Medication consent

Informed Consent for Treatment with Krystexxa (pegloticase)

Informed consent for treatment with Krystexxa.

About this form

Krystexxa (pegloticase) is used to treat chronic gout in adults who have not responded to or cannot tolerate other gout treatments. It works by converting uric acid to a substance that is easier for the body to remove.

!Anaphylaxis and infusion reactions can occur. Premedication is required and patients are observed during/after each infusion.
!Patients with G6PD deficiency must NOT receive Krystexxa due to risk of severe hemolytic anemia.
!Monitor uric acid levels; treatment is typically discontinued if levels remain elevated.
!Worsening of heart failure can occur.

Progress

Benefits

I understand that the potential benefits of this treatment include: *

Effective uric acid reduction in patients with severe, treatment-resistant chronic gout.Can resolve tophi and reduce gout flares over time.

Common side effects

I have been informed of the most common side effects, which include: *

Gout flares (often during the first months)Infusion reactionsNauseaBruising

Acknowledgements

I have had the opportunity to discuss this treatment with my physician. *

Yes — I have had this opportunity

All of my questions have been answered to my satisfaction. *

Yes — my questions have been answered

I understand my financial responsibility for this treatment. *

Yes — I understand

Any additional questions or notes for our team

Sign & submit

Patient name *Date of birth *Email address *Patient signature (type your full name) *Date *

Acknowledgement. I certify that I have read and understood this consent form, that I have had the opportunity to discuss it with my physician, and that I agree to receive treatment with Krystexxa (pegloticase).

Submitting transmits this form securely to our office. For urgent medical issues please call our office or 911.

Trouble with the form?

Call our office and we'll either walk you through it or send a paper version.

Call (916) 677-4744 ← All forms