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Gout - Management
How do I manage someone with renal impairment?
- Acute attacks of gout are relatively rare in people with renal impairment, due to the anti-inflammatory effects of uraemia. However, following a kidney transplant, people are vulnerable to gout (which has an atypical upper limb and polyarticular presentation due to the effects of immunosuppressant drug regimens).
- Allopurinol is effective in people with renal impairment and it can be used after transplantation, but interactions with cytotoxic medication (e.g. azathioprine) need to be considered, and colchicine and nonsteroidal anti-inflammatory drugs (NSAIDs) are best avoided in these people.
- Since allopurinol is excreted by the kidney, impaired renal function may lead to retention of allopurinol and/or its metabolites, with consequent prolongation of plasma half-life, therefore the dose should be modified based on the person's creatinine clearance or glomerular filtration rate (GFR) as outlined in Table 1.
- Once allopurinol has been started, it is best to check urate levels and renal function every 2–4 weeks for the first 3 months.
- See the section on allopurinol for more prescribing information.
Table 1. Modification of allopurinol dosage with reduced renal function from any cause.
Glomerular Filtration Rate (GFR)* | Usual dose of allopurinol |
|---|
> 80 mL/min | 200–300 mg each day |
60–80 mL/min† | 100–200 mg each day |
30–60 mL/min | 50–100 mg each day |
15–30 mL/min | 50–100 mg alternate days |
On dialysis | 50–100 mg each week |
* Or based on the creatine clearance. † Most apparently healthy 80-year-olds have this level of renal insufficiency. |
|
- It is not necessary to adjust the dose of febuxostat in people with mild or moderate renal impairment. However, as with allopurinol, it may increase azathoprine and mercaptopurine levels. The efficacy and safety of using febuxostat in people with severe renal impairment (creatinine clearance <30 ml/min) has not been fully evaluated [ABPI Medicines Compendium, 2010].
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