Written by Mary Marschner
Spoon Feed
In patients with CKD and gout, acute flares should avoid NSAIDs and consider either dose-adjusted colchicine, oral steroids, or intra-articular steroids; for urate lowering, start low and go slow with allopurinol.
Gout and CKD – a lot to consider before deciding on treatment
Gout is highly prevalent in patients with CKD, something to take into account when considering potential treatment options and dosing for gout flares and urate-lowering therapy. This review covers current guidelines from the American College of Rheumatology and the European Alliance of Associations for Rheumatology, along with some new studies. It also discusses considerations for transplant patients and when to test for HLA-B*5081 due to the risk of developing allopurinol hypersensitivity syndrome.
For flares, avoid NSAIDs in patients with CKD. Preferred options include short-course corticosteroids and renally adjusted colchicine (e.g. 0.6 mg once daily), while IL-1 inhibitors may be used in refractory cases. You can also consider intra-articular steroids if they are available within 24 hours.
For urate-lowering therapy, start with allopurinol, titrated slowly regardless of eGFR. HLA-B*5801 screening is advised in high-risk groups, which include people of Southeast Asian descent and African Americans. Febuxostat is safe in CKD.
- In transplant patients, extra caution is required; xanthine oxidase inhibitors interact with azathioprine, and colchicine toxicity is increased with cyclosporine.
- I appreciate that this review covered a rare side effect, allopurinol hypersensitivity syndrome, which tends to present 30 days after initiation of allopurinol, with rash, eosinophilia, leukocytosis, fever, hepatitis, and kidney failure. It even touched on kidney transplant patients who are at risk of medication reaction considerations.
How does this change my practice?
It’s been a while since I fully reviewed treatment of gout in CKD patients, and this article will certainly make me pause and be more thoughtful about treatment choices and follow-up recommendations.
Source
Gout Management in Patients With CKD. Am J Kidney Dis. 2025 Jul 1:S0272-6386(25)00924-2. doi: 10.1053/j.ajkd.2025.04.020. Epub ahead of print. PMID: 40609855
