How to manage a patient with hyperuricaemia, chronic bilateral leg swelling, and multiple medication allergies, currently taking Bendroflumethiazide (a diuretic) and a statin (for cholesterol management)?

Management of Hyperuricemia and Chronic Leg Swelling in a Patient with Multiple Medication Allergies

The most appropriate management for this patient is to discontinue bendroflumethiazide and switch to a calcium channel blocker for hypertension management, as thiazide diuretics are directly contributing to both hyperuricemia and leg swelling.

Current Clinical Situation

• 74-year-old patient with hyperuricemia (uric acid 0.46, target <0.36), chronic bilateral leg swelling, and multiple medication allergies 1
• Currently taking bendroflumethiazide 5mg BD (a thiazide diuretic) and a statin 2
• Multiple medication allergies including candesartan (rash, hair loss), allopurinol (keratitis, hair loss), Fosamax (couldn't hold pen after 3 tablets), morphine (immediate nausea), and probenecid 3
• Comorbidities include Type 2 diabetes, hypertension, gout, osteoporosis, and history of falls 4

Medication-Induced Hyperuricemia

• Thiazide diuretics, including bendroflumethiazide, are among the most common medications that contribute to hyperuricemia and gout by reducing uric acid excretion by the kidneys 1
• The FDA label for bendroflumethiazide specifically warns that "hyperuricemia may occur or frank gout may be precipitated in certain patients receiving thiazide therapy" 2
• Bendroflumethiazide is also contributing to the patient's chronic bilateral leg swelling through its mechanism as a diuretic 4

Management Algorithm

Step 1: Address Medication Contributing to Hyperuricemia

• Discontinue bendroflumethiazide as it is directly contributing to both hyperuricemia and leg swelling 4, 2
• Replace with a calcium channel blocker such as amlodipine for hypertension management, which does not adversely affect uric acid levels 4, 1

Step 2: Consider Alternative Treatments for Hyperuricemia

• Given the patient's allergy to allopurinol and probenecid, options are limited 5
• Consider referral to a rheumatologist for specialized management of hyperuricemia in the setting of multiple drug allergies 3
• If medication is necessary for hyperuricemia management, consider desensitization protocols for allopurinol under specialist supervision 3

Step 3: Management of Chronic Leg Swelling

• With discontinuation of bendroflumethiazide, leg swelling may improve 4
• Consider compression stockings and leg elevation as non-pharmacological approaches 4
• Monitor for improvement in leg swelling after discontinuation of bendroflumethiazide 4

Special Considerations for This Patient

• Multiple medication allergies significantly limit treatment options and require careful consideration of alternatives 5, 3
• The patient's elevated uric acid level (0.46) is likely exacerbated by bendroflumethiazide therapy 2, 6
• Chronic bilateral leg swelling may be multifactorial but is likely worsened by bendroflumethiazide 4
• Type 2 diabetes management should be considered when changing antihypertensive medication 4

Monitoring and Follow-up

• Monitor serum uric acid levels 4-6 weeks after discontinuation of bendroflumethiazide 7
• Assess improvement in leg swelling at follow-up appointment 4
• Monitor blood pressure closely after switching from bendroflumethiazide to a calcium channel blocker 4
• Regular monitoring of renal function is recommended, especially with the patient's history of gout and diabetes 4

Common Pitfalls and Caveats

• Pitfall: Continuing thiazide diuretics despite hyperuricemia - Thiazides are a common and often overlooked cause of secondary hyperuricemia 1, 6
• Pitfall: Focusing only on urate-lowering therapy without addressing contributing medications - Removing the offending agent (bendroflumethiazide) should be the first step 4, 2
• Caveat: Multiple drug allergies require careful consideration - Desensitization protocols may be needed if essential medications are contraindicated due to allergies 3
• Caveat: Asymptomatic hyperuricemia generally doesn't require specific treatment - Focus should be on removing contributing factors rather than adding new medications 7

By discontinuing bendroflumethiazide and switching to a calcium channel blocker, this patient's hyperuricemia and leg swelling may improve significantly without requiring additional medications that could trigger allergic reactions 4, 1, 2.