Management of Patients with Gout and Kidney Disease: A Review of Available Therapies and Common Missteps.

Gout, a common form of inflammatory arthritis, is characterized by deposition of monosodium urate crystals in articular and periarticular tissues. Repeated flares of gout cause joint damage as well as significant healthcare utilization and decreased quality of life. Individuals with chronic kidney disease (CKD) have a higher prevalence of gout. Treating individuals with CKD and gout is challenging due to the lack of quality data to guide management in this specific population. This often leads to suboptimal treatment of patients with gout and impaired renal function, as concerns regarding the efficacy and safety of available gout therapies in this population often result in significant inter-physician variability in treatment regimens and dosages. Acute gout flares are treated with various agents, including nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, glucocorticoids, and - more recently - interleukin-1 inhibitors. These medications can also be used as prophylaxis if urate lowering therapy (ULT) is initiated. While these drugs can be used in patients with gout and CKD, there are often factors that complicate treatment such as the numerous medication interactions involving colchicine as well as the impact of glucocorticoids on common comorbidities like diabetes and hypertension. ULT is recommended to treat recurrent flares, tophaceous deposits, and in those with moderate-to-severe CKD with a serum urate goal < 6 mg/dL recommended to prevent flares. While many misconceptions exist around the risks of using urate-lowering agents in patients with CKD, there is some evidence that these medications can be used safely in individuals with renal impairment. Additional questions exist as to whether gout treatment is indicated for individuals on renal replacement therapy. Furthermore, there is conflicting data on whether ULT can impact renal function and cardiovascular disease in patients. All of these factors contribute to the unique challenges physicians face when treating patients with gout and CKD.