Gout Management In Patients With Ckd
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Gout is a painful form of inflammatory arthritis that occurs in the setting of hyperuricemic monosodium urate crystals deposited in joints and tissues.1 Almost 40% of patients with gout have chronic kidney disease .2 Incidence of gout increases as kidney function decreases.
The kidneys excrete uric acid, predisposing CKD patients to hyperuricemia. Unfortunately, these patients have contraindications to a number of agents used in the management of gout.3,4 In addition, thiazide and loop diuretics, medications that elevate serum uric acid levels, are often the first-line treatments for CKD.5 According to guidelines recently published by the American College of Rheumataology , CKD is an indication for urate-lowering therapy in patients with a history of gout attacks or hyperuricemia.5
Each year there are 3.9 million patient visits for gout, and the majority of cases are managed by a primary-care provider .2 This article is designed to help guide PCPs in the management of gout in CKD patients while reflecting the 2012 ACR recommendations. Table 1 describes the stages of CKD.
|Despite greater efficacy of febuxostat as a ULT agent compared with allopurinol, does cost limit how you prescribe it?|
Kidney Disease Can Lead To Gout
When you have chronic kidney disease , your kidneys do not work as well as they should to filter wastes out of your body. These wastes include uric acid, which is naturally found in your blood. When you have kidney disease, your kidneys cannot filter out uric acid as well as they should. Too much uric acid building up in the body is the cause of gout.Most people with early stage kidney disease do not know they have it. Gout can be a warning sign of kidney disease. If you have gout, ask your doctor if you should be tested for kidney disease.
How Gout Affects Your Kidney Disease Risk
Your risk for kidney disease jumps quite high when you suffer from gout: about 40 percent of gout patients also have chronic kidney disease. Moreover, the more advanced the kidney disease, the likelier you are to suffer from gout symptoms.
A Dangerous Cycle
Experts suspect that the relationship between kidney disease and gout is so pronounced because each condition feeds the other.
On the one hand, the kidneys excrete uric acid, and that uric acid can accumulate and crystallize, causing gout. However, hyperuricemia can also speed up the progression of kidney disease by overwhelming the waste-removing organs.
The result? A vicious cycle that puts your kidneys at great risk of damage, and eventually, failure.
The Source of the Trouble
As is the case with many chronic diseases, ongoing low-grade inflammation is likely the culprit behind the elevated risk of kidney, hyperuricemia and gout. In these diseases, inflammation is systemic that is, not necessarily limited to a specific area which creates a widespread problem that is difficult to control.
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What Are The Symptoms Of Gout
- Severe joint pain. Although gout can affect any joint, it commonly occurs in the big toe, ankles, knees, elbows, wrists, and fingers.
- Inflammation and redness. When the crystals settle in a joint, that joint becomes red, swollen, and tender.
- Limited range of motion. As the crystals form around your joints, you may not be able to move your joints properly, or they may feel stiff.
Expert Q& a: Safe Oa Medications For Kidney Health
Kidney problems can complicate your osteoarthritis treatment plan.
Question: My question concerns arthritis and kidney health. I haveosteoarthritis, but I cannot take many medications because I have kidney problems. Is there any treatment I could try that would not affect my kidneys? Answer: For patients with many types of arthritis,kidney problemscan indeed complicate treatment plans. If you have diminished kidney function, you may need to avoid nonsteroidal anti-inflammatory drugs , such as ibuprofen or naproxen , but there are many other options for arthritis and kidney patients. The first option is acetaminophen , which is an analgesic, not an NSAID.
Injections of hyaluronic acid compounds, which are designed to supplement a substance that gives joint fluid its viscosity, for example, may provide relief in affected joints without involving the kidneys. These products includeHyalgan,OrthoVisc,SupartzandSynvisc.
There are also topical products for arthritis that affects only one or two joints. A gel form of the prescription NSAID diclofenac is one option. Only a very small amount of the drug gets into the bloodstream, so it may be safe for your kidneys. However, topicals may not work well for hip pain, because the joint is too deep for the medication to penetrate.
Other nonprescription topicals include:
Don Miller, PharmDProfessor, Department of Pharmacy PracticeNorth Dakota State University
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Who Is Affected By Gout
Gout can affect anyone. It usually occurs earlier in men than women. It generally occurs after menopause in women. Men can be three times more likely than women to get it because they have higher levels of uric acid most of their lives. Women reach these uric acid levels after menopause.
People are more likely to get gout if they have:
- Obesity, or a lot of extra weight.
You are also more likely to develop gout if you:
- Consume a diet high in animal proteins
- Consume a significant amount of alcohol
- Are on water pills .
What Are The Implications
Chronic kidney disease is a lifelong condition which is often progressive. Treatment of kidney disease is limited to prevention of deterioration by control of blood pressure and other risk factors. For end-stage disease dialysis or kidney transplant may be required. As the incidence of chronic kidney disease is increasing, finding new ways to slow progression is important.
