Saturday, November 26, 2022

How To Treat Gout With Kidney Disease

If Youre Not Able To Control Gout With Oral Medications Krystexxa Is A Safe And Effective Alternative

A letter about gout and kidney disease | Gout treatment | American Kidney Fund
Intended for U.S residents only.

What is the most important information I should know about KRYSTEXXA ?

Serious allergic reactions may happen in some patients who receive KRYSTEXXA. These allergic reactions can be life threatening and usually happen within 2 hours of the infusion.

USE

KRYSTEXXA is a prescription medicine used in adults to help reduce the signs and symptoms of gout that are not controlled by other treatments.

IMPORTANT SAFETY INFORMATION

What is the most important information I should know about KRYSTEXXA ?

Serious allergic reactions may happen in some patients who receive KRYSTEXXA. These allergic reactions can be life threatening and usually happen within 2 hours of the infusion.

KRYSTEXXA should be given to you by a doctor or nurse in a healthcare setting where serious allergic reactions can be treated. Your doctor or nurse should watch you for any signs of a serious allergic reaction during and after your treatment with KRYSTEXXA.

Tell your doctor or nurse right away if you have any of these symptoms during or after your treatment with KRYSTEXXA:

  • Wheezing, shortness of breath, cough, chest tightness, chest pain, or trouble breathing
  • Dizziness, fainting, fast or weak heartbeat or feeling nervous
  • Reddening of the face, itching, hives, rash, or feeling warm
  • Swelling of the throat or tongue, throat tightness, hoarse voice or trouble swallowing

Who should not receive KRYSTEXXA?

Before you receive KRYSTEXXA, tell your doctor if you:

Medicines For Gout Prevention And Complications

Your doctor can prescribe medicines that can help keep a healthy level of uric acid in your body, which can prevent future gout attacks and the complications from gout. When you have gout, your body either makes too much uric acid, or cannot get rid of enough of it, which causes it to build up. Some medicines are safe to take when you have kidney disease, but some are not. Talk to your doctor about which medicines are safe for you.

Allopurinol

Allopurinol is a medicine for people who make too much uric acid. It is the most common medicine used to treat chronic gout. Your doctor can tell you if allopurinol is safe for you to take if you have kidney disease.

Probenecid

Probenecid is a medicine that works for people who cannot get rid of enough uric acid. It works to remove extra uric acid through your urine. Probenecid can increase your risk of kidney stones. Probenecid is not safe to take for many people with kidney disease, so talk to your doctor for more information about probenecid.

Pegloticase

Pegloticase is an infusion medicine given by injection into your vein at your doctors office, usually every two weeks. It is used for severe chronic gout when other medicines do not work. Pegloticase can quickly bring your uric acid level down to a lower level than most medicines can. Talk to your doctor about whether pegloticase is safe for you.

Gout And Chronic Kidney Disease

Gout and chronic kidney disease frequently coexist, as both of these diseases are affected by the high levels of uric acid in the body. Many people with CKD have uncontrolled gout that can exacerbate their condition and lead to other complications. If you are prone to gout, you are at an increased risk of developing kidney disease and vice versa.

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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.

Why Was This Study Needed

Kidney Disease And Gout

Moderate to severe kidney disease affects 2.6 million people in England. It has a variety of causes including diabetes and inflammation. Management aims to slow progression through a variety of measures including lowering blood pressure, blood thinners, stopping smoking and dietary advice.

Uric acid is a breakdown product of blood cells and foods rich in purines. Blood levels are often high in people with impaired kidneys. It is not known whether this is a cause or consequence of chronic kidney disease.

There has been renewed interest in the relationship between uric acid levels and kidney disease with recent research showing a possible link between uric acid and the worsening of kidney disease in patients with and without diabetes. There has been conflicting evidence about whether reducing the levels of uric acid can limit the decline in kidney function or cardiovascular disease. The researchers aimed to address this through pooling the available research.

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Gout And Kidney Disease : Risk Factors

Here is a list of the major contributing factors, and risk factors, of gout:

In particular, alcohol: alcohol has two mechanisms that induce gout attacks

Such as :

  • alcohol increases uric acid production
  • alcohol reduces kidney function, thereby reducing the removal of uric acid via the urine
  • Risk factors :

    • Diet high in purine-containing foods
    • Family history of gout
    • Polynesian background
    • Thiazide diuretics

    Based on the above factor, we can see that gout and kidney disease are related to the cause of the uncomfortable pain.

