For Gout’s Sake! Managing Gout in CKD

The For Kidneys Sake podcast series is brought to you by Imperial College Healthcare NHS Trust and North West London Integrated Care Board (NWL NHS).

In this episode of For Kidneys Sake, consultant nephrologists Prof Jeremy Levy and Dr Andrew Frankel discuss the relationship between gout and chronic kidney disease (CKD). They explore how CKD increases the risk of developing gout due to impaired uric acid excretion and sometimes the effects of commonly prescribed medications such as diuretics. The conversation demystifies the clinical presentation of gout in CKD patients and clarifies that the diagnosis remains unchanged; it’s typically a clinical judgement, supported by elevated uric acid levels.

Most importantly, the episode offers a detailed and practical discussion on managing acute gout attacks in CKD patients, covering the nuanced use of NSAIDs, colchicine, and steroids depending on the severity of kidney impairment. The hosts also stress the importance of lifestyle modifications, including dietary changes and exercise, as well as when and how to initiate preventative treatments like allopurinol or febuxostat. With a tone that balances clinical depth and approachability, Jeremy and Andrew provide valuable guidance for GPs, pharmacists, and healthcare professionals managing these intersecting conditions.

Key Takeaways: 

1. Gout is more common in people with CKD due to reduced uric acid excretion and side effects of common medications. 

2. Diagnosis of gout in CKD patients remains clinical and mirrors that in the general population. 

3. NSAIDs can be used cautiously in early CKD (GFR >45) for short durations, but not repeatedly; colchicine and steroids are alternatives, and for more advanced stages of CKD. 

4. Lifestyle changes – especially diet and exercise – play a vital role in reducing gout attacks. 

5. Allopurinol should be started at 100mg in CKD and titrated based on uric acid levels, with febuxostat as a second-line option.

Resource Links:
NICE GUIDELINES [NG203] chronic kidney disease: assessment and management Overview | Chronic kidney disease: assessment and management | Guidance | NICE

Northwest London CKD guidelines for primary care Chronic kidney disease (nwlondonicb.nhs.uk)

The purpose of this podcast is to inform and educate health care professionals working in the primary care and community setting. The content is evidence based and consistent with NICE guidelines and North West Guidelines available at the time of publication.

The content of this podcast does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement.

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Transcript

Jeremy Levy
So, hello, I'm Jeremy Levy. I'm a consultant nephrologist of Imperial Healthcare NHS Trust.

Andrew Frankel
Hello and I'm Andrew Frankel and I work with Jeremy as a consultant kidney doctor at Imperial. So today we want to talk about gout and in fact I think I'm going to learn a great deal myself today we all know that gout is not some Victorian disease that no longer troubles our patients but actually remains a common problem I think I'm right that there are about 180,000 new cases in the UK every year.

Almost 3% of the UK population live with gout as a recurrent problem. And many of these people also have chronic kidney disease. So we get questions via our advice and guidance line quite frequently from GPs and pharmacists about how to treat acute attacks of gout in people with CKD and then how to prevent this recurring. So Jeremy.

Jeremy Levy
Well, that's right Andrew, gout is really common. It's not a rare disease. And of course, is not just common overall, but it's more common in people living with chronic kidney disease. And there are several reasons for this. Firstly, CKD, chronic kidney disease itself, impairs your excretion of uric acid, of course, which causes gout. So that increases the risk of gout attacks, both acute and chronic gouty disease.

Secondly, the medicines that people with chronic kidney disease take increase the risk of gout. These are perfectly sensible medicines but they just have that as a side effect. For example, diuretics and especially thiazide diuretics, cyclosporine and even aspirin increase your risk of gout. Thirdly, there are quite a few diseases where the two are intertwined. Raised levels of uric acid actually lead to kidney damage and hence chronic kidney disease.

So the gout and the chronic kidney disease are actually linked by uric acid causing both problems. Now those are rarer, but they're very, very important. So for all those reasons, gout is definitely more common in people living with CKD.

Andrew Frankel
OK then Jeremy, so let's start with first common question – diagnosis. Is there any difference in making the diagnosis in people with CKD?

Jeremy Levy
Well that was my easy question wasn't it? At my start of a 10 as it were. No, absolutely no difference whatsoever. It's not one of these problems that manifest in a different way if you've got chronic kidney disease. Hot painful swollen joints, often a single joint and often the big toe for reasons that remain very unclear. Lots of theories but nobody knows. Exactly the same as people who don't have chronic kidney disease.

And it's usually a clinical diagnosis. There's no blood test needed usually. It's usually pretty obvious. But measuring uric acid levels is very helpful. There is a differential diagnosis as with any sort of monoarticular hot joint. But in general, it's pretty obvious. And serum uric acid levels are high. They're high as in the general population where you'd expect. So the upper limit of normal is about 400 micromoles per litre in men, 350 in women.

In gout, most people have uric acids in the range 450 to 600. So, manifests exactly the same as everybody else. Hot swollen joints, often the big toe, high blood uric acid levels.

