What is the best treatment option for a patient with a gout attack who has developed acute kidney injury (AKI) secondary to nonsteroidal anti-inflammatory drug (NSAID) use?

Treatment of Acute Gout with AKI Secondary to NSAIDs

For your patient with acute gout who has developed AKI from NSAIDs, use corticosteroids as first-line therapy—specifically oral prednisone 30-35 mg daily for 3-5 days, or intra-articular corticosteroid injection if only one or two joints are involved. 1, 2

Why Corticosteroids Are the Best Choice

• Corticosteroids are considered first-line therapy in patients without contraindications due to their safety profile and low cost, with prednisolone 35 mg daily for 5 days being effective for acute gout 2
• NSAIDs are absolutely contraindicated in your patient since they have already caused AKI and should not be restarted 1, 3
• Intra-articular aspiration and injection of long-acting steroid is an effective and safe treatment for an acute attack, particularly when one or two large joints are involved 1

Why Not Colchicine in This Scenario

While colchicine is typically a first-line option, it poses significant risks in patients with AKI:

• Colchicine clearance is decreased by 75% in patients with end-stage renal disease, and toxicity increases substantially with renal impairment 4, 3
• For patients with severe renal impairment (CrCl <30 mL/min), colchicine dosing must be reduced to 0.3 mg/day for prophylaxis, and treatment courses should not be repeated more than once every two weeks 4
• Colchicine toxicity is increased in patients with CKD, and dosage reduction is required based on level of kidney function 3
• All participants treated with colchicine in clinical trials experienced gastrointestinal side effects (diarrhea and/or vomiting), which can worsen dehydration and renal function 5

Specific Treatment Algorithm

If 1-2 joints involved:

• Perform arthrocentesis and intra-articular corticosteroid injection (e.g., triamcinolone acetonide 40 mg for large joints like knee) 1
• This provides rapid, effective relief while avoiding systemic drug exposure in a patient with compromised renal function 1

If polyarticular involvement:

• Use oral corticosteroids: prednisone 30-35 mg daily for 3-5 days 1, 2
• Corticosteroids do not require dose adjustment for renal impairment 2

If colchicine must be considered (only after renal function stabilizes):

• Wait until AKI resolves and renal function is stable 4
• If CrCl 30-50 mL/min: use standard dosing (1.2 mg then 0.6 mg one hour later) but monitor closely; do not repeat treatment course more than once every two weeks 4
• If CrCl <30 mL/min: reduce to single dose of 0.6 mg only; do not repeat more than once every two weeks 4
• Colchicine is most effective when initiated within 12-24 hours of symptom onset, so delayed treatment reduces efficacy 6, 7

Critical Monitoring Points

• Monitor renal function closely during treatment since the patient has demonstrated susceptibility to drug-induced AKI 3, 8
• Avoid combining corticosteroids with NSAIDs due to concerns about synergistic gastrointestinal toxicity 6
• Check for contraindications to corticosteroids (uncontrolled diabetes, active infection, recent GI bleeding) before prescribing 1

Long-Term Management Considerations

• Do not interrupt ongoing urate-lowering therapy (if patient is on any) during the acute attack 1, 2
• Once the acute attack resolves, ensure the patient is on appropriate urate-lowering therapy (allopurinol or febuxostat) to prevent future attacks 1, 2
• Interestingly, patients previously prescribed allopurinol showed lower risk of acute renal events, suggesting urate-lowering therapy may have renoprotective effects 8
• When starting or adjusting urate-lowering therapy, provide prophylaxis with low-dose colchicine (0.6 mg daily) or low-dose NSAIDs for at least 8 weeks—but in your patient with AKI history, use colchicine only after renal function normalizes and with appropriate dose adjustment 1, 2

Common Pitfalls to Avoid

• Do not restart NSAIDs in this patient, even at lower doses, given the documented AKI 3
• Do not use full-dose colchicine without checking renal function and adjusting accordingly 4, 3
• Do not use high-dose colchicine regimens (>1.8 mg in first hour), which provide no additional benefit but substantially increase toxicity 6, 4
• Do not delay treatment—initiate corticosteroids promptly as treatment within 24 hours of symptom onset provides optimal outcomes 1, 2