From the Guidelines
The treatment of gout flares in advanced chronic kidney disease (CKD) should prioritize low-dose corticosteroids, such as prednisone 10-20 mg daily for 5-7 days with a taper, due to their lack of renal dose adjustment requirements and effectiveness in managing gout flares without worsening kidney function. When considering the management of gout flares in advanced CKD, it is crucial to weigh the benefits and risks of various treatment options, prioritizing those that minimize renal toxicity and optimize gout control. The use of colchicine at reduced doses (0.3-0.6 mg daily or every other day) is an option for short-term use but requires close monitoring for toxicity 1. Intra-articular steroid injections directly into the affected joint can provide targeted relief without systemic effects, offering an alternative for patients with severe joint involvement. NSAIDs should be avoided in advanced CKD due to risks of worsening kidney function and fluid retention, as highlighted in recent guidelines 1. For prophylaxis after the acute flare resolves, consider low-dose colchicine (0.3 mg daily or every other day) or low-dose prednisone (2.5-5 mg daily) while initiating urate-lowering therapy like allopurinol (start at 50-100 mg daily) or febuxostat (20-40 mg daily), with doses adjusted based on kidney function, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. Proper hydration, joint rest, and ice application remain important non-pharmacological approaches. Regular monitoring of kidney function, uric acid levels, and medication side effects is essential in these patients to balance gout management with kidney protection. Key considerations include the patient's overall health status, the presence of other comorbidities, and the potential for drug interactions, emphasizing the need for personalized care plans. By prioritizing evidence-based treatments and closely monitoring patient responses, healthcare providers can effectively manage gout flares in advanced CKD while minimizing the risk of adverse outcomes. The most recent and highest quality studies, such as those published in 2020 by the American College of Rheumatology 1, provide the foundation for these recommendations, ensuring that treatment strategies are aligned with the latest scientific evidence and clinical guidelines.
From the FDA Drug Label
For treatment of gout flares in patients with mild (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, while the dose does not need to be adjusted for the treatment of gout flares, a treatment course should be repeated no more than once every two weeks. For patients with gout flares requiring repeated courses, consideration should be given to alternate therapy For patients undergoing dialysis, the total recommended dose for the treatment of gout flares should be reduced to a single dose of 0.6 mg (one tablet). For these patients, the treatment course should not be repeated more than once every two weeks
The recommended treatment for gout flare in patients with advanced CKD is as follows:
- For patients with severe renal impairment, the dose does not need to be adjusted, but the treatment course should be repeated no more than once every two weeks.
- For patients undergoing dialysis, the total recommended dose for the treatment of gout flares should be reduced to a single dose of 0.6 mg (one tablet), and the treatment course should not be repeated more than once every two weeks. It is essential to monitor patients closely for adverse effects of colchicine and consider alternate therapy for patients requiring repeated courses 2.
From the Research
Treatment of Gout Flare in Advanced CKD
- The management of gouty arthritis in patients with chronic kidney disease (CKD) is challenging due to limited treatment options and the risk of worsening renal function with inappropriate treatment dosing 3, 4.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are not recommended for patients with CKD as they can exacerbate or cause acute kidney injury, while colchicine toxicity is increased in patients with CKD, requiring dosage reduction based on kidney function 3.
- Allopurinol, febuxostat, and pegloticase are effective treatments for controlling elevated uric acid levels, but their use in patients with CKD requires careful consideration, including dosage reductions and monitoring of renal function 3, 5.
- The Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN) has identified key areas for research to address the challenges faced in the management of gout and CKD, including the development of standardized gout flare definitions and the inclusion of patients with CKD in clinical trials 4, 6.
Gout Flare Prophylaxis and Therapy
- Colchicine, interleukin-1 inhibitors, NSAIDs, and glucocorticoids have been studied for the prevention and treatment of gout flares in patients with CKD, but the evidence is limited and often not stratified by renal function 4.
- Clinical trials have largely excluded patients with severe CKD, making it difficult to extrapolate results to this population 4.
- The use of urate-lowering therapy (ULT) in patients with advanced CKD is variable, and professional bodies have issued conflicting recommendations regarding the treatment of gout in patients with concomitant CKD 6, 5.
Research Priorities
- Further research is needed to address the challenges faced in the management of gout and CKD, including the development of effective and safe treatment strategies for patients with advanced CKD 4, 6.
- The inclusion of patients with CKD in clinical trials and the use of standardized gout flare definitions are essential for advancing our understanding of gout management in this population 4, 6.