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Severe Hyperuricemia

german translation / full article

Simon Kostner

Question

A 83-year-old multimorbid patient is in stage 5 of kidney failure (eGFR 10 ml/min) due to diabetic nephropathy. But he, so far, refused dialysis. For several weeks, he is suffering from repeated severe attacks of gout in various joints. The blood uric acid showed a value of 17 mg/dl. Can allopurinol be given, or which therapy to lower uric acid level is most suitable for him?

Answer

Allopurinol can be given even in case of such a severe renal insufficiency. However, this should happen in very low doses because of accumulation. It is recommended to monitor by monthly blood tests the uric acid, the possible toxic effects (in liver, kidney and blood count) and – if it is available – the oxipurinol level (metabolite of allopurinol) to achieve the desired reduction of uric acid level with the lowest possible dose.

The newer xanthine oxidase inhibitor febuxostat should not be used in such impaired renal function; a recommendation based on a lack of safety data. Uricosuric agents such as probenecid are also contraindicated.

The most recent therapy with the „biological“ pegloticase have as many side effects as high costs and is reserved for specialized centers as ultima ratio. We could not find out, whether it can be used in cases with reduced kidney function.


(State: 29.05.2015)

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