brand logo

Am Fam Physician. 2021;104(5):513-514

Author disclosure: No relevant financial affiliations.

Clinical Question

Should allele testing be done before prescribing allopurinol to prevent severe cutaneous adverse reactions (SCARs) such as Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug reaction with eosinophilia and systemic symptoms?

Evidence-Based Answer

Moderate evidence supports allele testing for HLA-B*58:01 before initiating allopurinol to decrease the incidence of SCARs in higher risk populations. (Strength of Recommendation [SOR]: B, based on systematic review and meta-analysis of population-controlled studies, prospective cohort studies.) Patient populations who are not at increased risk should not be screened. (SOR: C, based on consensus recommendation.)

Evidence Summary

A 2015 nonrandomized prospective cohort study (n = 2,926) evaluated the use of prospective genotyping for HLA-B*58:01 before initiation of allopurinol to prevent SCARs, including Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, and others.1 Historical incidence was used for the control group. The study included 15 medical centers in various regions across Taiwan from July 2009 to August 2014. Exclusion criteria included individuals who had a history of allopurinol-induced hypersensitivity, had a history of bone marrow transplant, or were not of self-described Han Chinese descent. HLAB*58:01 genotyping with real-time polymerase chain reaction was performed before starting treatment with allopurinol for all patients, and all patients were counseled on SCARs, with HLA-B*58:01-positive patients (n = 571) being recommended alternative treatments and non-carriers (n = 2,339) being started on allopurinol. The mean estimated historical incidence of allopurinol-induced SCARs in the control group from 2001 to 2004 was 0.30% per year (95% CI, 0.28% to 0.31%). This range of years was used to prevent confounding with early adopters of pretreatment genotyping. This study had a sufficient number of patients for a power of 86% to detect a reduction of allopurinol-induced SCARs from 0.30% per year to 0.03%. None of the study participants were diagnosed with SCARs, a significant difference (two-tailed P; P = .0026) compared with historical incidence, which predicted seven occurrences of SCARs.

A 2018 nonrandomized prospective study of 542 patients from 10 Korean hospitals evaluated the usefulness of screening for the HLAB*58:01 allele to identify at-risk individuals for allopurinol-induced SCARs.2 The patients had chronic renal insufficiency, defined as a glomerular filtration rate of less than 60 mL per minute for at least three months, with concurrent hyperuricemia, and each was genotyped for the HLA-B*58:01 allele. Of the enrolled patients, 503 were negative and treated with allopurinol at appropriate renal dosing, and 39 were HLA-B*58:01 allele positive and were treated with the alternative medication, febuxostat (Uloric), at appropriate renal dosing. The enrolled patients were compared in a retrospective manner with the historical incidence of SCARs in 4,002 matched patients from the same hospitals. Patients were followed biweekly for 90 days using phone surveys. Patients who withdrew consent or stopped allopurinol therapy were excluded from the analysis. A two-sided, one-sample binomial test was used to compare the prospective study and the historical control data with two-tailed P values. One of the 39 HLA-B*58: 01 allele-positive and 52 of the negative patients withdrew consent or were lost to follow-up. None of the participants in this study developed SCARs, and 38 cases of SCARs were identified in the historical control patients (0% vs. 0.95%; P = .029).

A 2011 systematic review and meta-analysis included six studies for analysis—three case-control studies, two case-population studies, and one retrospective cohort study.3 The primary outcome of this analysis was the carrier frequency of HLA-B*58:01 in allopurinol-induced cases of Stevens-Johnson syndrome and toxic epidermal necrolysis compared with each control group. Studies included patients self-identified as Han Chinese, Thai, Japanese, Korean, and mixed European populations, including patients self-described as South American, African, Asian, and European. Four studies were included in a pooled quantitative analysis—total HLA-B*58:01 carriers were 54 of 55 among case patients and 74 of 678 among the control patients. The pooled odds ratio for allele carriers developing Stevens-Johnson syndrome or toxic epidermal necrolysis was 96.6 (95% CI, 24.5 to 381.0). Five studies were included in a separate analysis that compared patients with the HLA-B*58:01 genotype and allopurinol-induced cases of Stevens-Johnson syndrome and toxic epidermal necrolysis with the general population. HLA-B*58:01 carrier frequency was 72.5% (50 of 69) for case patients and 5% (171 of 3,378) for population control patients. This group of studies had a pooled odds ratio of 79.3 (95% CI, 41.5 to 151.4). A subgroup analysis of populations of both allele-positive self-described Asian and self-described non-Asian cohorts revealed a statistically significant association between allopurinol-induced Stevens-Johnson syndrome and toxic epidermal necrolysis for both cohorts, with an odds ratio of 74.2 (95% CI, 27.0 to 204.1) and 101.5 (95% CI, 45.0 to 228.8), respectively, indicating a broader utility to allele testing to prevent SCARs in HLAB*58:01 carriers.

Already a member/subscriber?  Log In

Subscribe

From $145
  • Immediate, unlimited access to all AFP content
  • More than 130 CME credits/year
  • AAFP app access
  • Print delivery available
Subscribe

Issue Access

$59.95
  • Immediate, unlimited access to this issue's content
  • CME credits
  • AAFP app access
  • Print delivery available

Article Only

$25.95
  • Immediate, unlimited access to just this article
  • CME credits
  • AAFP app access
  • Print delivery available
Purchase Access:  Learn More

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (https://www.cebm.net).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to https://www.fpin.org or email: questions@fpin.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of FPIN’s Clinical Inquiries published in AFP is available at https://www.aafp.org/afp/fpin.

Continue Reading

More in AFP

More in Pubmed

Copyright © 2021 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.