Abstract
BackgroundIn gout, long-term urate-lowering therapy (ULT) promotes dissolution of tissue urate crystal deposits. However, no studies using combined xanthine oxidase inhibition and uricosuric ULT have focused on clinical outcomes or adverse events (AEs) beyond 12 months of therapy. Our objective in the present study was to examine efficacy and long-term safety in patients with tophaceous gout receiving febuxostat plus lesinurad as combination therapy.MethodsPatients receiving combined lesinurad and febuxostat in the 12-month core CRYSTAL study continued at the same doses in the extension study (“200CONT”, “400CONT”), whereas those receiving only febuxostat 80 mg were randomized to lesinurad 200 or 400 mg with febuxostat (“200CROSS”, “400CROSS”). The primary endpoint was the proportion of patients experiencing complete resolution (CR) of at least one target tophus by extension month (EM) 12. The key secondary endpoint was mean rate of gout flares requiring treatment from the end of EM 2 to the end of EM 12. Secondary endpoints included reduction in the sum of areas for all target tophi. Safety assessments included AEs and laboratory data for the entire extension study (median length of lesinurad exposure, 800 days).ResultsOf 235 patients completing the core study, 196 (83.4%) enrolled in the extension: 200CONT (n = 64), 200CROSS (n = 33), 400CONT (n = 65), and 400CROSS (n = 34). At EM 12, 59.6%, 43.5%, 66.7%, and 50.0% of patients, respectively, had CR of at least one target tophus. The sum of areas for all target tophi was reduced by 76.4%, 58.1%, 77.5%, and 62.8%, respectively. The adjusted mean (SE) rates of gout flares requiring treatment from the end of EM 2 to the end of EM 12 were 0.6 (0.19), 1.3 (0.48), 0.2 (0.08), and 1.9 (0.93), respectively. Target sUA < 5.0 mg/dl was achieved by 77.1%, 79.2%, 88.5%, and 71.4% of patients, respectively. Exposure-adjusted incidence rates of treatment-emergent adverse events (TEAEs) and renal-related TEAEs in the core study were not increased with prolonged lesinurad exposure in the extension study.ConclusionsPatients receiving lesinurad plus febuxostat therapy for 2 years continued to be at sUA target. Patients exhibited a progressive increase in CR of at least one target tophus, progressive reduction in tophus size, and reduction of gout flares requiring treatment over the second year, with AEs consistent with those observed in the core study.Trial registrationClinicalTrials.gov, NCT01510769. Registered on 13 January 2012.
Highlights
In gout, long-term urate-lowering therapy (ULT) promotes dissolution of tissue urate crystal deposits
Gout is characterized by increased body urate stores, reflected in elevated serum urate levels, and deposition of monosodium urate crystals in joints and other tissues
When hyperuricemia is inadequately treated in gout, the disease can progress over time to palpable tophus formation and chronic erosive arthritis [1]
Summary
Long-term urate-lowering therapy (ULT) promotes dissolution of tissue urate crystal deposits. Our objective in the present study was to examine efficacy and long-term safety in patients with tophaceous gout receiving febuxostat plus lesinurad as combination therapy. Gout is characterized by increased body urate stores, reflected in elevated serum urate (sUA) levels (hyperuricemia), and deposition of monosodium urate crystals in joints and other tissues. The goal of long-term management of gout is to reduce and maintain sUA below saturating levels (> 6.8 mg/dl), typically < 6.0 mg/dl, or < 5.0 mg/dl for patients with more severe gout, including palpable tophi [1, 2]. Sustained lowering of sUA reduces the volume of monosodium urate crystals, lowers the incidence of gout flares, and promotes tophus resolution [3,4,5]. Uricosuric therapies target renal underexcretion of uric acid, which contributes to hyperuricemia in most people with gout [7]
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