From the Guidelines
For treating acute gout in patients with chronic kidney disease (CKD), colchicine at a reduced dose is often the first choice, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1.
Treatment Options
- Start with 0.6 mg once or twice daily (rather than the loading doses used in patients with normal kidney function) and monitor closely for side effects.
- Alternatively, prednisolone 30-40 mg daily for 3-5 days can be effective and is generally safe in CKD.
- 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.
Special Considerations
- For patients with severe CKD (stages 4-5), intra-articular corticosteroid injections directly into the affected joint may be the safest option if only one or two joints are involved.
- During treatment, maintain adequate hydration, continue allopurinol if already prescribed (but don't start it during an acute attack), and apply ice to affected joints for additional pain relief.
Rationale
These recommendations balance the need to control gout inflammation while minimizing additional kidney stress, as many standard gout medications are cleared by the kidneys and can accumulate to toxic levels in CKD patients.
Key Takeaways
- Colchicine is the preferred first-line treatment for acute gout in CKD patients, with a reduced dose to minimize side effects.
- Prednisolone is a suitable alternative, while NSAIDs should be avoided due to their potential to worsen kidney function.
- Intra-articular corticosteroid injections may be considered for patients with severe CKD and limited joint involvement.
From the FDA Drug Label
The dosage of allopurinol tablets to accomplish full control of gout and to lower serum uric acid to normal or near-normal levels varies with the severity of the disease. Since allopurinol tablets and its metabolites are primarily eliminated only by the kidney, accumulation of the drug can occur in renal failure, and the dose of allopurinol tablets should consequently be reduced With a creatinine clearance of 10 to 20 mL/min, a daily dosage of 200 mg of allopurinol tablets is suitable. When the creatinine clearance is less than 10 mL/min, the daily dosage should not exceed 100 mg.
Medication for Acute Gout in CKD Patients:
- Allopurinol can be used to treat gout in patients with CKD, but the dose needs to be adjusted based on the creatinine clearance.
- The recommended dose for patients with a creatinine clearance of 10 to 20 mL/min is 200 mg daily, and for those with a creatinine clearance less than 10 mL/min, the dose should not exceed 100 mg daily 2.
- Colchicine can also be used to treat acute gout, but the label does not provide specific dosing recommendations for patients with CKD 3.
From the Research
Medication for Acute Gout in Patients with CKD
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are not recommended for patients with CKD due to the risk of exacerbating or causing acute kidney injury 4.
- Colchicine is a recommended first-line treatment for acute gouty arthritis attacks, but dosage reduction is required in patients with CKD due to increased toxicity 4.
- Corticosteroids are an alternative treatment option for acute gout in patients with CKD, as they do not have the same renal toxicity concerns as NSAIDs 5, 6.
- Low-dose colchicine may be an effective treatment for acute gout in patients with CKD, with a similar benefit to NSAIDs and a lower risk of adverse events compared to high-dose colchicine 7.
Urate-Lowering Therapy
- Allopurinol, febuxostat, and pegloticase are effective treatments for controlling elevated uric acid levels after the treatment of an acute attack, but may require dosage adjustments in patients with CKD 4, 8, 6.
- Allopurinol dosage reductions may be necessary in patients with CKD to minimize the risk of adverse effects 4, 8.
- Febuxostat has not been studied in patients with creatinine clearance <30 mL/min, and its use in this population is not well established 4.