both increase Other (see comment). Use Caution/Monitor. Medications that may cause hepatotoxicity when combined with valoctogene roxaparvovec may potentiate the risk of elevated liver enzymes. Closely monitor these medications and consider alternative medications in case of potential drug interactions.valproic acidSerious - Use Alternative (1)valproic acid, lesinurad. Other (see comment). Avoid or Use Alternate Drug. Comment: Avoid coadministration with inhibitors of epoxide hydrolase (valproic acid) which may interfere with metabolism of lesinurad.voriconazoleMonitor Closely (1)voriconazole will increase the level or effect of lesinurad by affecting hepatic enzyme CYP2C9/10 metabolism. Modify Therapy/Monitor Closely.warfarinSerious - Use Alternative (1)allopurinol increases effects of warfarin by anticoagulation. Avoid or Use Alternate Drug. >10% Serum creatinine elevation 1.5 x to <2.0 x baseline, lesinurad 400 mg/allopurinol (11%) 1-10% Blood creatinine, lesinurad 400 mg/allopurinol (8%) Serum creatinine elevation ≥2.0 x baseline, lesinurad 400 mg/allopurinol (7%) Influenza, lesinurad 200 mg/allopurinol (4.9%) Serum creatinine elevation 1.5 x to <2.0 x baseline, lesinurad 200 mg/allopurinol (4.4%) Headache, lesinurad 200 mg/allopurinol (4.2%) Blood creatinine elevation, lesinurad 200 mg/allopurinol (3.7%) Renal failure, lesinurad 400 mg/allopurinol (3.5%) Gastroesophageal reflux disease (3.2%) Nephrolithiasis, lesinurad 400 mg/allopurinol (2.2%) Major adverse cardiovascular events (eg, cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke), lesinurad 400 mg/allopurinol (1.85%) Serum creatinine elevation ≥2.0 x baseline, lesinurad 200 mg/allopurinol (1.5%) Renal failure, lesinurad 200 mg/allopurinol (1%) <1% Major adverse cardiovascular events, lesinurad 200 mg/allopurinol (0.61%) Nephrolithiasis, lesinurad 200 mg/allopurinol (0.5%) Frequency Not Defined ALT increased AST increased Blood alkaline phosphatase increased Diarrhea Maculopapular rash Nausea Rash Postmarketing Reports Most common Gastrointestinal disorders: Diarrhea, nausea Investigations: Blood alkaline phosphatase increased, AST increased, ALT increased Skin and subcutaneous tissue disorders: Rash, maculopapular rash Less common (<1%) Blood and lymphatic system disorders: Ecchymosis, thrombocytopenia, eosinophilia, leukocytosis, leukopenia Gastrointestinal disorders: Vomiting, abdominal pain, gastritis, dyspepsia General disorders and administration site conditions: Pyrexia Hepatobiliary disorders: Hepatitis (including hepatic necrosis and granulomatous hepatitis), hepatomegaly, hyperbilirubinemia, cholestatic jaundice Musculoskeletal and connective-tissue disorders: Myopathy, arthralgia Nervous system disorders: Headache, peripheral neuropathy, neuritis, paresthesia, somnolence, ageusia Renal and urinary disorders: Renal failure, azotemia Respiratory, thoracic and mediastinal disorders: Epistaxis Skin and subcutaneous tissue disorders: Erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, leukocytoclastic vasculitis, purpura, bullous dermatitis, exfoliative dermatitis, eczema, pruritus, urticaria, alopecia, onycholysis, lichen planus Vascular disorders: Necrotizing vasculitis, vasculitis Black Box Warnings Acute renal failure reported with lesinurad and more commonly occurs when administered as monotherapy; lesinurad should be used in combination with a xanthine oxidase inhibitor; adverse reactions related to renal function, including acute renal failure, reported after initiating Lesinurad 200 mg in combination with allopurinol associated with increased incidence of serum creatinine (Scr) elevations, mostly reversible Interrupt treatment if Scr increases to >2 times baseline; discontinue treatment if CrCl <45 mL/min Interrupt treatment and measure Scr promptly if symptoms of acute uric acid nephropathy (eg, flank pain, nausea or vomiting) occur Do not restart lesinurad/allopurinol unless an alternative cause of serum creatinine abnormalities is found Evaluate renal