Gout Therapy Research Articles

Anti-hyperuricemic and Anti-inflammatory Effects of Marantodes pumilum as Potential Treatment for Gout.

Marantodes pumilum (Primulaceae) has been used in Malaysian folk medicine to help women regain strength after delivery and for “sickness in the bones.” It was previously revealed that its extracts inhibited xanthine oxidase (XO) activity in vitro. The leaves and roots of M. pumilum var. alata (MPA), var. pumila (MPP), and var. lanceolata (MPL) were individually extracted in ethanol (80%). The anti-hyperuricemic activity was initially assessed by XO inhibition with a spectrophotometric in vitro assay. The most active extract was further investigated on hyperuricemic rat model induced by potassium oxonate to determine serum uric acid levels and liver XO effect. The in vitro anti-inflammatory activity was carried out on monosodium urate (MSU) crystal-induced pro-inflammatory cytokines (i.e., interleukin (IL)1α, IL-1β, IL-6, IL-8, and tumor necrosis factor (TNF)-α) secretion using human peripheral blood mononuclear cells and ELISA technique, and prostaglandin E2 (PGE2)secretion using radioimmunoassay. The active extract was then investigated on gout-induced inflammation with MSU crystals to determine pro-inflammatory cytokines and PGE2 secretion levels in the synovial fluid of rat knee joint. Quantitative analysis using validated HPLC was performed on the extracts to determine presence of bioactive flavonoids. The findings revealed that extract of MPP leaves gave the highest inhibitory activity on XO (IC50 130.5 μg/mL) compared to other extracts tested. However, all extracts possessed significantly lower activity compared to allopurinol (IC50 0.13 μg/mL). Oral administration of MPP leaf extract (200 mg/kg) significantly reduced serum uric acid level in hyperuricemic rats in time-dependent manner to the baseline level and it was as effective as allopurinol (5 mg/kg). The extract also inhibited liver XO activity (25%) compared to allopurinol (45%). In vitro anti-inflammatory assay showed that extract of MPP roots inhibited MSU crystals-induced secretion of IL-1α, IL-1β, IL-8, TNF-α, and PGE2 with IC50 values of 36, 25, 38, 18, and 46 μg/mL, respectively. Oral administration of the MPP root extract (200 mg/kg) significantly decreased IL-1α, IL-1β, IL-6, TNF-α, and PGE2 levels in rat’s synovial fluid as effective as indomethacin. There were no significant body weight changes of all experimental animals. MPP extracts showed presence of myricetin, quercetin and kaempferol. Myricetin was detected with values of 0.2 and 0.6 mg/g for root and leaf extracts, respectively. The anti-hyperuricemic of MPP leaf and anti-inflammatory of MPP root indicated that MPP may be promising for complementary therapy of gout.

Enhanced Physical Stability and Synchronized Release of Febuxostat and Indomethacin in Coamorphous Solids.

Coamorphous formulation, a homogeneous monophasic amorphous system composed of multiple components, has been demonstrated as an effective approach for delivering drugs with poor aqueous solubility. In this study, we prepared the coamorphous system composed of two poorly soluble drugs febuxostat (FEB) and indomethacin (IMC) by using cryogenic milling. The combination of these two drugs in the coamorphous form can attain a synergistic effect, especially on gout therapy. Coamorphous solid of FEB and IMC in 1:1molarratio exhibited superior physical stability compared with the individual amorphous components, as evidenced by X-ray powder diffractions after 30days of storage at ambient and elevated temperature. In addition, the FEB-IMC coamorphous system has been demonstrated to show enhanced dissolution performance. The intrinsic dissolution rates of two components in the coamorphous system exhibited the synchronized drug release. Based on the FT-IR spectroscopy, the excellent physical stability and synchronized release of FEB-IMC coamorphous system could be attributed to the heterodimer structure formed by strong hydrogen bonding interactions between these drugs. Furthermore, the supersaturation potential of FEB-IMC coamorphous solids was also investigated through the cosolvent quenching method. The FEB-IMC coamorphous system can effectively inhibit the fast crystallization of FEB in the supersaturated solution. However, the maximum achievable supersaturation of IMC in the coamorphous system decreases to only one fifth of that achieved for the pure amorphous IMC. These results are relevant for understanding the physical stability and complex solution behaviors of the coamorphous formulation.