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    Epidemiology Of The Association

    Some genetic studies also suggest that hyperuricemia may confer risk for CKD, especially in Mexican American, Native American, and Italian populations2020 Macias-Kauffer LR, Villamil-Ramirez H, Leon-Mimila P, Jacobo-Albavera L, Posadas-Romero C, Posadas-Sanchez R, et al. Genetic contributors to serum uric acid levels in Mexicans and their effect on premature coronary artery disease. Int J Cardiol. 2019 Mar 279:168-73.,3636 Testa A, Mallamaci F, Spoto B, Pisano A, Sanguedolce MC, Tripepi G, et al. Association of a polymorphism in a gene encoding a urate transporter with CKD progression. Clin J Am Soc Nephrol. 2014 Jun 9:1059-65.,3737 Voruganti VS, Franceschini N, Haack K, Laston S, MacCluer JW, Umans JG, et al. Replication of the effect of SLC2A9 genetic variation on serum uric acid levels in American Indians. Eur J Hum Genet. 2014 Jul 22:938-43.. However, a recent large Mendelian randomization study did not find any association between serum uric acid, eGFR, and CKD77 Jordan DM, Choi HK, Verbanck M, Topless R, Won HH, Nadkarni G, et al. No causal effects of serum urate levels on the risk of chronic kidney disease: a Mendelian randomization study. PLoS Med. 2019 Jan 16:e1002725..

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    Clinical Trials Of Uric Acid In Chronic Kidney Disease

    Experimental trials of uric acid lowering drugs in CKD have been mixed . One analysis suggested that a primary reason for the mixed results was that some trials were too short or underpowered to show meaningful progression in the control groups, thus making it difficult to show a benefit in the treatment group. In essence, if the control group does not demonstrate worsening of the underlying disease, it is challenging for any treatment to demonstrate protection. Indeed, studies showing meaningful progression :261-2. decrease in the control group over the time course of the study) were associated with a benefit of urate-lowering therapy. This analysis argued for urate-lowering therapy in participants with hyperuricemia and CKD5858 Sato Y, Feig DI, Stack AG, Kang DH, Lanaspa MA, Ejaz AA, et al. The case for uric acid-lowering treatment in patients with hyperuricaemia and CKD. Nat Rev Nephrol. 2019 Dec 15:767-75..

    Role Of Combination Ult

    Preventing Gout Attacks and Treating Gout with diet for Kidney Patients

    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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    Gout And Kidney Disease Unfortunately Go Hand In Hand

    Gout can often seem, to begin with, a pretty innocuous condition random joint pains lasting a few hours or days at best.

    But soon, very soon, the gout attacks seem to be unrelenting, causing joint specific inflammation, pain, heat, and decreased movement.

    However, have a tool kit of natural medicines to help reverse this condition easily a little further down.

    If you are currently suffering from joint pain but are unsure if it is gout or not, here is a good diagnostic checklist:

    • 30 years of age or greater
    • 95% of cases are males
    • During attacks body temperature may rise to 39°C
    • Gout is a familial disease. A familial disease is hereditary, passed on from one generation to the next
    • Increased uric acid levels in the blood
    • Monosodium urate monohydrate builds up in and around the joints of extremities, causing gout
    • Occurs commonly together with uric acid kidney stones
    • Periods of being asymptomatic, followed by acute attacks
    • Rapid onset, of classically one joint in the fingers or toes , occurring frequently at night.
    • Swelling, heat, stiffness of joint
    • Shiny red or purple coloration of joint

    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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    Drugs Used For Flare Prophylaxis

    Although the medications used for flare prophylaxis are the same as those used to treat flares, they are generally used at lower doses and for longer periods of time . A post hoc analysis of three phase III RCTs in people starting febuxostat who also received prophylaxis with colchicine included participants with an eGFR of < 30ml/min/1.73m2 but again the results were not stratified by renal function. Long-term use of colchicine in the general population has been associated with bone marrow suppression and neuromyotoxicity, but whether these effects are increased in those with gout and CKD is unknown. Whereas short-term courses of glucocorticoids can be considered to have an acceptable riskbenefit profile, long-term use of glucocorticoids for flare prophylaxis can be associated with an increased risk of glucocorticoid-related adverse events, particularly infections, as seen in other rheumatic diseases,. This risk could be particularly concerning in a population that is already at high risk of severe infections, such as those with CKD. Whether the gout flare rate when starting ULT is the same in those with CKD as in those without, and whether prophylaxis is always required, are unknown, although a recent study of incremental use of febuxostat suggested that prophylaxis might not be required when a dose-escalation approach is used.

    Other Ways To Treat Gout

    Do home based gout remedies actually work? in 2020 ...

    Medicine is considered the most effective treatment method for gout, but there are lifestyle changes you can make to manage your symptoms during a gout attack, or help prevent gout attacks from happening. Learn more about other ways to manage symptoms of gout during an attack here. Learn more about preventing future gout attacks here.

    Educational content made possible by Horizon Therapeutics.

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    How Do You Lower Uric Acid Levels And Treat Gout Naturally

    The foundation for treating gout lies in making some changes with your diet, keeping physically active and losing weight if you are overweight. Weight loss has been linked to a decrease in uric acid levels and leads to reductions in gout incidence and exercise is a strong preventor of gout.

    The great thing is that making these changes wont just lower your risk for gout but also every other metabolic disease that is associated with elevated uric acid levels including kidney disease, heart disease and diabetes.

