What is the optimal treatment for acute gout flare in patients with Impaired Renal (kidney) Function?

From the Guidelines

For acute gout flare in patients with poor kidney function, colchicine at a reduced dose is often the first-line treatment, using 0.6 mg once or twice daily instead of the higher loading doses used in patients with normal renal function, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. Alternatively, prednisolone at 20-30 mg daily for 5 days with a quick taper over another 5-7 days can be effective and is generally safe in renal impairment. NSAIDs should be avoided due to their potential to worsen kidney function, as stated in the 2016 updated EULAR evidence-based recommendations for the management of gout 1. Ice packs and rest of the affected joint can provide symptomatic relief. Joint aspiration with corticosteroid injection (such as triamcinolone 40 mg or methylprednisolone 40-80 mg) directly into the affected joint is another excellent option if the flare affects only one or two joints and can be performed by a trained clinician. It's essential to maintain adequate hydration during treatment and to address the underlying cause of hyperuricemia once the acute flare resolves, potentially with medications like allopurinol (starting at a low dose of 50-100 mg daily) or febuxostat, which may be better tolerated in renal impairment, as suggested by the management of acute and recurrent gout guideline from the American College of Physicians 1. Some key points to consider when treating gout in patients with poor kidney function include:

• Calculating the estimated glomerular filtration rate (eGFR) at the time of diagnosis for CKD classification and monitoring it regularly in parallel with SUA measurement, as emphasized in the 2016 updated EULAR evidence-based recommendations for the management of gout 1.
• Treating as early as possible, with colchicine effective when given within 12 hours of symptoms onset, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.
• Using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day), as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.
• Implementing a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.

From the FDA Drug Label

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 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).

The best treatment for acute gout flare with poor kidney function is colchicine.

• For patients with mild to moderate renal impairment, the dose does not need to be adjusted, but patients should be monitored closely for adverse effects.
• For patients with severe renal impairment, the treatment course should be repeated no more than once every two weeks.
• For patients undergoing dialysis, the total recommended dose should be reduced to a single dose of 0.6 mg. 2

From the Research

Treatment Options for Acute Gout Flare with Poor Kidney Function

• The management of gout is more complex in the presence of chronic kidney disease 3.
• For patients with acute gout and poor kidney function, treatment options include colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids 4, 5, 6.
• Low-dose colchicine is a safer option compared to high-dose colchicine, with a comparable tolerability profile to placebo 5, 6.
• Systemic corticosteroids have similar efficacy to therapeutic doses of NSAIDs, with studies supporting oral and intramuscular use 5, 6.
• IL-1β inhibitors, such as canakinumab, are effective for the treatment of acute attacks in subjects refractory to and in those with contraindications to NSAIDs and/or colchicine 5, 6.

Considerations for Patients with Poor Kidney Function

• Hyperuricaemia is an independent risk factor for renal function decline, and urate-lowering therapy might be beneficial in subjects with renal impairment 3.
• Allopurinol and febuxostat are used to prevent flare-ups, although febuxostat is associated with an increase in all-cause and cardiovascular mortality and is therefore not routinely recommended 4, 7.
• For patients with recalcitrant gout, pegloticase is effective, but its immunogenicity significantly threatens the achievement of sustained urate lowering responses 7.

Treatment Strategies

• The main aim of gout therapy is to fully dissolve the urate crystals, thus curing the disease 3.
• Avoidance of attacks-prophylaxis-and their prompt treatment if they occur, along with accurate information to patients, completes the treatment strategy 3.
• Lifestyle modifications form a part of gout prevention, and novel therapies, such as novel uricosurics, are being developed 7.