Hyperuricaemia and gout

Gout is a painful, inflammatory disease that affects more men than women. The incidence of gout has increased substantially over the past few decades, as evidenced by information from the Rochester project. Some of the risk factors for the development of gout include: increased ethanol intake, high dietary purine consumption, obesity and the use of certain drugs, such as diuretics. Another important risk factor for the development of gout is hyperuricaemia. Hyperuricaemia results from an imbalance between the rate of production and excretion of uric acid in the body. An excess of uric acid thus builds up in the body, supersaturating body fluids and leading to the formation of monosodium urate crystals. These crystals accumulate in tissue and around joints, leading to an acute gout attack. Gout can be divided into four phases, namely asymptomatic hyperuricaemia, acute gout attacks or recurrent gout, intercritical gout and chronic tophaceous gout. Various treatment options are available for gout, and the treatment for each gout patient is determined by the stage of the disease. Nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, corticotropin and colchicine are used for the treatment of acute gout attacks. Allopurinol and probenecid are used for long-term hypouricaemic therapy, while NSAIDs and colchicine are prescribed for the prophylaxis of future gout attacks. All of these treatments have side-effects, ranging from mild to life-threatening in nature. There is a need for novel gout therapies that have fewer side-effects but are still as effective.

Novel 3-[4-alkoxy-3-(1H-tetrazol-1-yl) phenyl]-1,2,4-oxadiazol-5(4H)-ones as promising xanthine oxidase inhibitors: Design, synthesis and biological evaluation.

Xanthine oxidase (XO) is a critical target for the therapy of hyperuricemia and gout. In this study, a number of 3-[4-alkoxy-3-(1H-tetrazol-1-yl) phenyl]-1,2,4-oxadiazol-5(4H)-ones (3a-3w) were newly designed by a bioisosteric replacement and hybrid strategy with the hope of obtaining novel and effective nonpurine XO inhibitors. Subsequently, these compounds were synthesized through a three-step procedure, with good yields. In addition, the in vitro bovine XO inhibitions were measured by spectrophotometric determination of uric acid formation at 295nm using allopurinol as a positive control. As a result, compound 3j was found to be the most potent XO inhibitor, with an IC50 value of 0.121µM, which was approximately 63-fold more potent than allopurinol, and the analysis of the structure-activity relationships indicated that the hydrophobic group at 4'-position was essential for inhibitory potency. Additionally, the molecular modeling results showed that the 1,2,4-oxadiazol-5(4H)-one moiety binds to XO active site via various hydrogen bonds with Arg880 and Thr1010. Moreover, the compound 3j was demonstrated to be a mixed-type nonpurine XO inhibitor. Furthermore, the hypouricemic studies on a rat model, induced by potassium oxonate, demonstrated that serum uric acid levels could be effectually reduced by compound 3j at an oral dose of 15mg/kg. Therefore, compound 3j could be a promising lead compound for the treatment of hyperuricemia and gout.

Effects of Conventional Uric Acid-Lowering Therapy on Monosodium Urate Crystal Deposits.

