How Do Urate-lowering Drugs Suit The Case For Different Levels Of Renal Function? This Article Gives You The Answer

Hyperuricemia (HUA) is a metabolic disease caused by purine metabolism disorders. It refers to the level of blood uric acid in adults on an empty stomach > 420 μmol/L twice on different days under a normal purine diet. In recent years, with the continuous improvement of people's living standards, the prevalence of HUA has been increasing year by year.

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However, there are still many people who think that high uric acid is not a big deal. They usually do not deliberately control their diet, and they take medicine according to their mood and do not follow the doctor's advice. But such an approach is undoubtedly worse for patients with renal insufficiency because the continuous increase of uric acid will further harm the kidneys and cause permanent kidney damage.

According to the "Multidisciplinary Expert Consensus on the Diagnosis and Treatment of Hyperuricemia-related Diseases in China (2017 Edition)", it is pointed out that HUA patients need comprehensive and long-term management, and the timing of drug initiation is determined according to the blood uric acid level and combined clinical symptoms/signs. And formulate corresponding treatment goals for stratified management.

Uric acid-lowering drugs commonly used clinically include two types: inhibiting uric acid synthesis and promoting uric acid excretion. Drugs should be selected according to the etiology, comorbidities, and liver and kidney functions.

So for patients with normal or insufficient renal function, how to choose uric acid-lowering drugs?

Drugs that inhibit uric acid synthesis

The mechanism of action of these drugs is to reduce uric acid synthesis by inhibiting xanthine oxidase (XO), thereby reducing blood uric acid levels.

Allopurinol

1) Normal renal function: The initial dose of ordinary tablets is 50mg once, 1-2 times a day, and can be increased by 50-100mg every week to 200-300mg a day, divided into 2-3 times, and the maximum daily dose is 600mg. The sustained-release preparation is 250mg once a day, and the dose is adjusted according to the condition and biochemical examination results.

2) Renal insufficiency: Reduce the dose of glomerular filtration rate (eGFR) < 60ml/min, the recommended dose is 50-100mg per day; eGFR < 15ml/min is prohibited.

3) Precautions: Allopurinol can cause exfoliative dermatitis, toxic epidermal necrolysis, and other serious adverse reactions. Renal insufficiency and HLA-B*5801 gene positivity are related risk factors. It is recommended to perform genetic testing before taking allopurinol.

febuxostat

1) Normal renal function: the initial dose is 20-40mg/d, once a day, if the blood uric acid level is not up to standard within 2-4 weeks, the dose should be increased by 20mg each time, and the maximum dose is 80mg/d.

2) Renal insufficiency: eGFR>30ml/min, no need to adjust the dose; eGFR<30ml/min, the recommended starting dose is 20mg/d, once a day.

3) Precautions: For patients with renal insufficiency with eGFR<30ml/min, to ensure the safety and effectiveness of treatment, febuxostat is preferred as a urate-lowering drug.

Use febuxostat for high uric acid.

Drugs that promote uric acid excretion

These drugs mainly reduce blood uric acid levels by inhibiting renal tubular reabsorption and increasing uric acid excretion.

Probenecid

1) Normal renal function: 0.25g once, twice a day, and can be increased to 0.5g once a week, twice a day.

2) Renal insufficiency: When patients with mild renal insufficiency use this drug to treat gouty arthritis if the 24-hour uric acid excretion does not exceed 700mg, the general daily dose should not exceed 2g. eGFR<30ml/min disabled.

3) Precautions: Generally, it is not used as the first-choice treatment drug. During the medication period, keep adequate water intake to prevent the formation of kidney stones, and alkalize the urine if necessary.

Benzbromarone

1) Normal renal function: 50-100mg once a day, the maintenance dose depends on the condition.

2) Renal insufficiency: It can be used in patients with mild and moderate renal insufficiency; eGFR<20ml/min is contraindicated.

3) Precautions:

2) Fenofibrate: When eGFR>60ml/min, there is no need to adjust the dose; when eGFR30-59ml/min, reduce the dose; when eGFR<30ml/min, use with caution.

3) SGLT-2 inhibitors: when eGFR>60ml/min, no dose adjustment is required; eGFR45-59ml/min is used in reduced doses; when eGFR<45ml/min, use with caution.