What is the optimal treatment approach for gout in a patient with solitary kidney (one kidney) and hypertension (high blood pressure)?

From the Guidelines

For someone with gout who has only one kidney and hypertension, the best treatment approach is to start with non-pharmacological measures and use febuxostat as the preferred urate-lowering therapy (ULT) due to its safety profile in patients with kidney impairment, as recommended by the 2020 American College of Rheumatology guideline 1. When managing gout in a patient with a single kidney and hypertension, it's crucial to balance the control of gout with the protection of the remaining kidney function and management of hypertension.

Non-Pharmacological Measures

• Weight loss if overweight
• Limiting alcohol intake, especially beer and spirits
• Avoiding high-purine foods like organ meats, shellfish, and red meat
• Staying well-hydrated
• Encouraging low-fat dairy products and regular exercise

Pharmacological Treatment

For acute gout attacks,

• Colchicine at a lower dose (0.6 mg once or twice daily) is preferred over NSAIDs, which can worsen kidney function and hypertension 1.
• Corticosteroids like prednisone (20-30 mg daily for 5-7 days with a taper) may be used for acute flares when other options aren't suitable. For long-term prevention,
• Febuxostat (40-80 mg daily) is generally safer than allopurinol for those with kidney impairment, though it requires dose adjustment and careful monitoring of kidney function 1.
• Losartan may be beneficial as it helps control hypertension while also having mild uricosuric effects. Regular monitoring of kidney function, uric acid levels, and blood pressure is essential, with target serum uric acid levels below 6 mg/dL, as suggested by the 2017 updated EULAR evidence-based recommendations for the management of gout 1. Any medication regimen should be started at lower doses and adjusted gradually under medical supervision to minimize risks to the remaining kidney.

From the FDA Drug Label

The use of colchicine or anti-inflammatory agents may be required to suppress gouty attacks in some cases Patients with decreased renal function require lower doses of allopurinol tablets than those with normal renal function. Lower than recommended doses should be used to initiate therapy in any patients with decreased renal function and they should be observed closely during the early stages of administration of allopurinol tablets In patients with severely impaired renal function or decreased urate clearance, the half-life of oxipurinol in the plasma is greatly prolonged. Therefore, a dose of 100 mg per day or 300 mg twice a week, or perhaps less, may be sufficient to maintain adequate xanthine oxidase inhibition to reduce serum urate levels Allopurinol and its primary active metabolite, oxipurinol, are eliminated by the kidneys; therefore, changes in renal function have a profound effect on dosage In patients with decreased renal function or who have concurrent illnesses which can affect renal function such as hypertension and diabetes mellitus, periodic laboratory parameters of renal function, particularly BUN and serum creatinine or creatinine clearance, should be performed and the patient’s dosage of allopurinol tablets reassessed With a creatinine clearance of 10 to 20 mL/min, a daily dosage of 200 mg of allopurinol tablets is suitable. When the creatinine clearance is less than 10 mL/min, the daily dosage should not exceed 100 mg. With extreme renal impairment (creatinine clearance less than 3 mL/min) the interval between doses may also need to be lengthened

For a patient with one kidney and hypertension, the best way to treat gout is to:

• Start with a low dose of allopurinol (100 mg daily) and increase at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained
• Monitor renal function closely, particularly BUN and serum creatinine or creatinine clearance
• Adjust the dosage of allopurinol based on the patient's renal function
• Consider using colchicine or anti-inflammatory agents to suppress gouty attacks if necessary
• Maintain a fluid intake sufficient to yield a daily urinary output of at least 2 liters and a neutral or slightly alkaline urine
• Monitor for adverse effects of colchicine, especially in patients with renal impairment 2, 2, 3

From the Research

Treatment Options for Gout with One Kidney and Hypertension

• The treatment of gout in patients with one kidney and hypertension requires careful consideration of the patient's comorbidities and the potential effects of medications on kidney function 4, 5.
• Colchicine, nonsteroidal anti-inflammatory drugs, and corticosteroids can be used to relieve pain in adults with acute gout episodes, but their use may need to be adjusted in patients with kidney disease 4.
• Urate-lowering therapies, such as allopurinol and febuxostat, can be used to prevent gout flares, but their use may need to be monitored closely in patients with kidney disease due to the potential for adverse effects 4, 5.
• Losartan, an antihypertensive medication, has mild uricosuric properties and may be a useful treatment option for patients with hypertension and gout 6.

Considerations for Patients with Chronic Kidney Disease

• Patients with chronic kidney disease are at increased risk of gout and hyperuricemia, and their treatment requires a team approach involving nephrologists and rheumatologists 7.
• The management of gout in patients with chronic kidney disease is complex and requires careful consideration of the patient's kidney function and the potential effects of medications on kidney function 7.
• Uric acid is a toxin that can accumulate in patients with kidney disease, and its management is critical to preventing gout and other complications 7.

Management of Hypertension in Patients with Gout

• Hypertension is a common comorbidity in patients with gout, and its treatment requires careful consideration of the potential effects of medications on uric acid levels 6.
• Diuretics, which are commonly used to treat hypertension, can increase uric acid levels and worsen gout, but alternative treatments such as losartan may be available 6.
• The management of hypertension in patients with gout requires a balanced approach that takes into account the potential effects of medications on both blood pressure and uric acid levels 6.