Management of Gout in CKD Patients

• are influenced by significant impairment of renal function
• treatment of hyperphosphatemia caused by kidney disease can also affect serum uric acid levels.

Prophylatic therapy

• The clearance of colchicine is reduced in patients with CKD, increasing the risk of neuromyopathy
• cr clearance of 35 to 49 mL/min : 0.6 mg once daily
• cr clearance of 10 to 34 mL/min : 0.6 mg every two to three days
• cr clearance below 10 mL/min : contraindicated
• Colchicine is not dialyzable
• Concurrent use of medications(inhibit CYP3A4 or P-glycoprotein) with colchicine may thus increase the risk of myelosuppression, and fatal pancytopenia
• Low doses of glucocorticoids may reduce the frequency of acute gout attacks, but a prophylactic benefit for glucocorticoids is not supported by adequate evidence.

Urate Lowering Therapy

• half-lives of allopurinol and its active metabolite, oxypurinol, are prolonged in renal failure
• we thus recommend a reduction in the starting dose of allopurinol, depending upon the severity 
• The initial dose of allopurinol should not exceed 100 mg daily in any patient and should be reduced to 50 mg daily in patients in CKD stage 4 or with more severe renal impairment  [GFR] <30 mL/min)
• cautious up-titration of the dose of allopurinol is warranted: 
• in 100 mg increments every two to five weeks in patients with GFR ≥30 mL/min
• in 50 mg increments in patients with CKD stage 4 or with more severe disease)
• Allopurinol should not be administered to patients with acute kidney injury (acute renal failure); the acute episode will not initially reflect the severity of the reduced renal function

Treatment of Hyperphostemia

• A modest lowering of serum urate is a potentially beneficial side effect of treatment of hyperphosphatemic patients with phosphate binding agents (eg, calcium-containing antacids or sevelamer)

Reference:

1. www.uptodate.com