Some uric acid-lowering medications are cheap and relatively safe. These results should help inform shared decision making for people with high uric acid levels.
The results due next year from a larger Australian RCT of 369 adults are eagerly anticipated.
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Other Risk Factors For Gout
As mentioned, eating a lot of foods high in purines and taking certain medications can cause gout. However, there are other risk factors that can increase your chances of developing gout. Here are some of them:
- High blood pressure
- Kidney disease
Gout tends to run in families. If you have a close relative with gout, youre more likely to develop it as well.
Role Of Combination Ult
Combination therapy with a XOI and a uricosuric can be very effective, and if uricosuric toxicity is a consequence of urate concentration within renal tubules then combination therapy could theoretically ameliorate such toxicity. However, as uricosuric treatment is usually not considered for patients with advanced CKD this approach is largely untested.
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Drugs Used To Manage Gout Flares
NSAIDs are generally contra-indicated in people with CKD, and the published literature in gout generally aimed to show the potential for renal-related adverse effects in people with CKD. Although NSAIDs have well-established adverse effects, there has been some suggestion that these drugs could be used in those with end-stage renal disease for short periods of time.
There are a small number of randomized controlled trials of colchicine for treatment of gout flares, and none of these reported outcomes stratified by renal function. Pharmacokinetic studies have indicated that clearance of colchicine is decreased in those with severe kidney impairment and that there is minimal clearance of colchicine by haemodialysis. Thus, the recommendations for use of colchicine in CKD remain largely empirical.
What Else Should I Ask My Healthcare Provider About Gout
Consider asking your healthcare provider:
- What is causing the gout?
- Do I have any joint damage?
- What can I do to prevent future attacks?
- Can any gout medications help me?
- How long will I need to take gout medications?
A note from Cleveland Clinic
Gout is a painful form of arthritis. Extra uric acid in your body creates sharp crystals in the joints, leading to swelling and extreme tenderness. Gout usually starts in the big toe but can affect other joints. Gout is a treatable condition, and the uric acid level can be decreased by medication and lifestyle changes. Talk to your healthcare provider about medications that can reduce uric acid levels. They can also discuss changes you can make to your diet and lifestyle to prevent and reduce gout attacks.
Last reviewed by a Cleveland Clinic medical professional on 11/15/2020.
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Gout Medication Is Linked With Adverse Effect On Heart And Kidney Disease
For those who suffer from gout, taking a popular medication may lead to a heightened risk of heart disease and kidney disease. The medication allopurinol is commonly used to treat gout, which is a painful condition becoming more common globally.
For the eight million Americans who suffer from gout, sudden and severe attacks of pain in the joints arent the only things to worry about. Published in CMAJ , allopurinol has shown a link to heart disease in patients taking the medication for gout. The US Food and Drug Administration recently issued a warning about another gout medication, febuxostat, which has been linked to cardiovascular disease. This warning caused an increase in allopurinol prescriptions, but now researchers are also warning about this drug.
For a better understanding of the association between heart disease and hospitalizations for allopurinol-associated severe adverse skin reactions in a general population, researchers from Canada and the United States looked at data from Population Data BC. This database includes health and prescription information on almost all 4.7 million residents in British Columbia.
Drugs Used For Flares And Prophylaxis
For drugs used in the management of gout flares or flare prophylaxis when starting ULT , the efficacy outcomes of interest are resolution or prevention of gout flares, respectively. For this G-CAN Consensus Statement, safety outcomes for each drug were individualized. The specific issues identified with medications used for the management of gout flares and prophylaxis in people with CKD are discussed below, and the G-CAN-proposed research priorities are outlined in Box .
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Effects On Other Treatments
Some drugs interact with allopurinol, so you should discuss any new medication with your doctor before starting it. You should also tell anyone else treating you that youre taking allopurinol.
Do not use complementary treatments, such as herbal remedies, without discussing this first with your doctor or pharmacist. Some of them could react with allopurinol.
You should avoid taking aspirin while youre being treated for gout. If youre in pain, you can take paracetamol and NSAIDs. But remember you should only take one NSAID at a time so do not take another if you have already been prescribed one to reduce the effects of gout attacks.
Allopurinol can also react with drugs that are often prescribed for high blood pressure, such as bendroflumethiazide, indapamide, lisinopril, ramipril.
It can also reduce the breakdown of the leukaemia drug mercaptopurine, so the dose of mercaptopurine will need to be reduced if you take this drug.
Allopurinol may also increase the risk of developing a rash if you take them with the antibiotics ampicillin or amoxicillin.
What Did It Find
- Uric acid lowering therapy reduced the risk of a kidney failure event from 29% in the control group to 12% in the therapy group .
- End-stage renal disease was reduced from 12% in the control group to 7% in the therapy group .
