What is the treatment for urate nephropathy in a patient with a new acute polyarticular gout attack?

Treatment of Urate Nephropathy in a Patient with Acute Polyarticular Gout Attack

For patients with urate nephropathy and acute polyarticular gout, treatment should include aggressive management of the acute attack with anti-inflammatory agents while simultaneously addressing the underlying hyperuricemia, with appropriate dose adjustments for renal function. 1

Management of Acute Polyarticular Gout Attack

First-line Treatment Options:

• For severe polyarticular attacks, initial combination therapy is appropriate, particularly with involvement of multiple large joints 1
• Recommended combination approaches include:
  • Colchicine plus NSAIDs
  • Oral corticosteroids plus colchicine
  • Intra-articular steroids with any other modality 1

Specific Medication Recommendations:

Corticosteroids (preferred in renal impairment):

• Oral prednisone 0.5 mg/kg per day for 5-10 days at full dose then stop, or 2-5 days at full dose followed by 7-10 day taper 1
• Intra-articular steroids can be used for 1-2 affected joints (dose varies by joint size) 1
• For severe cases, IV methylprednisolone at 0.5-2.0 mg/kg may be appropriate 1

Colchicine (requires dose adjustment in renal impairment):

• If not already on prophylactic colchicine: 1.2 mg followed by 0.6 mg one hour later, then continue with prophylactic dosing 12 hours later 1
• Dose must be reduced in patients with renal impairment to avoid toxicity 2

NSAIDs (use with caution in renal impairment):

• Generally not recommended in patients with significant renal impairment as they can worsen kidney function 2
• If used, should be given with a proton pump inhibitor where indicated 1

Management of Urate Nephropathy

Immediate Interventions:

• Ensure adequate hydration with fluid intake sufficient to yield at least 2 liters of urine output daily 3
• Maintain neutral or slightly alkaline urine to prevent renal precipitation of urates 3
• Continue ongoing urate-lowering therapy (ULT) without interruption during the acute attack 1, 4

Urate-Lowering Therapy:

• For patients not already on ULT, it can be initiated during the acute attack (contrary to traditional practice) 4
• Allopurinol should be started at a low dose (100 mg daily) in patients with renal impairment 3
• For severe renal impairment (creatinine clearance <10 mL/min), daily dosage should not exceed 100 mg 3
• With extreme renal impairment (clearance <3 mL/min), dosing interval may need to be extended 3
• Target serum uric acid level should be below 6 mg/dL 3, 5

Prophylaxis During Urate-Lowering Therapy

• Anti-inflammatory prophylaxis should be initiated with or just prior to ULT 1
• Low-dose colchicine (0.6 mg once or twice daily, adjusted for renal function) is first-line 1
• Low-dose prednisone (<10 mg/day) is an option if colchicine and NSAIDs are contraindicated 1
• Continue prophylaxis for at least 6 months, or 3-6 months after achieving target serum urate levels (depending on presence of tophi) 1

Special Considerations for Renal Impairment

• Monitor renal function closely, especially during early stages of allopurinol therapy 3
• Patients with decreased renal function require lower doses of allopurinol than those with normal renal function 3
• For patients allergic to allopurinol with tophaceous gout and renal impairment, rasburicase infusions have been used successfully in some cases 6
• Bone marrow depression has been reported in patients receiving allopurinol, particularly with concomitant medications 3

Monitoring

• Measure serum uric acid levels regularly to ensure target levels (<6 mg/dL) are achieved 3
• Monitor renal function, particularly in patients with pre-existing renal disease 3
• Assess for resolution of acute gout symptoms and adjust therapy accordingly 1
• Watch for signs of medication toxicity, especially with colchicine in renal impairment 2