What is the most ideal medication for a 91-year-old female with a past medical history (PMHx) of Chronic Kidney Disease (CKD) presenting with a gout flare and Impaired Renal Function, specifically with a creatinine clearance indicating Severe Renal Impairment?

From the Guidelines

For a 91-year-old female with CKD and a creatinine clearance of 21 presenting with a gout flare, colchicine at a reduced dose is the most ideal medication, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. The recommended regimen is 0.3 mg once or twice daily, not to exceed 0.6 mg per day. This lower dose helps minimize toxicity while still providing anti-inflammatory benefits. Some key points to consider when treating gout in patients with CKD include:

• Avoiding NSAIDs due to their potential to worsen kidney function
• Using colchicine with caution and at reduced doses to minimize the risk of neuromuscular toxicity
• Considering alternative treatments, such as prednisolone 10-20 mg daily for 5-7 days, if colchicine is contraindicated
• Monitoring for gastrointestinal side effects like diarrhea and nausea when administering colchicine, and discontinuing if these occur
• Starting urate-lowering therapy with allopurinol at a very low dose of 50-100 mg daily with gradual titration based on uric acid levels and renal function, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. It's also important to note that the 2016 updated EULAR evidence-based recommendations for the management of gout suggest that colchicine and NSAIDs should be avoided in patients with severe renal impairment 1. However, the most recent guidelines from the American College of Rheumatology 1 provide more specific recommendations for the management of gout in patients with CKD, and should be prioritized in clinical decision-making.

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 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).

The most ideal medication for a 91-year-old female with a past medical history (PMHx) of Chronic Kidney Disease (CKD) presenting with a gout flare and a creatinine clearance of 21 mL/min is colchicine.

• The dose should be 0.6 mg as a single dose, given the patient's severe renal impairment.
• The treatment course should not be repeated more than once every two weeks.
• The patient should be monitored closely for adverse effects of colchicine 2.

From the Research

Ideal Medication for Gout Flare in a 91-Year-Old Female with CKD

• The patient's condition involves a history of chronic kidney disease (CKD) with a creatinine clearance of 21, indicating severe renal impairment 3, 4, 5, 6, 7.
• Management of gout in elderly subjects can be complicated by comorbidities and polypharmacy, and the choice of medication should be based on potential benefits and consequences of therapy, considered in tandem with individual patient-specific characteristics 3.
• Colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), and corticosteroids are all efficacious in the treatment of acute gout in the older adult, but each has its limitations and potential risks, especially in patients with severe renal impairment 3, 4, 7.
• Colchicine use is restricted in severe renal and hepatic dysfunction, and NSAID therapy is not recommended in older patients with congestive heart failure, renal failure, or gastrointestinal problems 3, 4, 7.
• Corticosteroids pose little risk when used in the short-term and may be preferred in patients with contraindications to colchicine or NSAIDs 3.
• Urate-lowering therapy (ULT) with allopurinol or febuxostat may be considered for prevention of gout, but dose reduction is recommended in patients with renal impairment, and febuxostat does not require dose adjustment in mild to moderate renal disease 3, 5, 6, 7.
• The lack of quality data to guide management of gout in patients with CKD often leads to suboptimal treatment, and nephrologists should be involved in the management of gout in renal patients 6, 7.