What are the treatment options for Rheumatoid Arthritis (RA) in patients with Chronic Kidney Disease (CKD)?

From the Guidelines

Treatment of rheumatoid arthritis (RA) in patients with chronic kidney disease (CKD) should prioritize the use of hydroxychloroquine, leflunomide, and sulfasalazine, with careful dose adjustments and monitoring, as recommended by the 2021 American College of Rheumatology guideline 1. When managing RA in patients with CKD, it is essential to consider the potential risks and benefits of each medication.

• Hydroxychloroquine (200-400mg daily) is generally safe and requires minimal dose adjustment, making it a suitable option for patients with CKD.
• Methotrexate should be used cautiously, with reduced dosing (5-10mg weekly instead of standard 15-25mg) in moderate CKD and avoided in severe CKD (eGFR <30 ml/min), as it may increase the risk of toxicity in patients with impaired kidney function 2.
• Leflunomide (10-20mg daily) can be used with normal dosing but requires close monitoring of liver function and blood counts, as it may increase the risk of hepatotoxicity and myelosuppression.
• Sulfasalazine (1-3g daily) is generally safe but should be used cautiously in advanced CKD, as it may increase the risk of kidney damage. For biologics, TNF inhibitors like etanercept and adalimumab typically don't require dose adjustments, while rituximab (1000mg IV every 6 months) and abatacept may need dose modifications based on CKD severity, as recommended by the EULAR guidelines 2. JAK inhibitors like tofacitinib should be used at reduced doses (5mg once daily instead of twice daily) in moderate to severe CKD, as they may increase the risk of toxicity in patients with impaired kidney function. NSAIDs should be avoided due to their potential to worsen kidney function, and low-dose corticosteroids (prednisone 5-10mg daily) can be used for flares but should be tapered as soon as possible due to their metabolic complications. Regular monitoring of kidney function, including creatinine and eGFR every 3-6 months, is essential, along with monitoring for medication side effects and disease activity, to ensure optimal management of RA in patients with CKD.

From the Research

Treatment Options for Rheumatoid Arthritis (RA) in Patients with Chronic Kidney Disease (CKD)

• The treatment of RA in patients with CKD is challenging due to the potential toxicities of most disease-modifying antirheumatic drugs (DMARDs) and NSAIDs 3.
• Biologic agents, such as etanercept, may be a safe and effective treatment option for RA patients with CKD, as they have been shown to improve disease activity and decrease steroid requirements without causing significant renal toxicity 3.
• The dosage of rheumatic medications in patients with CKD is an important consideration, and special attention should be paid to the potential need for dosage modifications 4.
• Biologic agents have been shown to lower the risk of incident CKD and progressive eGFR decline in patients with RA 5.
• Traditional DMARDs, such as sulfasalazine, methotrexate, and hydroxychloroquine, may also be safe for use in patients with CKD, as they have been shown to not induce more short- or long-term renal complications compared to single DMARD therapy 6.
• A review of the safety and efficacy profiles of medications used to treat rheumatologic disease in the setting of CKD provides practical guidance for rheumatologists, nephrologists, and general physicians when prescribing these medications 7.

Biologic Agents in RA Treatment

• Biologic agents, such as etanercept, have been shown to be effective in treating RA in patients with CKD 3.
• The use of biologic agents has been associated with a lower risk of incident CKD and progressive eGFR decline in patients with RA 5.
• Biologic agents may be a preferred treatment option for RA patients with CKD due to their safety and efficacy profiles 3, 5.

Traditional DMARDs in RA Treatment

• Traditional DMARDs, such as sulfasalazine, methotrexate, and hydroxychloroquine, may be safe for use in patients with CKD 6.
• The dosage of traditional DMARDs in patients with CKD is an important consideration, and special attention should be paid to the potential need for dosage modifications 4.
• Traditional DMARDs may be used in combination with biologic agents to achieve optimal treatment outcomes in patients with RA and CKD 6, 7.