Gout and CKD: A Common, Complicated Combination

The demographic data tells a perplexing story. Approximately 1 out of 5 adults with gout have chronic kidney disease (CKD) stage 3, 4, or 5. As kidney function declines, 24% of adults with estimated glomerular filtration rate (eGFR) <60 cc/min experience concurrent gout vs only 2.9% of those with eGFRs ≥90 cc/min. Mastering the complicated confluence of gout and CKD is difficult. “Usual” doses of standby agents (allopurinol and colchicine) are inappropriate.

Let’s discuss some dos and don’ts with the 4 questions below.

Question 1. Regarding CKD, a new recommendation in the American College of Rheumatology guidelines was to:

A. Treat all patients with asymptomatic hyperuricemia and CKD with febuxostat
B. Initiate urate lowering therapy (ULT) after only 1 gout flare in patients with CKD stage 2 or worse
C. ULT is contraindicated with CKD stage 4 or worse
D. Use high dose steroids to treat gout flares in patients with CKD stages 4 and 5

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Answer: B. Gout flares are more difficult to treat in persons with comorbid CKD, so early ULT may reduce the number of future flares in this population. Allopurinol is the primary ULT used in patients with CKD, including those on dialysis.

Question 2. In patients with CKD stages 4 and 5, what is the recommended starting dose and up-titration schedule for allopurinol?

A. 100 mg/day and increase 50 mg per week until a uric acid level of ≤6 mg/dL is reached
B. Febuxostat should be used instead of allopurinol in this population
C. 50 mg allopurinol to start, up-titrated by 50-100 mg every 2-5 weeks
D. Allopurinol is contraindicated in dialysis patients

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Answer: C. Although allopurinol dosing is affected by decreased eGFRs, it remains an important therapeutic agent in this population.

Question 3. In managing gout flares in patients with CKD, which one of the following statements is true:

A. Colchicine can be used in CKD stage 3-5 with appropriate dose adjustments
B. For gout flares, the starting dose of prednisone is 60 mg
C. Dexamethasone should not be used in patients with CKD
D. Anakinra, an interleukin-1 inhibitor, has not been used in CKD gout patients in the US

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Answer: A. It has been a misconception that allopurinol and colchicine are contraindicated in advanced CKD. For colchicine, if creatine clearance (CrCl) is ≥30 cc/min, a dosage adjustment is not indicated. Adjustments are necessary, however, if CrCl is <30 cc/min and dialysis patients should receive 0.6 mg as a single dose, which should not be repeated for 14 days.

Prednisone starting dosages are 30 mg/day and dosage adjustments are not required in CKD. Dexamethasone is preferred for CKD gout patients with congestive heart failure (dexamethasone has no mineralocorticoid effect). Anakinra use in CKD/gout has become more frequent in the US, but is off-label.

Question 4. When prophylaxis with colchicine or corticosteroids is utilized during up-titration of allopurinol, the appropriate duration of prophylaxis is:

A. 2 weeks
B. 6 months
C. 6 weeks

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Answer: B. Guidelines recommend maintaining anti-inflammatory prophylactic treatment for at least 6 months – continuing until serum urate target is reached and clinical signs have resolved (last flare, tophus resorption).

Concurrent gout and CKD is an increasing reality in primary care. Despite misconceptions, allopurinol, colchicine, and corticosteroids have become “go to” agents in CKD, with appropriate dosing and up-titration strategies.

The original article is a “must read.”

References:

Vargas-Santos AB, Neogi T. Management of gout and hyperuricemia in CKD. Am J Kidney Dis. 2017;70:422-439.