Andrew Frankel
Okay so that's simple. Let's just move on a little bit and make it a little harder. What about the acute attack? How should we be treating a patient with CKD with an acute attack? Are there any differences?

Jeremy Levy
So this is where it doesn't get hard but it causes confusion and the fundamental thing is this whole story about non-steroidal anti-inflammatory drugs. We all know that NSAIDs, non-steroidals and that's naproxen, ibuprofen etc are brilliant at treating acute gout in the general population but then we all also know that we're meant to avoid non-steroidals in chronic kidney disease and so that's what causes the hurdle, the dilemma in treating people with gout and CKD.

But in people with early chronic kidney disease, so that's CKD G2 or even G3A, so we're talking about GFRs down to about 45, then a single three to five day course of a non-steroidal is not going to cause any harm, especially if you make sure you tell the patient not to be dehydrated, to drink plenty of fluids, not to get volume depleted.

In that setting, so GFR is above about 45, a single course of non-steroidals that is not prolonged will be very effective and will not be harmful. Now you mustn't give repeat prescriptions or suggest people take repeated courses and nor should they have prolonged courses. But in that setting, it is not impossible to use anti-inflammatories and for some people that can be very, very effective. But of course you can't…

Andrew Frankel
Jeremy, can I just make the point though, it's really helpful and reassuring that you can use the NSAIDs. One of the things that I do advise primary care is if you've got them on a short course and you check their kidney function, don't be surprised if the GFR is a little lower during the course, particularly in an acute episode of gout.

Jeremy Levy
I think that's very sensible and lots of reasons for that Andrew. It's not just the NSAIDs, it's the fact they're in pain and they've got other things going on and there's inflammation. You're absolutely right and usually this is a transient effect that resolves pretty quickly. So yes, often the GP will have done a blood test, won't they, with the acute attack and it might be before treatment started but very important point so thank you.

But if you don't want to use a non-steroidal or can't use them and that especially means if the GFR is less than about 45 when you really shouldn't, the next best option in treating this acute attack of gout is colchicine. Colchicine, also a very old drug, can be very, very effective. We all know that it can cause some loose stools or diarrhoea or even vomiting. So again, it's really important that people don't get dehydrated. They need to drink plenty.

You can use one to two tablets, often two tablets when the attack starts. That in the UK and Europe is a thousand micrograms. Then one tablet twice a day is the dose and generally for five to seven days. You can use colchicine — despite warnings in the BNF — down to a GFR of about 15 mls per minute. So for CKD stages three and four, a week's course of colchicine, two tablets when the attack starts, then one twice a day for the next week is very useful.

…but you can't use higher doses. For some people that isn't enough, but that dose is very effective in many people. You also need to be careful about drug interactions with colchicine — for example, cyclosporine, diltiazem, verapamil, clarithromycin, erythromycin, ketoconazole. These interactions are very important to check.

After colchicine, a short course of steroids is really effective. Prednisolone, 20 to 30 milligrams starting as soon as possible when an attack starts, for about a week, then a rapid taper over the next five days. For example: 30 mg for seven days, 20 mg for two days, 10 mg for two days, 5 mg for two days, then stop.

…and if a person has had an acute attack, do review their regular medicines. For example, a thiazide diuretic could be stopped if possible, but never stop drugs like cyclosporine without specialist input.

Andrew Frankel
That is really helpful Jeremy. We have the non-steroidal anti-inflammatory drugs that can be used in people with CKD as long as the GFR is above 45. Otherwise, colchicine using that regime you described, two initially, then one twice a day for up to a week or so. A course of prednisolone for a week then rapidly tailing. So you've got the acute attack dealt with. What about preventing further attacks? Is that again any different in people with CKD?

Jeremy Levy
So actually, no, it's not different, Andrew. We'll talk on the doses, but fundamentally, it's not different. But as you know, before I talk about medicines, I'm going to bang on about diet and exercise. It's really, really important in gout. Firstly, what many people don't know is all those awful fizzy drinks, especially if they're made in America, contain this sugar that's called high fructose corn syrup. And that is fills fizzy drinks in the US, less used in Europe and the UK.

problem with high fructose corn syrup is that it's metabolised to uric acid and therefore it makes go out worse and it keeps blood uric acid levels high. In the UK the sugar used in fizzy drinks is beet or cane sugar and that is not metabolised to uric acid. Doesn't mean they're good for you of course but that's not going to affect your uric acid so much. So drinks with high fructose corn syrup look at the label and if you're buying them from outside the UK they'll be full of it.

And then, I'm sure you'll remember this Andrew, given your regime, exercise lowers uric acid levels and reduces inflammation. So exercise cleaning while you've got an acute attack, it's pretty difficult to do, but in general will lower uric acid levels and that will help. And then the standard things that we sort of know about in the diet that raise uric acid levels and that's red meat, shellfish, beer, pork, you'd have to drink quite a lot, many ultra processed foods.

