Table 1.
Urate-lowering agents with recommendations for urate-lowering management in patients with normal and reduced kidney function.
| Urate-lowering agents | Doses | Recommendations for CKD 3–5 | Recommendations for CKD 5D (dialysis) |
|---|---|---|---|
| Xanthine oxidase inhibitors (XOI)a | |||
| Allopurinol | Starting: 50–100 mg daily; maximal approved: 800 mg/day (900 mg/day in the UK) | CrCl ≥30 mL/min: start with ≤100 mg/day18; CrCl <30 mL/min: start with 50 mg/day18 | Intermittent HD: should be administered post-dialysis28,29, start with 100 mg alternate days post-dialysis; daily HD: additional 50% of dose may be required post-dialysis; daily PD: start with 50 mg/day; all types of RRT: up-titrate dose with 50 mg-increments every 2–5 weeks, measure serum urate pre-dialysis |
| Febuxostat | Starting: 40 mg daily; maximal approved: 80 mg/day (120 mg in Europe) | Insufficient data for CrCl <30 mL/min | Despite some successful reports of dialysis patients using febuxostat up to 80 mg/day, this agent is not FDA-approved for use in dialysis due to a lack of trials in this population30–34 |
| Uricosuric Agentsb | |||
| Benzbromaronec | Starting: 25–50 mg daily; maximal approved: 200 mg/day | Contraindicated if CrCl <20 mL/min | Contraindicated |
| Lesinuradd | Starting: 200 mg daily together with XOI; maximal approved: 200 mg/day | Contraindicated if CrCl <45 mL/min | Contraindicated |
| Probenecid | Starting: 250 mg twice daily; maximal approved: 2000 mg/day | Not effective if CrCl ≤30 mL/min | Contraindicated |
| Sulfinpyrazonec | Starting: 50 mg twice daily; maximal approved: 800 mg/day | Not effective if CrCl ≤30 mL/min | Contraindicated |
| Recombinant uricase | |||
| Pegloticase | Starting: 8 mg IV every 2 weeks; maximal approved: 8 mg IV every 2 weeks | No dose adjustment needed | No dose adjustment needed35 |
a
Titrate dose every 2–5 weeks to reach the serum urate target; for allopurinol, this up-titration can occur beyond the CrCl-based dose
b
Titrate dose every 2–5 weeks to reach the serum urate target
c
Not available in the USA;
d
Approved for use only in combination with a xanthine oxidase inhibitor.
Abbreviations: CKD: chronic kidney disease; CrCl: creatinine clearance; HD: hemodialysis; IV: intravenous; PD, peritoneal dialysis; RRT, renal replacement therapy