What are the management options for gout in a patient with impaired renal (kidney) function?

From the Guidelines

Managing gout in patients with impaired kidneys requires careful consideration of medication selection and dosing adjustments to minimize further kidney damage and optimize quality of life. For acute gout flares in these patients, colchicine can be used at reduced doses (0.3-0.6 mg once or twice daily instead of the standard regimen) with careful monitoring for toxicity, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. Low-dose corticosteroids are often preferred for acute flares, such as prednisone 10-20 mg daily for 5-7 days with a taper, as they don't require renal adjustment. NSAIDs should generally be avoided due to their potential to worsen kidney function, as noted in the 2016 updated EULAR evidence-based recommendations for the management of gout 1. For long-term urate-lowering therapy, allopurinol should be started at a low dose (50-100 mg daily) and gradually increased based on kidney function and uric acid levels, with a target serum urate below 6 mg/dL, as recommended by the 2020 American College of Rheumatology guideline 1. Febuxostat may be an alternative for those who cannot tolerate allopurinol, starting at 20-40 mg daily. Probenecid is not effective in patients with significant kidney impairment (eGFR <30 mL/min) and should be avoided. Regular monitoring of kidney function, uric acid levels, and medication side effects is essential. Lifestyle modifications are particularly important in these patients, including:

• Weight management
• Limiting purine-rich foods
• Avoiding alcohol (especially beer)
• Maintaining adequate hydration unless fluid restricted These approaches balance effective gout management while minimizing further kidney damage, as many standard gout medications are either cleared by the kidneys or can potentially affect kidney function. It is also important to consider the patient's overall health and comorbidities when making treatment decisions, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 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 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). Patients with decreased renal function require lower doses of allopurinol tablets than those with normal renal function. Lower than recommended doses should be used to initiate therapy in any patients with decreased renal function and they should be observed closely during the early stages of administration of allopurinol tablets In patients with severely impaired renal function or decreased urate clearance, the half-life of oxipurinol in the plasma is greatly prolonged. Therefore, a dose of 100 mg per day or 300 mg twice a week, or perhaps less, may be sufficient to maintain adequate xanthine oxidase inhibition to reduce serum urate levels

Gout Management in Impaired Kidneys:

• For patients with mild to moderate renal impairment, colchicine dose adjustment is not required, but close monitoring is necessary.
• For patients with severe renal impairment, the starting dose of colchicine should be 0.3 mg/day, and any increase in dose should be done with close monitoring.
• For patients undergoing dialysis, the starting dose of colchicine should be 0.3 mg given twice a week with close monitoring.
• For patients with decreased renal function, allopurinol doses should be lower than recommended, and patients should be observed closely during the early stages of administration.
• In patients with severely impaired renal function, a dose of 100 mg per day or 300 mg twice a week of allopurinol may be sufficient to maintain adequate xanthine oxidase inhibition. 2 3

From the Research

Gout Management in Patients with Impaired Kidneys

• Gout is a common form of acute inflammatory arthritis caused by the deposition of monosodium urate crystals within synovium of joints, and its management is more complex in the presence of chronic kidney disease 4.
• Hyperuricaemia is an independent risk factor for renal function decline, and evidence suggests that urate-lowering therapy might be beneficial in subjects with renal impairment 4.
• The main aim of gout therapy is to fully dissolve the urate crystals, thus curing the disease, and avoidance of attacks-prophylaxis-and their prompt treatment if they occur, along with accurate information to patients, completes the treatment strategy 4.

Treatment Options

• Standard pharmacotherapies for gout flares include colchicine, NSAIDs, and oral or intramuscular corticosteroids, with IL-1 inhibitors newly established as an option for flare refractory to standard therapies 5.
• Urate-lowering therapies aim to prevent gout flares, with an emphasis on treat-to-target strategy, and initial treatments include allopurinol and febuxostat, with uricosuric agents as adjuncts 5.
• Allopurinol and febuxostat are used to prevent flare-ups, although febuxostat is associated with an increase in all-cause and cardiovascular mortality and is therefore not routinely recommended 6.

Considerations in Patients with Chronic Kidney Disease

• A major reason for ineffective management of gout and hyperuricemia is the complexity in managing these patients, with some medications contraindicated and others requiring special dosing, potential drug interactions, and other factors 7.
• Nephrologists should consider gout as a major complication of chronic kidney disease and actively manage it in their patients, and a team approach to gout management that includes the nephrologist is recommended 7.
• Allopurinol and febuxostat achieved serum urate goals in patients with gout, and allopurinol was noninferior to febuxostat in controlling flares, with similar outcomes noted in participants with stage 3 chronic kidney disease 8.