DMARDs and gout therapy in patients with chronic arthritis and end-stage renal disease: a descriptive guide

The coexistence of chronic arthritis - here defined as rheumatoid arthritis, spondyloarthritis and gout - and end-stage renal disease (ESRD) is clinically relevant, underscoring the need for safe medication choices and dosage adjustments. However, drug use in dialysis patients is challenging, as it requires balancing treatment efficacy - potentially reduced by drug removal during dialysis - with the risks associated with impaired renal function, such as overdose and drug toxicity. In the absence of evidence-based guidelines, this paper aims to summarize the existing literature and offer a descriptive guide for the use of DMARDs and gout therapy in ESRD patients with chronic arthritis.

A literature search using three different databases (Cochrane, PubMed and Embase) was conducted, yielding 41 articles.

In patients with ESRD, methotrexate is contraindicated, leflunomide appears safe and effective, sulfasalazine and hydroxychloroquine are not recommended because of inconsistent data. Biological DMARDs are considered safe and effective, with existing evidence likely applicable to the entire class. Limited data exist for targeted synthetic DMARDs. However, apremilast appears relatively safe, whereas JAK inhibitors are generally not recommended because of an increased cardiovascular risk. For gout patients on dialysis, urate-lowering therapy is often required. It is recommended to initiate treatment with a lower dose of allopurinol or febuxostat, both of which are effective and well tolerated. Colchicine also appears to be safe at low doses in patients on hemodialysis.

Treatment decisions in ESRD patients with chronic arthritis should be individualized, with strict monitoring.