What is the treatment for gout in a patient with Chronic Kidney Disease stage 4 (CKD4) and impaired renal function?

From the Guidelines

Treatment for gout with stage 4 chronic kidney disease (CKD) should prioritize allopurinol as the first-line urate-lowering therapy (ULT), starting at a low dose of 50-100 mg daily, with careful monitoring of kidney function and uric acid levels, aiming for a target serum urate below 6 mg/dL, as recommended by the 2020 American College of Rheumatology guideline 1.

Key Considerations

• For acute flares, colchicine at a reduced dose of 0.3-0.6 mg daily can be used, with careful monitoring for toxicity, while NSAIDs should be avoided due to their potential to worsen kidney function 1.
• Febuxostat (40-80 mg daily) may be an alternative for patients who cannot tolerate allopurinol, as suggested by the 2017 EULAR evidence-based recommendations for the management of gout 1.
• Corticosteroids like prednisone (20-40 mg daily for 5-7 days) can be used for acute flares when colchicine is contraindicated.
• Dietary modifications, including limiting purine-rich foods, maintaining adequate hydration, and avoiding high-fructose corn syrup, are also important, as supported by the 2017 EULAR recommendations 1.

Monitoring and Adjustments

• Regular monitoring of kidney function, uric acid levels, and medication side effects is essential, with dose adjustments made as needed based on the patient's response and kidney function status, as emphasized by the 2020 American College of Rheumatology guideline 1.
• The goal of treatment is to achieve a target serum urate below 6 mg/dL, with a lower target (<5 mg/dL) recommended for patients with severe gout, as suggested by the 2017 EULAR recommendations 1.

From the FDA Drug Label

For the prophylaxis of gout flares in patients with mild (estimated creatinine clearance [Cl cr] 50 to 80 mL/min) to moderate (Cl cr 30 to 50 mL/min) renal function impairment, adjustment of the recommended dose is not required, but patients should be monitored closely for adverse effects of colchicine. However, in patients with severe impairment, the starting dose should be 0.3 mg/day and any increase in dose should be done with close monitoring. For patients undergoing dialysis, the starting doses should be 0.3 mg given twice a week with close monitoring For treatment of gout flares in patients with mild (Cl cr 50 to 80 mL/min) to moderate (Cl cr 30 to 50 mL/min) renal function impairment, adjustment of the recommended dose is not required, but patients should be monitored closely for adverse effects of colchicine However, in patients with severe impairment, while the dose does not need to be adjusted for the treatment of gout flares, a treatment course should be repeated no more than once every two weeks. For patients with gout flares requiring repeated courses, consideration should be given to alternate therapy For patients undergoing dialysis, the total recommended dose for the treatment of gout flares should be reduced to a single dose of 0.6 mg (one tablet).

Gout treatment with CKD4:

• For prophylaxis of gout flares, the starting dose should be 0.3 mg/day with close monitoring.
• For treatment of gout flares, a single dose of 0.6 mg can be given, but the treatment course should not be repeated more than once every two weeks.
• Patients should be monitored closely for adverse effects of colchicine.
• Consideration should be given to alternate therapy for patients requiring repeated courses. 2 2

From the Research

Gout Treatment in CKD4 Patients

• Gout and chronic kidney disease (CKD) frequently coexist, but quality evidence to guide gout management in people with CKD is lacking 3.
• The use of urate-lowering therapy (ULT) in the context of advanced CKD varies greatly, and professional bodies have issued conflicting recommendations regarding the treatment of gout in people with concomitant CKD 3.
• Nephrologists should consider gout as a major complication of chronic kidney disease and actively manage it in their patients, as many patients with CKD have a history of gout yet are not effectively treated to target serum urate levels 4.

Urate-Lowering Therapies

• Allopurinol and febuxostat are the most commonly used urate-lowering therapies with established safety and efficacy in CKD patients 5.
• Febuxostat may be more renoprotective than allopurinol in patients with both hyperuricemia and CKD based on evidence from small long-term retrospective studies with serious risk of bias 5.
• Allopurinol and febuxostat achieved serum urate goals in patients with gout, and allopurinol was noninferior to febuxostat in controlling flares, with similar outcomes noted in participants with stage 3 chronic kidney disease 6.

Management of Gout in CKD Patients

• The pharmacology of acute gout flares and urate lowering is complicated in patients who also have evidence of CKD, primarily because of an increased risk of medication toxicity 7.
• Recipients of kidney transplants are particularly at risk of debilitating gout and medication toxicity, and nephrologists should be involved in the management of gout in renal patients 7.
• A team approach to gout management that includes the nephrologist is recommended, as many nephrologists do not primarily manage gout despite it being a common complication of chronic kidney disease 4.