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Managing hyperuricemia and gout in chronic kidney disease: a clinical conundrum
Kulanka H Premachandra1,2, Richard O Day1,2, Darren M Roberts1,2,3,4
1Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital.
Insights
Managing gout in chronic kidney disease (CKD) is challenging due to guideline gaps and medication concerns. Urate-lowering therapy is recommended for severe gout, with careful titration in CKD patients.
Area of Science:
- Nephrology
- Rheumatology
- Pharmacology
Background:
- Controversy exists regarding hyperuricemia's impact on chronic kidney disease (CKD) progression.
- Gout management in CKD patients is often suboptimal, with prescribers concerned about adverse drug reactions.
- Recent evidence questions the benefit of urate-lowering therapy (ULT) for asymptomatic hyperuricemia in CKD.
Purpose of the Study:
- To review and discuss the prescribing of medications for gout treatment in patients with CKD.
- To address the controversies and challenges in managing gout within the CKD population.
Main Methods:
- Review of current literature and expert guidelines on gout management in CKD.
- Discussion of pharmacological approaches and treatment strategies for hyperuricemia and gout in CKD patients.
Main Results:
- Lack of consensus in expert guidelines contributes to suboptimal gout management.
- Prescriber concerns regarding adverse effects of gout medications in CKD patients are prevalent.
- ULT is recommended for severe, recurrent, or tophaceous gout with joint damage in CKD.
Conclusions:
- A treat-to-target approach with ULT, initiated at low doses and titrated based on serum urate levels, is advised for gout in CKD.
- Treatment selection should consider drug accessibility, disease severity, and comorbidities.
- Further research is needed to clarify the benefits of treating asymptomatic hyperuricemia in CKD.
Purpose Of Review:
There is controversy regarding the impact of hyperuricemia on the progression of chronic kidney disease (CKD), and gout remains sub optimally managed in this population. We discuss the prescribing of drugs for the treatment of gout in patients with CKD.
Recent Findings:
There is a lack of consensus from expert guidelines, and prescribers have concerns regarding the risk of adverse reactions from medicines used to treat gout. These situations appear to contribute to suboptimal management of gout in this cohort. Recent data have challenged the role of urate lowering therapy (ULT) in the management of asymptomatic hyperuricemia in CKD.
Summary:
ULT should be commenced in all patients with severe, recurrent disease, tophaceous gout and evidence of joint damage. Most international guidelines recommend a treat-to-target approach for the management of gout. In CKD, ULT should be started at low dose with up titration adjusted to serum urate levels, rather than being based on the creatinine clearance. If patients fail first-line therapy, alternative agents are utilized, the specific agent depending on ease of access, burden of disease and other comorbidities. This approach should be incorporated into routine practice to ensure optimal treatment of gout in CKD. More research is required to investigate whether treatment of asymptomatic hyperuricemia has clinical benefits.
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