Management of gout in advanced renal disease

Gout is the most common inflammatory arthritis, and its prevalence is increasing in part due to the rise in chronic kidney disease (CKD). Guidelines for managing gout from the American College of Rheumatology (ACR) and the European Alliance of Associations for Rheumatology (EULAR) provide limited guidance for patients with advanced renal disease, partly due to the exclusion of this group of from clinical trials. This, along with concerns about adverse drug reactions contributes to the undertreatment of gout in advanced CKD. Gout management involves different phases: treatment of acute gout flares, implementing prophylaxis to prevent attacks and urate-lowering therapy (ULT). In this review, we examine the management of gout, with particular attention to recommended adjustments for patients with advanced CKD, those undergoing dialysis, or individuals who have received renal transplants. We review the medications used in the management of gout and suggest adjustments for their selection and dose in patients with advanced CKD. The article discusses colchicine, glucocorticoids, and IL1-β inhibitors for acute gout treatment and provides recommendations for flare prophylaxis. We review the use of xanthine oxidase inhibitors (allopurinol, febuxostat) and pegloticase as urate-lowering therapies for patients with advanced CKD, on dialysis, or with renal transplants. The possible side effects of gout treatments in patients with CKD and the suggested monitoring protocols are discussed. The potential impact of allopurinol, colchicine, and IL1-β inhibitors on cardiovascular disease outcomes are reviewed. Finally, new targets and drugs being explored for treating gout in patients with advanced CKD are discussed.