Management of Gout in Patients Initiating Dialysis

Rationale for Continuing Urate-Lowering Therapy

The American College of Rheumatology strongly recommends continuing urate-lowering therapy indefinitely rather than stopping it, even after achieving target serum urate levels 1
The European League Against Rheumatism guidelines specifically state that serum urate levels below 6 mg/dL should be maintained lifelong 1
Clinical evidence demonstrates that when urate-lowering therapy is discontinued in patients who achieved clinical remission, only 13% remained flare-free during 5-year follow-up 1

Frequent gout flares (≥2/year) is a strong indication for maintaining urate-lowering therapy, as recommended by the American College of Rheumatology and supported by evidence from Arthritis care & research 3
Presence of subcutaneous tophi is a strong indication for continuing therapy, as recommended by the American College of Rheumatology and supported by evidence from Arthritis care & research 3
Radiographic damage attributable to gout is a strong indication for maintaining treatment, as recommended by the American College of Rheumatology and supported by evidence from Arthritis care & research 3
Chronic kidney disease stage ≥3 is a conditionally recommended indication for urate-lowering therapy initiation and continuation, as supported by evidence from Annals of the Rheumatic Diseases 5

Maintain serum uric acid levels below 6 mg/dL (360 μmol/L) lifelong, as recommended by the European League Against Rheumatism and supported by evidence from Annals of the Rheumatic Diseases 5
For patients with severe gout manifestations (tophi, chronic arthropathy, frequent attacks), target serum uric acid <5 mg/dL (300 μmol/L) until complete crystal dissolution, as supported by evidence from Annals of the Rheumatic Diseases 5
Monitor serum urate levels every 6 months once target is achieved to ensure continued efficacy, as recommended by the American College of Rheumatology and supported by evidence from Praxis Medical Insights: Practical Summaries of Clinical Guidelines 1

Do not discontinue febuxostat simply because the patient is starting dialysis, as this is a critical error that leads to recurrence of gout flares and crystal reaccumulation, as recommended by the American College of Rheumatology and supported by evidence from Praxis Medical Insights: Practical Summaries of Clinical Guidelines 1
Do not assume dialysis will adequately control uric acid levels, as pharmacologic urate-lowering therapy remains necessary for gout management, as supported by evidence from Arthritis care & research and Annals of the Rheumatic Diseases 3, 5