association with severe Allopurinol hypersensitivity reactions. However, I almost never seen this done in practice for African American patients. Does anyone else do this routinely in their practice?

 

[VA Hopeful Dr]

Nope

 

[dozitgetchahi]

Question for other PCP’s, Rheumatologists, or other Allopurinol prescribers. Lexicomp recommends screening not only persons of certain Asian ancestry, but also all African Americans for the HLA-B*5801 allele prior to starting Allopurinol given the higher prevalence of the allele in these populations and the association with severe Allopurinol hypersensitivity reactions. However, I almost never seen this done in practice for African American patients. Does anyone else do this routinely in their practice?

Rheumatology here. Nope.

The test is fairly expensive and isn’t especially easy to get authorized by insurance…and even if it is positive, insurance companies still may not authorize febuxostat without first trying allopurinol.

 

[mszzeta]

Rheumatology here. Nope.

The test is fairly expensive and isn’t especially easy to get authorized by insurance…and even if it is positive, insurance companies still may not authorize febuxostat without first trying allopurinol.

I am also a rheumatologist just finished fellowship. I have not had much experience dealing with insurance, but I am told to check HLA-B*5801 in African American.

If HLA-B*5801 comes back pos, the risk of allopurinol would be much higher than benefit? Untreated gout can lead to disability, while SJS/TEN can lead to death. I would probably let the pt to buy febuxostat out of pocket, or prescribe allopurinol and ask pt to throw them into trash bin to get the insurance requirement. Anyway, I am extremely disappointed by these nonsense insurance companies. I hope they can be legally held liable for putting so much harm in patients

 

[dozitgetchahi]

I am also a rheumatologist just finished fellowship. I have not had much experience dealing with insurance, but I am told to check HLA-B*5801 in African American.

If HLA-B*5801 comes back pos, the risk of allopurinol would be much higher than benefit? Untreated gout can lead to disability, while SJS/TEN can lead to death. I would probably let the pt to buy febuxostat out of pocket, or prescribe allopurinol and ask pt to throw them into trash bin to get the insurance requirement. Anyway, I am extremely disappointed by these nonsense insurance companies. I hope they can be legally held liable for putting so much harm in patients

Yes, it’s stupid.

I certainly try to order the test in African American patients with gout who have never started urate lowering medication before. If it gets approved, great. If not…febuxostat is often still a fairly expensive drug, and a lot of patients aren’t going to be willing/able to pay cash for it. Prior auths? Hahahaha. I’ve recently had to do prior auths for methotrexate and Plaquenil, in patients who had never tried any other DMARDs before. You can certainly try the good old “just throw out this script so we can get the other drug” trick, but strictly speaking, that’s illegal and if you do get caught doing that there can be hell to pay.

Welcome to the real world of medicine. Come on in - the water’s fine - but it’s still very different from academia. You do your best with what you can pull off, but there’s no question that insurance companies name the tune in a fair number of situations.

 

[ColonelForbin]

Rheumatology here. Nope.

The test is fairly expensive and isn’t especially easy to get authorized by insurance…and even if it is positive, insurance companies still may not authorize febuxostat without first trying allopurinol.

You've had insurance companies require trial of Allopurinol before approving Febuxostat even after explaining in the prior auth paperwork the patient was positive for the HLA-B*5801 allele?

 

[ColonelForbin]

Nope

Respect the opinion. Would just be curious to hear your thought process. ACR 2020 clinical practice guidelines for Gout treatment recommend screening both Southeast Asians and African Americans and site a study that it's cost effective at a population level. Do realize it is cumbersome to have patient return to clinic to sign consent for genetic testing and then go for an extra blood draw, all of which delays starting treatment.

 

[VA Hopeful Dr]

Respect the opinion. Would just be curious to hear your thought process. ACR 2020 clinical practice guidelines for Gout treatment recommend screening both Southeast Asians and African Americans and site a study that it's cost effective at a population level. Do realize it is cumbersome to have patient return to clinic to sign consent for genetic testing and then go for an extra blood draw, all of which delays starting treatment.

Expensive test that I doubt most insurances will pay for.

 

[dozitgetchahi]

You've had insurance companies require trial of Allopurinol before approving Febuxostat even after explaining in the prior auth paperwork the patient was positive for the HLA-B*5801 allele?

Yep. Look, I’ve had insurance companies try to force me to start methotrexate in a patient with a GFR way south of 30 because they didn’t want to pay for a biologic. Which is even more acutely dangerous.

 

[dozitgetchahi]

Respect the opinion. Would just be curious to hear your thought process. ACR 2020 clinical practice guidelines for Gout treatment recommend screening both Southeast Asians and African Americans and site a study that it's cost effective at a population level. Do realize it is cumbersome to have patient return to clinic to sign consent for genetic testing and then go for an extra blood draw, all of which delays starting treatment.

I agree with the thought process. Problem is getting insurance to go along with it. This is hardly the only situation in medicine where insurance companies blow off good evidence to save a buck.

I order the test, yes, but in many of these patients it either doesn’t get approved/drawn or the patient comes back screeching at me about a $500 bill for one lab test. Many African American patients I see are on Medicaid, and good luck getting that to pay for damn near anything (hell they won’t even compensate ME enough to break even on the visit).