Few studies have systematically and quantitatively addressed the impact of urate-lowering therapy on monosodium urate (MSU) deposits. This study was undertaken to analyze the effect of lifestyle measures and conventional urate-lowering therapy on MSU deposits in patients with gout. In this prospective study, subjects with gout according to the American College of Rheumatology/European League Against Rheumatism classification criteria and presence of MSU deposits seen on dual-energy computed tomography (DECT) scans received either lifestyle intervention or conventional urate-lowering therapy for a mean period of 18 months before a follow-up DECT scan. Detected MSU deposits were quantified by volumetric measurement and validated by semiquantitative scoring, and baseline and follow-up measurements were compared. Baseline and follow-up DECT scans were available for all 83 subjects. Six subjects discontinued treatment, and 77 subjects underwent a lifestyle intervention (n = 24) or were treated with allopurinol (n = 29), febuxostat (n = 22), or benzbromarone (n = 2) over the entire observation period. The mean serum uric acid (UA) level decreased from 7.2 to 5.8 mg/dl in the overall population. In patients who discontinued treatment, no change in MSU deposits or serum UA levels was observed. The burden of MSU deposits significantly decreased in patients undergoing lifestyle intervention (MSU volume P = 0.007; MSU score P = 0.001), and in patients treated with allopurinol (MSU volume and score P < 0.001) or febuxostat (MSU volume P < 0.001; MSU score P = 0.001). No significant decline in MSU deposits was noted in patients who discontinued treatment. These data show that lifestyle intervention and xanthine oxidase inhibitors significantly decrease the MSU deposit burden. Hence, conventional gout therapy not only lowers serum UA levels, but also reduces pathologic MSU deposits.

Effects of Lifestyle Measures and Conventional Therapy in Gout

Ms. Hoffmeister is a freelance medical writer in Camp Hill, Pennsylvania. To earn CME credit, you must read the CME articles and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This continuing medical enduring material activity expires November 30, 2021.The author, faculty, and staff in a position to control the content of this CME activity have disclosed that they and their spouses/life partners (if any) have no financial relationships with, or financial interests in, any commercial companies relevant to this educational activity.Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.Lippincott's Bone and Joint Newsletter is an independent publication solely owned and published by Wolters Kluwer and has no affiliation with the Journal of Bone & Joint Surgery.

Pembudidayaan dan Pembuatan Teh Daun Binahong untuk Mengobati Penyakit Asam Urat

The community service program aims to introduce binahong plants, and its benefits to overcome gout and how to cultivate. The community will be given the skill of how to make binahong leaf tea so that utilization of binahong leaves to overcome gout become more practical, right doses so the goal of therapy for gout can be achieved. Gout is one form of arthritis that is often associated with reddish, swollen, hot and stiff joints. The prevalence of gout from the year is increasing. Men have a higher risk of gout than women. Community efforts in treating gout using chemical drugs have been shown to cause serious side effects. The use of herbal medicine can be used as an alternative therapy in dealing with this disease. The binahong plant is an empirically widely used plant to treat various illness. One of them is gout. The use of this plant in gout support therapy is essential because, from the research result, this plant has many properties with minimal toxicity. The method used in this service is by providing counselling and training. The results of evaluating the implementation of cultivation and making of binahong leaf tea for the treatment of gout, many as 29 residents of RT 02 Mendalo Indah Jambi, Luar Kota Village. The benefits of binahong as a treatment for gout as well as residents also know how to cultivate binahong for self-treatment and economic improvement container of the citizens.

Rising Incidence of Acute Hospital Admissions due to Gout.

To describe trends in acute hospital admissions due to gout in England, with rheumatoid arthritis (RA) as a comparator, alongside prescribing trends for common gout medications. An ecological study was performed using UK National Health Service (NHS) Digital Hospital Episode Statistics data to calculate the incidence of unplanned admissions with primary diagnoses of gout or RA in adults in England between April 2006 and March 2017. NHS Digital Community Prescription data for allopurinol, febuxostat, and colchicine were considered over a similar period. The incidence of unplanned gout admissions increased by 58.4% over the study period, from 7.9 admissions per 100,000 population in 2006/07 to 12.5 admissions per 100,000 population in 2016/17 (p < 0.0001). Gout admissions increased as a proportion of all hospital admissions, and accounted for 349,768 bed-days cumulatively. Unplanned RA admissions halved over the study period, from 8.6 admissions per 100,000 population in 2006/07 to 4.3 admissions per 100,000 population in 2016/17 (p < 0.0001). Community prescriptions dispensed for allopurinol and colchicine have increased by 71.4% and 165.6%, respectively, since 2006 (p < 0.0001). Febuxostat prescriptions have increased 20-fold since 2010 (p < 0.0001), when prescription data became available. Acute gout admissions in England increased between 2006 and 2017, accompanied by increasing prescription of gout therapies. Acute admissions due to RA halved over the same time period. These data call for aggressive target-driven therapy for this highly treatable disease.

