Acute Flare of Gout in ESRF

NSAIDS:

• In patients with residual kidney function, including patients on peritoneal dialysis, NSAIDs should be avoided because of the risk of worsening of renal function
• any use of NSAIDs in this setting should only be done in consultation with the patient’s nephrologist. 
• In patients on chronic hemodialysis, NSAIDs may be used as an alternative to glucocorticoids, particularly in patients with milder attacks in whom lower doses and shorter courses can be employed. 
• Other concerns in patients on hemodialysis include concomitant use of anticoagulation and risk of gastrointestinal toxicity.

Colchicine:

• Colchicine is generally avoided in hemodialysis patients with acute gout flares because it is not removed by dialysis, and therefore these patients have a heightened risk of colchicine toxicity.
• Its therapeutic index is narrow and side effects associated with colchicine treatment such as nausea, vomiting, abdominal pain and profuse diarrhoea can be so intense as to limit its usefulness.
• However, according to Lexicomp, it provides some guidelines on gout flare treatment:
• Gout flare treatment
• Treatment of gout flares is not recommended in patients with renal impairment who are receiving colchicine for prophylaxis.
• CrCl 30 to 80 ml/minute: Dosage adjustment not required; monitor closely for adverse effects
• CrCl <30mL/minute: Dosage reduction not required but may be considered; treatment course should not be repeated more frequently than every 14 days.
• Dialysis: 0.6 mg as a single dose; treatment course should not be repeated more frequently than every days. Not removed by dialysis
• Hemodialysis: Avoid chronic use of colchicine

Steroids:

• We generally treat patients with advanced chronic kidney disease (CKD) or end-stage renal disease requiring maintenance dialysis with intraarticular, oral, or parenteral glucocorticoids.
• We suggest the use of oral glucocorticoids for patients who cannot take NSAIDs or colchicine and who are not candidates for intraarticular glucocorticoid injection because of polyarticular disease. 
• We also suggest the use of oral glucocorticoids if a clinician with adequate expertise in these techniques is not readily available. 
• We use prednisone (or other equivalent glucocorticoid) in doses of 30 to 50 mg once daily or in two divided doses until flare resolution begins, and we then taper the dose of glucocorticoids, usually over 7 to 10 days (according to UpToDate).
• Oral Prednisolone up to 0.5 mg/kg/day or its equivalent can be given and tapered off over 4-10 days (according to Management of Gout CPG 2008)

References: 

1. www.uptodate.com
2. lexicomp
3. CPG Management of Gout 2008