From the Guidelines
For treating gout in patients with chronic kidney disease (CKD), allopurinol is the preferred medication, starting at a low dose of 50-100 mg daily and gradually increasing while monitoring kidney function, with a target serum uric acid level below 6 mg/dL, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.
Key Considerations
- Allopurinol is the first-line urate-lowering therapy for patients with CKD, due to its effectiveness in reducing serum uric acid levels and preventing gout flares 1.
- The dose of allopurinol should be adjusted based on kidney function, with a starting dose of 50-100 mg daily and gradual increases as needed and tolerated 1.
- Febuxostat (40-80 mg daily) is an alternative for those who cannot tolerate allopurinol, but its use should be carefully considered in patients with CKD due to potential renal impairment 1.
- Probenecid is typically avoided in CKD as it loses effectiveness with decreased kidney function 1.
- Regular monitoring of kidney function, uric acid levels, and medication side effects is essential to ensure safe and effective treatment 1.
Lifestyle Modifications
- Weight management, limiting high-purine foods, avoiding alcohol (especially beer), and staying well-hydrated are important complementary approaches to medication therapy in managing gout with CKD 1.
- A healthy lifestyle, including regular exercise and a balanced diet, can help reduce the risk of gout flares and improve overall health outcomes 1.
Acute Flare Management
- For acute flares, a short course of low-dose prednisone (10-20 mg daily for 5-7 days) is generally safer than NSAIDs, which should be avoided in CKD due to their potential to worsen kidney function 1.
- Colchicine is often used as a first-line medication for acute gout flares, at a reduced dose of 0.3-0.6 mg daily, adjusted based on kidney function 1.
From the FDA Drug Label
For prophylaxis of gout flares in patients with mild (estimated creatinine clearance 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, the starting dose should be 0.3 mg/day and any increase in dose should be done with close monitoring.
For the prophylaxis of gout flares in patients undergoing dialysis, the starting doses should be 0.3 mg given twice a week with close monitoring
The medication used to treat gout in patients with Chronic Kidney Disease (CKD) is colchicine (PO).
- The dose of colchicine should be adjusted based on the severity of renal impairment.
- For patients with mild to moderate renal impairment, the recommended dose does not need to be adjusted, but close monitoring is required.
- For patients with severe renal impairment, the starting dose should be 0.3 mg/day.
- For patients undergoing dialysis, the starting dose should be 0.3 mg given twice a week 2.
From the Research
Medications for Gout in Patients with CKD
- Nonsteroidal anti-inflammatory drugs are not recommended for patients with CKD due to the risk of exacerbating or causing acute kidney injury 3
- Colchicine is a first-line treatment for acute gouty arthritis attacks, but dosage reduction is required in patients with CKD due to increased toxicity 3
- Allopurinol, febuxostat, and pegloticase are effective treatments for controlling elevated uric acid levels, but require careful consideration in patients with CKD:
- Allopurinol: dosage reductions may be necessary, and low-dose allopurinol may promote greater serum urate lowering in CKD patients 3, 4
- Febuxostat: has not been studied in patients with creatinine clearance <30 mL/min, but may be effective in patients with mild or moderate renal insufficiency 3, 5
- Pegloticase: requires further investigation in patients with CKD 3
Urate-Lowering Therapy (ULT) in Patients with CKD
- Indications for ULT include chronic kidney disease, two or more flare-ups per year, urolithiasis, the presence of tophus, chronic gouty arthritis, and joint damage 6
- Allopurinol and febuxostat are used to prevent flare-ups, but febuxostat is associated with an increase in all-cause and cardiovascular mortality and is not routinely recommended 6
- The goal of ULT is to achieve serum uric acid levels below 6 mg/dL, or less than 5 mg/dL in patients with tophi 7