What is the recommended treatment for a gout flare in a patient with stage G4 (Chronic Kidney Disease) kidney disease and impaired renal function?

From the Guidelines

The recommended treatment for a gout flare in a patient with stage G4 chronic kidney disease (CKD) is oral prednisone at 20-40 mg daily for 3-5 days, as it doesn't require renal dose adjustment, or colchicine at a reduced dose of 0.3-0.6 mg once daily, due to the increased risk of toxicity in renal impairment, as suggested by the 2020 American College of Rheumatology guideline for the management of gout 1. When managing gout flares in patients with stage G4 CKD, it is essential to consider the potential risks and benefits of each treatment option.

• Colchicine, a commonly used medication for gout flares, should be used with caution in patients with renal impairment, as it can increase the risk of toxicity 1.
• Nonsteroidal anti-inflammatory drugs (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.
• Intra-articular steroid injections can be used for single joint involvement, providing a targeted treatment approach.
• For patients with frequent flares, IL-1 inhibitors like anakinra (100 mg daily for 3-5 days) may be considered, though they are expensive. During treatment, patients should rest the affected joint, apply ice, and maintain hydration to help manage symptoms and prevent further complications. The underlying cause of gout flares is hyperuricemia, which worsens with declining kidney function as the kidneys cannot effectively excrete uric acid. After the acute flare resolves, urate-lowering therapy should be considered, with allopurinol started at a low dose (50-100 mg daily) and gradually increased while monitoring kidney function, 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). For these patients, the treatment course should not be repeated more than once every two weeks

For a patient with stage G4 kidney disease, the renal function is considered severe impairment.

• The dose of colchicine for treatment of gout flares does not need to be adjusted.
• However, 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.
• Since stage G4 is considered severe impairment but not necessarily requiring dialysis, the dose can be given as 0.6 mg, but the treatment course should not be repeated more than once every two weeks 2.

From the Research

Treatment of Gout Flare in Patients with Stage G4 Kidney Disease

The treatment of gout flare in patients with stage G4 kidney disease requires careful consideration of the patient's impaired renal function.

• Colchicine Use: According to a study published in 2024 3, colchicine can be used to treat gout flares in patients with severe chronic kidney disease, including those with stage G4 kidney disease, at reduced doses. The study found that colchicine was well tolerated and effective in 54 patients with severe CKD, including 22% who were on dialysis.
• Dosing Considerations: The same study 3 noted that initial colchicine dosages were ≤0.5 mg/day in 75.8% of cases, and no dosage exceeded 1 mg/day. Another study published in 2016 4 found that patients with CKD stage 4 were prescribed an average initial dose of 2.5 (±0.7) mg of colchicine, which may be too high for patients with stage G4 kidney disease.
• Alternative Treatments: A review published in 2014 5 recommended low-dose colchicine (0.5 mg once or twice a day) or low-dose NSAIDs such as naproxen 250 mg orally twice a day for prophylaxis of gout flares after initiation of urate-lowering therapy. However, NSAIDs are not recommended for patients with CKD due to the risk of exacerbating or causing acute kidney injury 6.
• Urate-Lowering Therapy: A study published in 2010 7 found that oral colchicine (Colcrys) was effective in treating acute gout flares, but the recommended dosage may need to be adjusted for patients with stage G4 kidney disease. Another study published in 2014 6 noted that allopurinol, febuxostat, and pegloticase are effective treatments for controlling elevated uric acid levels, but dosage reductions may be required for patients with CKD.

Key Considerations

• Patients with stage G4 kidney disease require careful monitoring and dose adjustment of colchicine to minimize the risk of toxicity.
• Alternative treatments, such as low-dose NSAIDs, may not be suitable for patients with CKD due to the risk of kidney injury.
• Urate-lowering therapy should be adjusted according to the patient's kidney function to minimize the risk of adverse effects.