What is the best course of action for a patient with gout, currently on colchicine and febuxostat, presenting with facial angioedema?

Immediate Management of Facial Angioedema in a Gout Patient on Colchicine and Febuxostat

Immediately discontinue both colchicine and febuxostat, secure the airway if there is any tongue or floor of mouth involvement, and initiate treatment with high-humidity oxygen, intravenous antihistamines, and intravenous corticosteroids.

Acute Angioedema Management

Airway Assessment and Intervention

• Assess for airway compromise immediately by examining the tongue, floor of mouth, and oropharynx 1
• Intubate emergently if there is massive tongue and floor of mouth edema, as this is the primary indication for airway intervention 1
• Patients with isolated facial swelling without tongue or oropharyngeal involvement typically do not require intubation 1
• If intubation is required, plan for extubation in 48-72 hours as angioedema is nonprogressive once treatment begins 1

Medical Treatment Protocol

• Discontinue the offending agents (both colchicine and febuxostat) immediately 1
• Administer high-humidity face tent oxygen 1
• Give initial dose of intravenous antihistamines 1
• Start intravenous corticosteroids and continue the course 1
• Most cases resolve within 24-48 hours, though significant tongue and oropharyngeal edema may take longer 1

Critical Pitfall

Once medical treatment is initiated, angioedema does not progress further—do not delay treatment waiting for worsening 1

Resuming Gout Management After Resolution

Urate-Lowering Therapy Selection

• Switch to allopurinol as the preferred first-line agent when restarting urate-lowering therapy 2
• Start allopurinol at ≤100 mg/day (lower if CKD stage ≥3) with subsequent dose titration to achieve serum urate <6 mg/dL 2
• Allopurinol is strongly recommended over febuxostat for all patients due to superior safety profile, efficacy when properly dosed, tolerability, and lower cost 2

Anti-inflammatory Prophylaxis

• Restart anti-inflammatory prophylaxis when initiating allopurinol, but avoid colchicine given the recent angioedema 2
• Use low-dose NSAIDs or prednisone/prednisolone ≤10 mg daily as alternative prophylaxis options 2
• Continue prophylaxis for 3-6 months rather than <3 months, with ongoing evaluation 2

Acute Flare Management Going Forward

• For future acute gout flares, choose corticosteroids or NSAIDs rather than colchicine 2
• Corticosteroids should be considered first-line given the contraindication to colchicine and potential comorbidities 2

Key Clinical Considerations

Drug-Induced Angioedema Context

While the evidence does not specifically link febuxostat or colchicine to angioedema in the provided guidelines, the temporal relationship with these medications necessitates their discontinuation 1. The most common adverse events with febuxostat include abdominal pain, diarrhea, and musculoskeletal pain, not typically angioedema 2. Colchicine's main adverse effects are gastrointestinal 2.

Monitoring After Medication Change

• When restarting with allopurinol, monitor for hypersensitivity reactions, particularly rash 2
• Consider HLA-B*5801 testing if the patient is of Southeast Asian descent (Han Chinese, Korean, Thai) before starting allopurinol 2
• Use a treat-to-target strategy with dose titration based on serial serum urate measurements to achieve and maintain levels <6 mg/dL 2