    The use of supplements can also be of assistance, but dietary and lifestyle changes really are key here.

    Nutritional And Herbal Supplements

    • Bromelain is a proteolytic enzyme that may assist in reducing pain, swelling and inflammation associated with gout. Take between meals.
    • Quercetin has been suggested to be beneficial because of its ability to inhibit xanthine oxidase which is the enzyme needed to make uric acid. Quercetin also reduces inflammation and has antioxidant properties.
    • Vitamin C- vitamin C supplementation was once thought to exacerbate gout however recent data has reversed that belief. In saying that, megadoses of vitamin C should be avoided as it may increase uric acid levels in a small number of people. Vitamin C has been clinically proven to reduce serum uric acid levels in relatively low doses.
    • Fish oil- reduces inflammation.
    • Folic acid- is an inhibitor of xanthine oxidase so may be of assistance in lowering uric acid levels.
    • Couch grass is a diuretic and has been used traditionally for its effects on renal secretion in gout. Couch grass, through its action as a diuretic promotes the removal of toxic build-up via the kidneys.
    • Turmeric – assists in the control of inflammation and pain. Has also been shown to lower uric acid concentrations.
    • Nettle leaf- a gentle diuretic that helps the body process and flush away toxins, reduces inflammation and may help reduce the symptoms of gout.

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    Strengths And Limitations Of This Study

    • The large sample size of more than 600000 patients and moderate follow-up period provided a powerful mechanism to examine multiple outcomes.

    • The study cohort analysed data from Clinical Practice Research Datalink, ensuring that results are broadly generalisable to primary care practices in the UK health system population.

    • Comprehensive data on several confounders were accounted for in the analysis, but these did not explain the strong relationship between gout and risk of advanced chronic kidney disease.

    Management Of Chronic Gout In Patient With Ckd

    Goutful: Gout and Kidney Disease

    Lowering serum uric acid levels to less than 6mg/dl in CKD patients with gout has a tendency to reduce acute gouty flares. The presence of CKD does not alter the need to reach this goal however, levels less than 5 mg/dl may be more appropriate in advance disease. Treatment options in the treatment of chronic gouty arthritis for lowering serum uric acid levels are as follows:

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    Appropriate Dosing Of Xois

    As mentioned above, allopurinol dosing in CKD is one of the most controversial areas in gout management owing to the risk of AHS in people with CKD. On the basis of primarily case series and a retrospective casecontrol study, there is general agreement that the starting dose of allopurinol should be low and increased slowly, although no prospective trial data are available to prove or disprove the rationale that such an approach will reduce the risk of AHS. Use of allopurinol is further complicated by the large inter-individual variability in the dose required to achieve the target serum urate concentration . Despite data suggesting that allopurinol dose escalation can achieve target serum urate concentrations even in those with kidney impairment,,, the belief that the allopurinol dose should be reduced in people with CKD remains pervasive. In comparison to allopurinol, febuxostat has a narrower dose range and there has been more willingness to use febuxostat in people with CKD. In the largest study of febuxostat in CKD, which enrolled 96 people with an eGFR in the range 1550ml/min/1.73m2, febuxostat 6080mg daily was associated with a reduction in serum urate concentration with no decline in renal function.

    The Cause Of This Condition

    Essentially gout is the deposit of monosodium urate crystals in and around the joints.

    Which are caused by increased levels of uric acid.

    Then, uric acid is formed when purines are broken down.

    Purines are found in certain foods such as meat, peas, and alcohol, and also occur naturally in our cells.

    High levels of uric acid cause inflammation and damage to joints and soft tissues.

    So gout can be either caused by the overproduction or underexcretion of uric acid, such as in kidney disease.

    In particular, gout can be a very common occurrence in those suffering from under functioning kidneys.

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    Level Of Renal Function Precluding Ult

    Because most large RCTs have excluded people with substantial renal impairment, there are few data from RCTs to inform decisions about when specific ULTs should not be used on the basis of kidney function. No studies have specifically examined the risks and benefits of not treating gout in people with CKD with ULT, and all current guidelines recommend ULT treatment in this population. In many patients, but not all, untreated gout causes considerable morbidity in its own right, and in those with CKD the only option for treating flares might be long-term corticosteroids, which is associated with further morbidity.

    Gout And Heart Disease

    Kidney Stone Vs Gout Pain

    Uric acid is a known risk factor for both hypertension and heart disease. Many epidemiological studies show a link between uric acid and coronary disease, including stroke and heart attack. With higher levels of uric acid in the body, it creates the environment for painful gout flares. And those who have gout are more likely to have heart health issuesincluding heart disease, blocked arteries and heart failure. Left untreated, gout can be very dangerous, with new research showing that having gout doubles a persons risk for heart attack or stroke.

    Uric acid is a normal waste product found in your bloodstream.

    Having more uric acid than the kidneys can get rid of can lead to a condition called hyperuricemia .

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