- Cardiovascular events such as heart attack and stroke affected 27% in the control group compared to 15% in the therapy group .
- There was no difference between the groups regarding death from any cause 4% died in the therapy group compared to 5% in the control group .
- There were low rates of side effects in the uric-acid lowering therapy group. Skin rash, muscle aches, and increased liver enzymes affected 2% of participants. There were no serious adverse effects.
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How Do You Treat Gout
- Eat a healthy diet.Following a healthy diet that includes whole grains, fruits, vegetables, and low-fat dairy products can decrease the frequency of gout attacks. Reduce your intake of alcohol, red meat, and high-purine foods.
- Exercise regularly. Exercise can help maintain a healthy weight. It also reduces the amount of uric acid your body produces.
- Ask about medications. If diet and exercise arent enough to reduce symptoms of gout, talk to your doctor about medications that may be available to you.
Who Can Take Allopurinol
Allopurinol is often recommended as the first choice of treatment to control gout. If your doctor prescribes it as soon as you are diagnosed, it may prevent future attacks and joint damage.
You will usually be offered allopurinol if blood tests show that your urate level is high enough for urate crystals to form, especially if one or more of the following applies:
- you are having frequent attacks of gout.
- your joints have been damaged by gout.
- your skin has visible deposits of urate crystals. These are firm white lumps, which are called tophi.
You may not be offered allopurinol, or you may be given a lower dose, if you:
- have ever had an allergic reaction to allopurinol.
- are currently having an attack of gout.
- have problems with your liver or kidneys.
- are of Han Chinese, Thai or Korean origin.
- have thyroid problems.
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Are Your Medications Causing Kidney Disease
No matter what kind of medication you take, whether over-the-counter or prescription, it is destined to take a trip through your kidneys. Because the kidneys provide the final pathway for excreting drugs and their metabolites, they are unfortunately subjected to high concentrations of potentially toxic substances.
Medications that can damage the kidneys are known as nephrotoxic medications. Some of these medications mildly worsen kidney function, others can cause acute kidney injury or lasting kidney damage.
Drugs cause nephrotoxicity in different ways but their main effects can be grouped into four categories:
The risk for kidney damage depends on your individual health and other medications you are taking. People with existing kidney conditions or damage are at much greater risk of harm by nephrotoxic medications.
Kidney Problems Can Complicate Treatment
There are many medications on the market to treat gout, but co-existing diseases make some options too dangerous. Non-steroidal anti-inflammatory drugs are often a first line of attack for acute gout attacks, but not a good choice for those with chronic kidney disease.
Likewise, colchicine is often used for gout pain, but brings side effects that can be too much to bear when another chronic disease is involved.
Drugs that block uric acid production, like allopurinol and febuxostat, can be a better solution, but any medication must be carefully limited and closely monitored to make sure no further damage is done to the kidneys. There is no universal course of action for treating gout and kidney problems simultaneously your doctor will have to choose and adjust mediation based on the severity of your gout pain, the severity of your kidney problems, and your overall health.
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The Link Between Gout And Kidney Disease
When your kidneys do not work the way that they should, it can lead to gout. Its important to treat and prevent future attacks of gout as it can lead to permanent joint and bone damage. Since kidney disease and gout are closely related, protecting your kidney function is one way to reduce symptoms of gout.
How Can I Manage My Gout And Protect My Kidneys
If you have gout, there are many things you can do to manage the disease and protect your kidneys. Start with the following5:
- Get Routine Blood TestsGet checked regularly to see if your uric acid level is normal and measure how well your kidneys are working .
- Take Your MedsAre you taking medicine to help manage your uric acid level and prevent gout flares? Even if your uric acid levels improve, do not stop taking your medications without first talking with your doctor.
- Drink Lots of WaterConsuming at least eight cups of water each day can help flush out your kidneys and reduce the amount of uric acid in your bloodstream.
- Eat a Gout-Friendly DietAvoid high-purine foods such as red meat, shellfish and alcohol. Skip the processed foods and soft drinks, too.
- Make Healthy ChoicesMaintain a healthy weight and exercise regularly. If you smoke, stop.
- See Your Doctor RegularlyHe or she can help you manage any other health issues you have, including diabetes, high blood pressure and high cholesterol. And be sure to tell your doctor which medications and supplements you are taking.
NOTE: This article was not written by a medical professional and is not intended to substitute for the guidance of a physician. These are not Hikmas recommendations for gout flare prevention, but rather facts and data collected from various reliable medical sources. For a full list of resources and their attributing links, see below.
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Why Do Gout Attacks Happen More At Night
Gout attacks happen more often at night and in the early morning than during the day. You may have an attack start during your sleep. Doctors are not entirely sure why this happens, but some of the leading ideas are dehydration, lower body temperature, and changes in hormone levels during sleep.Talk to your doctor about ways to prevent gout attacks during your sleep.