Fried fruits and to a degree dairy products. That range of foods keep uric acid high. So we should be advising people to have a more plant-based diet, avoiding red meats, avoiding shellfish and beer, and again avoiding ultra processed foods will help reduce attacks of gout. So that is really important diet and exercise advice and that fizzy drink story.

Andrew Frankel
So that's incredibly helpful and really important to remember lifestyle. It's not all about the pharma But can I ask you one additional question about the pharma about the medicines? What do you need to do when you start someone on allopurinol for prevention, if you decide you're going to use it?

Jeremy Levy
That is the drugs to use, you say, allopurinol. Same as for somebody without CKD. So first of all, don't start during the acute attack. That's the same advice as in the general population. You've got to treat the acute attack and let that resolve. Then in chronic kidney disease, allopurinol, which we've been using for over 60 years, think 1960s it became available. First line, and you started 100 milligrams in people with chronic kidney disease.

So not the standard dose of 300 milligrams, the reduced dose of 100 milligrams once a day. But don't just leave it there. I see loads of patients who had it started, they're on 100 and they're still getting attacks because you can then increase the dose and titrate it against uric acid levels, which is what you're meant to do in the general population as well. So start at 100 milligrams of allopurinol, recheck the uric acid level about six weeks later.

and we're trying to get the serum uric acid level to less than about 300 micro moles per liter. And if it's still 500 on 100 milligrams of allopurinol, increase the dose to 200 milligrams. The maximum dose you can use at stages of CKD 3 and 4 is 300 milligrams. So you can get to 300 milligrams, but you need to go from 100 and go up relatively slowly. And it can be very, very effective. And then the last thing to say about the allopurinol really is that

You should start it, I think, after a single attack of gout in CKD, because actually the risk of recurrent attacks is very, very high, and that by itself can lead to ongoing kidney damage. And so in that setting, after one attack would be worth starting allopurinol, clearly if the patient wishes to. And when you start it, you're meant to cover it with colchicine, one tablet, sort of once or twice a day for about three or four weeks to allow the allopurinol to kick in.

there's this story, it's not a story, it's true, that sometimes it can induce flares of gout when you start it. So that's allopurinol. Thing to remember, it can cause some side effects and occasionally you can't use it and there are some drug interactions as well. The major drug interaction is azathioprine. You cannot use allopurinol in people on azathioprine. If you can't use allopurinol to prevent gout, next step.

Phobuxostat, one of the drugs I can rarely prescribe. Phobuxostat. It can be used in chronic kidney disease. You start at 40 milligrams. You can increase it to 80, but no higher. And that also works pretty effectively in chronic kidney disease for prevention of gout. And they are the two best options. There's a whole list of other things very rarely used. I would seek secondary care advice. And one drug you may have heard of, Benzbromelone, can be used, very...

much lower doses than in normal visits, really, it's created. So allopurinol, stick with that, or for books of stat, if you can't use allopurinol.

Andrew Frankel
That's great Jeremy, so primary care can really hang on to those two commoner treatments and understand how to use that. That's And I hadn't realised how much rheumatological knowledge you had. It's very impressive. Or that you remember the 1960s. That's even more impressive. So I need to remind my colleagues of one other little point, which is they need to ensure that they have clocked.

Whether a patient is a kidney transplant patient. So they may be coded as CKD because the GFR is less than 60, but they also need to be coded as a transplant patient because they are then on a number of other medications and there are potentially interactions with the impregnable oppressive drugs that we use in kidney transplants. And these drugs may not always appear on your practice list if they are prescribed from hospital.

So in that situation, the patient is a kidney transplant, indeed any transplant patient, always contact the transplant clinic about starting allopurinol or other long-term drugs rather than start yourself.

Jeremy Levy
I was going to butt in there Andrews earlier actually right, not just kidney transplants I mean the kidneys are the commonest aren't they but if people have had lung or heart or bowel transplants all the same story talk to the transplant unit

Andrew Frankel
Yep, absolutely the word transplant rather than kidney transplant. So my takeaway is Jeremy, diagnosis of gout is not different for people with or without CKD. Treatment of an acute attack, NSAIDs in very early CKD, cautiously, otherwise colchicine two doses a day for a week or prednisone 30 milligrams for a week.

and prevention? I will certainly remember avoiding high fructose corn syrups in my fizzy drinks. I will consider reducing red meat, beer, shellfish and certainly ultra processed food and then consider using allopurinol as my first choice starting at 100 but titrating gradually up to a maximum of 300 to try and get the year 8 to around And for transplant patients just ask the transplant team.

don't start new medicines in primary care.

Jeremy Levy
That's it, Andrew. Except I'm not sure the word takeaway was a good one in this context. Takeaways lead to gouts, don't they? ⁓ terrible joke. I think that's the nubbins of it. And the reason it's difficult, I think, is that whole story about reaching for non-steroidals. But yet the message we do give regularly about avoiding them in chronic kidney disease and yet in CKDs can be a problem. But actually, hopefully now it's crystal clear. Crystals, gout, uric acid.

Andrew Frankel
⁓ Jeremy, that is shameless. Thank you very much, bye.

Jeremy Levy
Bye.