Structure-based design of a hyperthermostable AgUricase for hyperuricemia and gout therapy.

Arthrobacter globiformis Uricase (AgUricase) is a homotetrameric uricase with the potential for therapeutic use in treating hyperuricemia-related diseases. To achieve sufficient therapeutic effects, it is essential for this enzyme to have high thermostability and long half-life in physiological condition. To improve the thermostability of this enzyme, we introduced a series of cysteine pair mutations into the AgUricase subunits based on its structural model and studied the thermostability of the mutant enzymes with introduced disulfide bridges. Two intersubunit cysteine pair mutations, K12C-E286C and S296C-S296C, were found to markedly increase the melting temperatures of the corresponding mutant enzymes compared with WT AgUricase. The crystal structure of the K12C-E286C mutant at 1.99 Å resolution confirmed the formation of a distinct disulfide bond between the two subunits in the dimer. Structural analysis and biochemical data revealed that the C-terminal loop of AgUricase was flexible, and its interaction with neighboring subunits was required for the stability of the enzyme. We introduced an additional intersubunit K244C-C302 disulfide bond based on the crystal structure of the K12C-E286C mutant and confirmed that this additional disulfide bond further stabilized the flexible C-terminal loop and improved the thermostability of the enzyme. Disulfide cross-linking also protected AgUricase from protease digestion. Our studies suggest that the introduction of disulfide bonds into proteins is a potential strategy for enhancing the thermostability of multimeric proteins for medical applications.

UPAYA PENINGKATAN PENGETAHUAN TENTANG ASAM URAT PADA LANSIA DI POSYANDU LANSIA RT 12 KELURAHAN RAWASARI

Lack of knowledge of the elderly about gout and various things related to gout will have a negative impact on the health of the elderly, family and society. One effort that can be done by nurses is to provide health education to the elderly. Elderly Posyandu in the Rawasari Community Health Center work area is one of the partners who have carried out the elderly posyandu activities according to the program, but in practice most of the elderly do not know about gout. The target and outcome of community service activities is to increase the knowledge of elderly gout, understanding, causes, signs and symptoms of gout, gout treatment, selection of foods that are allowed and which are not recommended for gout and complementary therapies for gout. The method of implementation used is survey, observation, interview, discussion, question and answer, demonstration through health education and examination of gout. This community service activity was attended by 25 elderly people. The results of this activity were 35% of elderly people suffering from gout, most of the elderly knew about gout and things related to gout, all the elderly attended health education from the beginning to the end and most actively participated during the activity. It is recommended to increase diposyandu activities for the elderly by providing health education with various material and regular health checks.

Crystal-Induced Joint Disease

The destructive potential of intracellular crystals has been recognized for over a century. The mechanisms by which crystals induce inflammation and bone and cartilage destruction have been elucidated over the past decade. The three most common crystal-induced arthropathies are caused by precipitation of monosodium urate monohydrate, calcium pyrophosphate dihydrate (CPP) and basic calcium phosphate. The definition, epidemiology, pathogenesis and etiology, diagnosis, and treatment of gout and CPP crystal deposition are reviewed, as well as the clinical stages of gout (i.e., acute gouty arthritis, intercritical gout, advanced gout, nonclassic presentations of gout, and other conditions associated with gout). Also reviewed are the clinical manifestations of calcium pyrophosphate dihydrate deposition disease (CPPD), such as asymptomatic CPPD, osteoarthritis with CPPD, acute CPP crystal arthritis, and chronic CPP crystal inflammatory arthritis. Figures illustrate renal transport of urate, monosodium urate crystals, acute gouty flare, advanced gouty arthritis, gouty synovial fluid, radiographic changes of advanced gout, ultrasound appearance of the femoral intercondylar cartilage, pharmacologic management of gout, the effect of gender and age on knee chondrocalcinosis, radiographs of chondrocalcinosis, and compensated polarized microscopy of CPPD. Tables present the major factors responsible for hyperuricemia, characteristics of classic gouty flares, antiinflammatory therapy for gout, and urate-lowering therapy. This chapter contains 90 references. This review contains 11 figures, 12 tables, and 88 references. Keywords: acute gouty arthritis, intercritical gout, advanced gout, asymptomatic CPPD, osteoarthritis with CPPD, acute CPP crystal arthritis, chronic CPP crystal inflammatory arthritis

