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Recurrent Clostridioides difficile infection — ABIM Board MCQ

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HardInfectious DiseaseRecurrent Clostridioides difficile infectionABIM Board

A 59-year-old man has disabling polyarticular tophaceous gout despite maximally tolerated allopurinol and a uricosuric agent. G6PD testing is normal, and he has no contraindication to methotrexate. Pegloticase is planned. Which strategy best improves the likelihood of sustained urate response?

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Correct answer: E — Start methotrexate with folate four weeks before pegloticase

The best answer is “Start methotrexate with folate four weeks before pegloticase”. The current FDA label recommends pegloticase every two weeks with weekly oral methotrexate and folate when methotrexate is appropriate, beginning methotrexate at least four weeks beforehand. Co-therapy reduces antidrug-antibody formation and improves durable response. Oral urate-lowering agents are stopped, premedication and pre-infusion urate monitoring are required, and loss of urate response signals infusion-reaction risk.

Reference: DailyMed FDA Label: KRYSTEXXA (pegloticase): https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=6e566303-d93a-4130-b764-25749829aa95