What is the best medication for a gout flare in a patient with pulmonary hypertension, heart failure, on torsemide (Torasemide), without impaired renal function or hepatic dysfunction?

From the Guidelines

For a patient with gout flare who has pulmonary hypertension, heart failure, and is on torsemide, but without kidney or liver issues, the best medication would be colchicine, as recommended by the 2020 American College of Rheumatology guideline for the management of gout 1. The recommended regimen is colchicine 1.2 mg initially, followed by 0.6 mg one hour later, then 0.6 mg once or twice daily until the flare resolves, as this lower-dose regimen helps minimize gastrointestinal side effects while maintaining efficacy, as suggested by the American College of Physicians 1. Some key points to consider when treating this patient include:

• NSAIDs should be avoided in this patient due to their potential to worsen heart failure and pulmonary hypertension by causing fluid retention, as noted in the management guidelines 1.
• Corticosteroids are another option but should be used cautiously as they can also cause fluid retention, which may exacerbate heart failure.
• Colchicine works by inhibiting neutrophil chemotaxis and activity in the inflamed joint, thereby reducing the inflammatory response to urate crystals.
• It's essential to monitor for potential side effects of colchicine, including diarrhea, nausea, and vomiting, as mentioned in the guidelines 1.
• If the patient is on certain medications like strong CYP3A4 inhibitors, the colchicine dose should be reduced, as indicated in the guidelines 1.
• For long-term management after the acute flare resolves, the patient should be evaluated for urate-lowering therapy to prevent future attacks, as recommended by the guidelines 1.

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

The best medication to use for a gout flare for a patient with pulmonary hypertension, heart failure, on torsemide, without any kidney or liver issues is colchicine.

• The patient has no kidney or liver issues, so no dose adjustment is required.
• The patient should be monitored closely for adverse effects of colchicine.
• Colchicine can be used at the recommended dose for the treatment of gout flares 2.

From the Research

Medication Options for Gout Flare in Patients with Pulmonary Hypertension and Heart Failure

• The patient's condition of pulmonary hypertension and heart failure, along with the use of torsemide, should be considered when selecting a medication for a gout flare 3, 4, 5.
• Colchicine is considered a safe option for treating acute gout flares in patients with cardiovascular disease or heart failure, and it may also reduce the risk of myocardial infarction 3, 6.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in patients with cardiovascular disease or heart failure due to the potential risk of adverse cardiovascular events 3.
• Short durations of low-dose glucocorticoids may be efficacious and safe for patients who cannot tolerate colchicine 3.
• The use of canakinumab and anakinra for acute gout flares is limited by their high cost, risk of serious infection, and relatively modest clinical benefit 3.

Considerations for Patients on Torsemide

• Torsemide is a loop diuretic used to treat edema associated with heart failure, and it has been shown to be effective in reducing body weight, improving pulmonary hemodynamics, and decreasing the severity of heart failure 7, 5.
• The patient's use of torsemide should be considered when selecting a medication for a gout flare, as loop diuretics can increase the risk of hyperuricemia and gout 7.
• However, torsemide has been shown to be well-tolerated in patients with heart failure, and its use is not a contraindication for the treatment of gout flares 7, 5.

Recommendations

• Based on the available evidence, colchicine is a suitable option for treating acute gout flares in patients with pulmonary hypertension and heart failure, including those on torsemide 3, 6.
• Short durations of low-dose glucocorticoids may be considered as an alternative option for patients who cannot tolerate colchicine 3.
• It is essential to individualize the selection of agents used for acute gout management and long-term urate-lowering therapy according to patient and agent cardiovascular risk factors 3.