What is the drug of choice for acute gouty arthritis in a patient with Chronic Kidney Disease (CKD) stage V on Hemodialysis (HD)?

Drug of Choice for Acute Gouty Arthritis in CKD Stage V on Hemodialysis

Oral corticosteroids (prednisone/prednisolone 30-35 mg daily for 3-5 days) are the drug of choice for acute gout flares in CKD stage V patients on hemodialysis. 1

Why Corticosteroids Are Preferred in This Population

Corticosteroids are the safest and most effective first-line option when both colchicine and NSAIDs must be avoided due to severe renal impairment. 1 In CKD stage V (GFR <15 mL/min), the two other standard first-line agents carry prohibitive risks:

• NSAIDs are absolutely contraindicated in severe CKD due to risk of acute kidney injury, cardiovascular complications, and fluid retention 1, 2
• Colchicine must be avoided entirely in severe renal impairment (GFR <30 mL/min) due to risk of fatal toxicity from accumulation 1, 2

Specific Dosing Regimen

• Fixed-dose prednisone 30-35 mg daily for 5 days is the most practical and effective regimen 1
• Alternative regimen: Prednisone 0.5 mg/kg per day for 5-10 days at full dose then stop, or taper over 7-10 days 1
• No dose adjustment is required for renal impairment with corticosteroids, unlike colchicine and NSAIDs 1

Route of Administration

• Oral route is first-line when the patient can take oral medications 1
• Parenteral glucocorticoids (IV, IM, or intra-articular) are strongly recommended over other alternatives when oral medications cannot be taken 1
• Intramuscular corticosteroids are equally effective when IV access is problematic 1

For Severe or Polyarticular Flares

• Combination therapy with oral corticosteroids plus colchicine can be considered for particularly severe attacks involving multiple joints, but only if GFR permits colchicine use (which it does not in stage V CKD) 1
• In stage V CKD, corticosteroid monotherapy remains the safest approach 1

Alternative if Corticosteroids Are Contraindicated

• IL-1 inhibitor (canakinumab 150 mg subcutaneously) should be considered for patients with contraindications to colchicine, NSAIDs, and corticosteroids 1
• Current infection is an absolute contraindication to IL-1 blocker use 1
• At least 12 weeks must elapse between canakinumab doses 1

Critical Monitoring Parameters

• Monitor for mood changes, dysphoria, elevated blood glucose, and fluid retention during corticosteroid therapy 1
• Increase blood glucose monitoring frequency in patients with diabetes 1
• Corticosteroids are contraindicated in patients with systemic fungal infections 1

Common Pitfalls to Avoid

• Do not use NSAIDs in any patient with CKD stage V—the renal and cardiovascular risks are unacceptable 1, 2
• Do not use colchicine in severe CKD (GFR <30 mL/min) or when patients are on strong CYP3A4/P-glycoprotein inhibitors (cyclosporine, clarithromycin), as fatal toxicity can occur 1
• Do not use prolonged high-dose corticosteroids (>10 mg/day) for prophylaxis—this is inappropriate and carries significant long-term risks 1
• Treat early—acute gout should be treated as soon as possible for best results 1

Regarding Urate-Lowering Therapy

While the question asks about acute flare treatment, it's worth noting that allopurinol is the preferred first-line urate-lowering therapy for all patients with CKD stage ≥3, including those on dialysis 3. However, urate-lowering therapy should be initiated with mandatory anti-inflammatory prophylaxis for 3-6 months, using low-dose prednisone (<10 mg/day) as the second-line prophylactic option if colchicine and NSAIDs are contraindicated 1. Start allopurinol at very low doses (≤50 mg/day) in severe CKD with subsequent titration 3.