function before treatment and periodically thereafter as clinically indicated; more frequent renal function monitoring recommended with CrCL < 60 mL/min or with Scr increases 1.5-2x baselineContraindications Severe renal impairment (CrCl <30 mL/min), end-stage renal disease, kidney transplant recipients, or patient on dialysis Tumor lysis syndrome or Lesch-Nyhan syndrome Known hypersensitivity to allopurinol, including previous occurrence of skin rash Cautions Increase risk of renal events; see Black Box Warnings Few cases reported of reversible clinical hepatoxicity with patients taking allopurinol; if anorexia, weight loss, or pruritus develops in patients on lesinurad/allopurinol, liver function should be evaluated; in patients with pre-existing liver disease, periodic liver function tests are recommended In clinical trials with lesinurad/allopurinol, major adverse cardiovascular events (eg, cardiovascular deaths, nonfatal myocardial infarctions, and nonfatal strokes) were observed Occasional occurrence of drowsiness was reported in patients taking allopurinol; caution when engaging in activities where alertness is mandatory Bone marrow depression has been reported in patients receiving allopurinol, most of whom received concomitant drugs with the potential for causing this reaction, ranging from 6 weeks to 6 years after initiating allopurinol therapy; see Drug interactions overview Rash and hypersensitivity Rash frequently reported in allopurinol patients; in some instances, a skin rash may be followed by more severe hypersensitivity reactions associated with exfoliation, fever, lymphadenopathy, arthralgia, and/or eosinophilia, including Stevens-Johnson syndrome and toxic epidermal necrolysis; treatment should be discontinued immediately at any appearance of skin rash or other allergic signs/symptoms Hypersensitivity reactions to allopurinol may be increased in patients with decreased renal function receiving thiazide diuretics and lesinurad/allopurinol concurrently; caution with coadministration of such combinations and patients should be observed closely Drug interactions overview Lesinurad is a substrate of CYP2C9, OAT1, and OAT3; no clinical studies have been conducted with OAT1/OAT3 inhibitors; caution with moderate CYP2C9 inhibitors or inducers Lesinurad is a weak inducer of CYP3A and has no relevant effect on any other CYP enzyme for induction (CYP1A2, CYP2C8, CYP2C9, CYP2B6, or CYP2C19) or inhibition (CYP1A2, CYP2B6, CYP2D6, CYP2C8, CYP2C9, CYP2C19, or CYP3A4); monitor for potential reduction in efficacy in CYP3A substrates Reported that allopurinol prolongs the half-life of dicumarol, a coumarin anticoagulant; prothrombin time should be reassessed periodically in patients receiving coumarin anticoagulants (dicumarol, warfarin) concomitantly with lesinurad/allopurinol Allopurinol with mercaptopurine or azathioprine Patients taking allopurinol and mercaptopurine or azathioprine require a reduction in dose to approximately one third to one quarter of the usual dose of mercaptopurine or azathioprine Subsequent dose adjustments of mercaptopurine or azathioprine should be made on the basis of therapeutic response and the appearance of toxic effects; closely monitor therapeutic response and appearance of toxicity Pregnancy No available human data on use of lesinurad/allopurinol or lesinurad in pregnant women to inform a drug-associated risk of adverse developmental outcomes. Limited published data on allopurinol use in pregnant women do not demonstrate a clear pattern or increase in frequency of adverse development outcomes Animal Data Lesinurad In an embryofetal development study in pregnant rats dosed during the period of organogenesis from gestation days 6-17, lesinurad was not teratogenic and had no affect fetal development or survival at exposures up to ~45 times the maximum recommended human dosage (MRHD) (on an AUC basis at maternal oral doses up to 300 mg/kg/day) In an embryofetal development study in pregnant rabbits