Evidence lacking on how to manage gout and concomitant CKD

How to prevent and manage gout flares in patients with renal impairment appears to be a largely evidence-free zone, leaving clinicians with little to guide their decisions, a study by Australian rheumatologists has found.

A literature review of gout flare prophylaxis and therapy use in people with CKD stages 3–5 has shown a concerning lack of quality data even for colchicine. Almost half of the available evidence on colchicine was based on case reports or cases series (20 of 49 studies).

The Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN)-initiated review, published in Arthritis Research & Therapy, also found the evidence that did exist for colchicine was inconsistent.

“For instance, 12 studies reported deteriorated renal function with colchicine use, whereas 7 other studies reported stable renal function with colchicine use.”

“As a result, given the underlying risk of bias on study quality for these studies, we cannot sufficiently conclude on the efficacy and/or safety outcomes on colchicine use for people with gout and concomitant CKD,” the review said.

The authors, including Dr Huai Leng (Jessica) Pisaniello and Professor Catherine Hill from the University of Adelaide, said the same applied to other therapies such as IL-1 inhibitors.

“The issue of IL-1 inhibition use for flare prophylaxis in patients with gout and advanced CKD remains essentially unexplored,” they said.

As expected, the evidence supported NSAIDs as contraindicated in advanced CKD.

“Indeed, the included case series/reports of NSAID use in this review favourably justify the avoidance of any NSAID use in individuals with gout and renal failure. Almost all studies found were only aiming at highlighting the nephrotoxic risk of NSAID use in this high-risk comorbid population with gout flare.”

“In the case of glucocorticoid use, all studies found described either refractory or very severe gout flare cases, which are not necessarily reflecting the common clinical practice of gout flare management. We did not find studies exploring the question of whether low doses of glucocorticoids could be part of the prophylaxis of gout flares.”

The authors called for improvements to current and future studies overall, including more standardised definition and assessment of gout flare, as well as renally adjusted dosing in participants with co-existing CKD.

“The dearth of high-quality data reporting in this high-risk comorbid population is concerning,” they wrote.

“Ideally, the efficacy and safety of gout flare and urate-lowering treatments based on stratified renal function should be emphasised in all gout studies, as gout and CKD often co-exist,” they added.

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