Gout Prevention in CKD (12)

Please advise on dose titration of allopurinol and gout management in this 62 year old man with CKD3 and multiple medical problems. He recently developed gout with a urate of 0.86. His CKD is stable, with eGFRs usually between 30-40 (latest eGFR 33).

I have given colchicine but pain is persistent and urate still very high.

Past medical history includes; Cor pulmonale, Type 2 Diabetes, COPD, AF, Morbid obesity (BMI 52).

He can attend clinics – would you recommend a medical or renal referral?

What further information would you seek before giving your opinion?

See more of the history or available results?

Current Medications; Metformin, Gliclazide, Digoxin, Lisinopril (5mg), Warfarin, Amiodarone, Furosemide (250mg/day)

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I have always thought that response to colchicine is almost useful as a diagnostic test; if he’s getting pain despite colchicine, is it really gout or is it another condition in conjunction with a high urate?

As for allopurinol, start when inflammation has subsided at 100mg / day. In CKD it is recommended to start low dose and titrate dose till urate <.35. Check urea and urate every few weeks.

If we are sure this is gout, and if colchicine is not settling his pain, he could have a short course of steroids‚ something like 5 days of prednisolone (20mg OD), but that may play up with his diabetes.

Does he need to be seen in clinic? – possibly and almost certainly if this problem becomes more complex. If gout control is difficult, rheumatology might be best first stop. His renal function is not deteriorating.

2 further thoughts;
1. He is close to the point where metformin is contra-indicated, in which case he may need to get into the diabetic clinic for advice on insulin
2. He is on a huge dose of furosemide which will undoubtedly push his urate up. If he has cor-pulmonale, I would expect him to have some peripheral oedema because of his right-ventricular pressures. If he is free of peripheral fluid, and especially if his BP is low or low-normal. I would cut his diuretic back a bit, allow him to gain some fluid in order to see what happens.


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