What is the treatment for gout in a patient with acute kidney injury (AKI)?

From the Guidelines

The treatment of gout in patients with acute kidney injury (AKI) should prioritize corticosteroids as the first-line therapy, due to their effectiveness and relatively safer profile compared to NSAIDs and colchicine in patients with renal impairment. According to the 2016 updated EULAR evidence-based recommendations for the management of gout 1, and the American College of Physicians guideline on management of acute and recurrent gout 1, the choice of drug should be based on the presence of contraindications, the patient’s previous experience with treatments, and the number and type of joint(s) involved.

Some key points to consider in the treatment of gout in patients with AKI include:

• Colchicine should be used with caution and at reduced doses (0.3-0.6 mg once or twice daily) due to its potential to accumulate in renal impairment and cause toxicity 1.
• NSAIDs should be avoided due to their potential to further damage the kidneys, especially in patients with renal disease, heart failure, or cirrhosis 1.
• Corticosteroids, such as prednisone 20-40 mg daily for 3-5 days, then tapered over 7-10 days, or intra-articular steroid injections for single joint involvement, are often the safest option and can be effective in reducing pain and inflammation 1.
• For long-term management, allopurinol should be started at a low dose (50-100 mg daily) and gradually increased while monitoring kidney function, and febuxostat may be an alternative for some patients with severe renal impairment 1.
• Fluid intake should be maintained at 2-3 liters daily unless contraindicated, and dietary modifications to reduce purine intake are recommended 1.
• Uric acid levels should be monitored regularly, aiming for levels below 6 mg/dL 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 patients with severe renal failure (Cl cr less than 30 mL/min), start with 0. 3 mg/day; any increase in dose should be done with adequate monitoring of the patient for adverse effects of colchicine

The treatment for gout in a patient with acute kidney injury (AKI) is not explicitly stated in the label. However, for patients with severe renal impairment, the dose does not need to be adjusted for the treatment of gout flares, but a treatment course should be repeated no more than once every two weeks.

• For patients with mild to moderate renal impairment, no dose adjustment is required, but close monitoring for adverse effects is recommended.
• For patients undergoing dialysis, the recommended dose is reduced to 0.6 mg (one tablet) and should not be repeated more than once every two weeks.
• For patients with severe renal failure, the starting dose should be 0.3 mg/day, with any increase in dose done with adequate monitoring for adverse effects 2.

From the Research

Treatment Options for Gout in Patients with Acute Kidney Injury (AKI)

• The treatment of gout in patients with AKI requires careful consideration of the patient's renal function and potential contraindications to certain medications 3, 4.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) are not recommended for patients with AKI, as they can exacerbate or cause further kidney injury 4.
• Colchicine is also used with caution in patients with AKI, as its toxicity is increased in patients with impaired renal function, and dosage reduction is required based on the level of kidney function 4.
• Alternative treatment options for acute gout in patients with AKI include corticosteroids, adrenocorticotropic hormone (ACTH), and interleukin-1 (IL-1) inhibitors, such as canakinumab 5.
• Anakinra, an IL-1β blocking agent, has been shown to be effective and safe in patients with stage 4-5 chronic kidney disease (CKD) or kidney transplantation 6.

Considerations for Treatment

• The choice of treatment for gout in patients with AKI should be individualized based on the patient's specific clinical circumstances and renal function 3, 4.
• Patients with AKI may require closer monitoring and adjustment of their medication regimen to minimize the risk of adverse effects 4.
• In some cases, patients with AKI may require referral to a rheumatology or nephrology specialist for further management and guidance 4.

Emerging Therapies

• New studies are emerging that compare the efficacy and safety of different treatment options for acute gout, including prednisolone and colchicine 7.
• These studies aim to provide further guidance on the optimal treatment approach for patients with acute gout, including those with AKI or CKD.