Efficacy and Safety of Gout Flare Prophylaxis and Therapy Use in People With Chronic Kidney Disease

A Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN)-Initiated Literature Review

Huai Leng Pisaniello; Mark C. Fisher; Hamish Farquhar; Ana Beatriz Vargas-Santos; Catherine L. Hill; Lisa K. Stamp; Angelo L. Gaffo

Disclosures

Arthritis Res Ther. 2021;23(130) 

In This Article

Background

Gout, a highly prevalent inflammatory arthritis worldwide, is often linked with renal impairment, among all other comorbidities clustered within the term 'metabolic syndrome'.[1,2] For instance, in a nationwide US representative study, 19.9% of adults with gout had CKD ≥ stage 3 (i.e. estimated glomerular filtration rate (eGFR) of < 60 mL/min/1.73 m2) compared with 5.2% of adults without gout.[3] Gout is also highly prevalent in individuals with pre-existing CKD. In an age-standardised gout prevalence study in the USA, nearly one-fourth of adults with CKD ≥ stage 3 reported having gout in comparison with 2.9% individuals with normal renal function.[4] The degree of renal impairment, especially in advanced CKD, invariably plays a major role in the treatment decision-making when managing gout.

Gout flares, when inadequately treated, can have a profound impact on physical functioning and quality of life.[5] According to the 2020 American College of Rheumatology (ACR) guideline, colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), and parenteral/oral glucocorticoids are recommended as the preferred first-line treatment options for managing gout flares.[6,7] These anti-inflammatory treatment options are also recommended as short-term prophylaxis for when commencing urate-lowering therapy (ULT).[6,7] However, the use of gout flare prophylaxis and therapy in people with CKD is not always straightforward. In the context of minimal or absence of residual renal function, treatment options for gout flare are limited, with potential risks of further renal impairment. Renally adjusted dosing is often required in people with CKD, although there is no specific evidence-based guidance in monitoring the efficacy and safety of the treatment used. Therefore, clinicians often remain judicious when facing this common clinical conundrum in the management of gout flares. It is reassuring that, based on a recent systematic review, colchicine use is relatively safe in all possible clinical indications, with diarrhoea and gastrointestinal symptoms being the most commonly reported adverse events.[8] However, no conclusion could be precisely drawn from this review on the safety profile of colchicine use in people with CKD.[8] Overall, for all anti-inflammatory drugs used for gout flare, lack of consensus on the appropriate dosing and treatment monitoring for this high-risk comorbid population remains. The extent of this deficiency in the literature in terms of the efficacy and safety data for gout flare prophylaxis and therapy is unknown.

Accordingly, in parallel with the mission of the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN), this G-CAN-initiated literature review aims to identify all available literature on gout flare prophylaxis and therapy use in people with CKD stages 3–5. In detail, we aim to explore the best available evidence that we currently have on the efficacy and safety of gout flare prophylaxis and therapy in this high-risk comorbid population, alongside the identification of important key areas for future research on this issue.

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