Data on treating gout in patients with chronic kidney disease (CKD) is lacking because this population is rarely included in clinical trials. This has led to variation in treatment regimens and dosages among physicians. In a recent article in Kidney360, Vijay Kannuthurai, MD, and Angelo Gaffo, MD, of the University of Alabama at Birmingham, reviewed the efficacy and safety of gout medications in patients with CKD. They highlighted common missteps and offered suggestions on gout flare treatment and prophylaxis and urate-lowering therapy based on their practice experience.
Common Missteps
- Failure to adjust colchicine dose or consider drug interactions for gout flare treatment and prophylaxis.
- Not adding a prophylactic agent for 3-6 months in patients starting urate-lowering therapy.
- Initiating allopurinol therapy at too high a dose.
- Limiting maximum allopurinol dose based on kidney function. Dose titration to reach serum urate targets can be safe and avoid gout undertreatment.
- Assuming febuxostat is more effective than allopurinol even though studies demonstrate that allopurinol is inferior to febuxostat in patients with CKD.
- Discontinuing urate-lowering therapy during a gout flare.
- Stopping urate-lowering therapy during acute kidney injury.
Prophylaxis and Treatment of Gout Flare
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Colchicine: Consider 0.3-0.6 mg orally every other day or twice weekly, depending on CKD stage, since this drug is partially renally cleared. Also beware of drug interactions such as with statins, cyclosporine, and macrolide antibiotics. Avoid using this drug in patients with end-stage kidney disease (ESKD).
Nonsteroidal antiinflammatory drugs (NSAIDs): These drugs are contraindicated in CKD, except in very select cases.
Systemic glucocorticoids: Use cautiously in patients with diabetes or hypertension. These drugs can increase the risk for infection.
Interleukin-1 inhibitor (anakinra): For patients with an estimated glomerular filtration rate (eGFR) less than 30 mL/min/1.73m2, dose every other day because the drug is mostly renally cleared. Nonfatal infections have been reported with use.
Urate-Lowering Therapy
Allopurinol: Consider using this xanthine oxidase inhibitor as a first-line agent, starting at 50 or 100 mg/day or less in CKD. Increase the dose every 2-5 weeks to achieve a serum urate target of 6 mg/dL or less. Monitor for allopurinol hypersensitivity syndrome.
Febuxostat: Start with 40 mg/day or less, then titrate this xanthine oxidase inhibitor every 2 to 5 weeks, to reach target serum urate levels of 6 mg/dL or less. Data are conflicting on whether febuxostat increases the risk for cardiovascular death.
Uricases: Only use these drugs (eg, pegloticase) in severe, refractory gout. May require concurrent use of immunomodulating drugs due to their immunogenicity.
Uricosurics: These drugs, which include probenecid and benzbromarone, rely on renal excretion and are contraindicated in CKD.
“In addition to including more patients with CKD [in trials], stratifying results by patients’ renal function and implementing standardized outcome measures in reporting gout flares as well as serum urate levels would also improve the utility of clinical trials in this area and help practitioners better serve this patient population,” according to the reviewers.
Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Reference
Kannuthurai V, Gaffo A. Management of patients with gout and kidney disease: a review of available therapies and common missteps. Kidney360. Published online August 1, 2023. doi:10.34067/KID.0000000000000221