dosed during the period of organogenesis from gestation days 7-20, lesinurad was not teratogenic and did not affect fetal development at exposures up to ~10 times the MRHD (on an AUC basis at maternal oral doses up to 75 mg/kg/day); severe maternal toxicity, including mortality, was observed in rats and rabbits at exposures equal to or greater than ~45 and 4 times the MRHD (on an AUC basis at maternal oral doses of 300 mg/kg/day in rats and 25 mg/kg/day and higher in rabbits), respectively Allopurinol In embryofetal development studies with pregnant rats or rabbits, allopurinol administered during the period of organogenesis (gestation days 8–16) was not teratogenic or fetotoxic in either species at doses up to ~6 times the MRHD (on a mg/m2 basis at maternal oral doses up to 200 mg/kg/day in rats and 100 mg/kg/day in rabbits) However, in an embryofetal development study with pregnant mice, single intraperitoneal doses of allopurinol on gestation days 10 or 13 produced significant increases in fetal deaths and teratogenic effects, including external and skeletal malformations, at 0.8 times the MRHD and higher (on a mg/m2 basis at maternal intraperitoneal doses of 50 or 100 mg/kg); it is uncertain whether the findings in mice represented a fetal effect or an effect secondary to maternal toxicity. Lactation Unknown if distributed in human breast milk Consider the developmental and health benefits of breastfeeding along with the mother’s clinical need for the drug, and any potential adverse effects on the breastfed infant from the drug or from the underlying maternal conditionPregnancy Categories A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk. B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk. C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done. D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk. X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist. NA: Information not available. Mechanism of Action Lesinurad: Selective uric acid reabsorption inhibitor (SURI); it acts by inhibiting the urate transporter, URAT1, which is responsible for the majority of the renal reabsorption of uric acid; it also inhibits organic anion transporter 4 (OAT4), a uric acid transporter associated with diuretic-induced hyperuricemia Allopurinol: Xanthine oxidase inhibitor that inhibits conversion of hypoxanthine to xanthine to uric acid; decreases production of uric acid without disrupting synthesis of vital purines Absorption Lesinurad Bioavailability: ~100% (monotherapy) Peak plasma time: 1-4 hr (single dose) Administration with a high-fat meal, decreases plasma concentration of lesinurad compared with fasted state Allopurinol Peak plasma time: 1-4 hr (allopurinol and oxypurinol) Peak plasma concentration, single 300 mg dose: 3 mcg/mL (allopurinol); 6.5 mcg/mL (oxypurinol) Distribution Protein bound: 98% (lesinurad) Vd: ~20 L (lesinurad) Metabolism Lesinurad undergoes oxidative metabolism mainly via the polymorphic cytochrome CYP2C9 enzyme; metabolites are not known to contribute to the uric-acid lowering effects of lesinurad; caution with use in CYP2C9 poor metabolizers, and in patients taking moderate CYP2C9 inhibitors; see Cautions Allopurinol is metabolized to oxypurinol (alloxanthine), which also is a xanthine oxidase inhibitor Elimination Half-life: 5 hr (lesinurad); 1-2 hr (allopurinol); ~26 hr (oxypurinol) Clearance: 6L/hr (lesinurad) Allopurinol is cleared essentially by glomerular filtration; oxypurinol is reabsorbed in the kidney tubules similarly to the reabsorption of uric acid Excretion: Feces (20%, allopurinol) Pharmacogenomics Caution with CYP2C9 poor metabolizers Oral Administration Take PO qDay in the morning with food and water Instruct patient to stay well hydrated (eg, 2 liters of liquid per day) Storage Store at 20-25°C (68-77°F); excursions permitted from 15-30°C (59-86°F) No images available for this drug. No images available for this drug.A Patient Handout is not currently available for this monograph.Print