Taking the “Ouch” Out of Gout Attacks in Heart Failure

Volume 15, Issue 4

Gout and heart failure are common comorbidities, owing mostly to the use of loop diuretics, which raise serum uric acid levels. Indeed, as heart failure progresses and loop diuretic doses are escalated, many patients with heart failure develop recurrent gout flares which can be difficult to treat.

Certain heart failure medications, however, can help with uric acid homeostasis. Angiotensin receptor blockers, for example, have uricosuric properties and can stimulate secretion of uric acid. Now that sacubitril/valsartan is the preferred renin-angiotensin-aldosterone system blocker, hopefully most patients with heart failure are already taking an angiotensin receptor blocker.

Not much is known regarding the role of gout medications during an acute heart failure decompensation. This week, a group of authors published a single center, retrospective study of 1047 patients hospitalized with acute heart failure exacerbation “with and without acute gout flare between March 2011 and December 2020.” Authors compared outcomes for individuals treated with colchicine for a gout flare vs those who did not have a flare or were not treated with colchicine.

Compared to control, colchicine treatment was associated with a significant reduction in in-hospital all-cause mortality (2.1% vs. 6.5%, P=.009). After adjusting for age, authors found a link between inpatient colchicine use and improved survival to discharge (HR .163, 95% CI .051-.525, P=.002) as well as reduced in-hospital cardiovascular mortality (HR .184, 95% CI .044-.770, P=.021).

This study must be viewed in the context of a single-center retrospective report. But the findings have more credibility in light of several randomized controlled trials showing colchicine reduced the risk of cardiovascular mortality in patients with ischemic heart disease. The mechanisms explaining these cardiovascular benefits remain to be fully elucidated, but the drug’s anti-inflammatory and immunomodulatory properties likely contribute to its benefits.

As pharmacists, it’s important for us to ensure that colchicine is dosed appropriately for the patient’s renal function, and to scan for important drug-drug interactions. Overexposure to colchicine can cause benign side effects like diarrhea, but can also cause serious side effects like myopathy.