Crystal-Induced Joint Disease

The destructive potential of intracellular crystals has been recognized for over a century. The mechanisms by which crystals induce inflammation and bone and cartilage destruction have been elucidated over the past decade. The three most common crystal-induced arthropathies are caused by precipitation of monosodium urate monohydrate, calcium pyrophosphate dihydrate (CPP) and basic calcium phosphate. The definition, epidemiology, pathogenesis and etiology, diagnosis, and treatment of gout and CPP crystal deposition are reviewed, as well as the clinical stages of gout (i.e., acute gouty arthritis, intercritical gout, advanced gout, nonclassic presentations of gout, and other conditions associated with gout). Also reviewed are the clinical manifestations of calcium pyrophosphate dihydrate deposition disease (CPPD), such as asymptomatic CPPD, osteoarthritis with CPPD, acute CPP crystal arthritis, and chronic CPP crystal inflammatory arthritis. Figures illustrate renal transport of urate, monosodium urate crystals, acute gouty flare, advanced gouty arthritis, gouty synovial fluid, radiographic changes of advanced gout, ultrasound appearance of the femoral intercondylar cartilage, pharmacologic management of gout, the effect of gender and age on knee chondrocalcinosis, radiographs of chondrocalcinosis, and compensated polarized microscopy of CPPD. Tables present the major factors responsible for hyperuricemia, characteristics of classic gouty flares, antiinflammatory therapy for gout, and urate-lowering therapy. This chapter contains 90 references. This review contains 11 figures, 12 tables, and 88 references. Keywords: acute gouty arthritis, intercritical gout, advanced gout, asymptomatic CPPD, osteoarthritis with CPPD, acute CPP crystal arthritis, chronic CPP crystal inflammatory arthritis

E045 A nurse-led telemedicine intervention for dose escalation of urate lowering therapy in gout

E045 A nurse-led telemedicine intervention for dose escalation of urate lowering therapy in gout

Flavonoids and Anthranquinones as Xanthine Oxidase and Monoamine Oxidase Inhibitors: A New Approach Towards Inflammation and Oxidative Stress.

The development of xanthine oxidase and monoamine oxidase inhibitors led to important breakthroughs in the therapy of oxidative damage, hyperuricemia, gout, neurological, neuropsychiatric disorders and management of reperfusion injury. Drugs obtained from natural sources play an important role in the treatment of various pathological disorders and act as a lead compound for the discovery of new synthetic drug substances. In this review, various pharmacological effects produced by the inhibition of xanthine oxidase and monoamine oxidase through natural and synthetic flavonoids as well as anthraquinones are discussed in detail. Several methods have been designed for monitoring enzymatic activity and its inhibitor screening of bioactive natural and synthetic flavonoids and anthraquinones. In this review, all the in-vitro and other computational approaches are critically discussed which provided the clue about structure activity requirements for further precise modifications on the basic scaffold.

Discovery of 2-phenylthiazole-4-carboxylic acid, a novel and potent scaffold as xanthine oxidase inhibitors

The xanthine oxidase (XO) plays an important role in producing uric acid, and therefore XO inhibitors are considered as one of the promising therapies for hyperuricemia and gout. We have previously reported a series of XO inhibitors with pyrazole scaffold to extend the chemical space of current XO inhibitors. Herein, we describe further structural optimization to explore the optimal heterocycle by replacing the thiazole ring of Febuxostat with 5 heterocycle scaffolds unexplored in this field. All of these efforts resulted in the identification of compound 8, a potent XO inhibitor (IC50 = 48.6 nM) with novel 2-phenylthiazole-4-carboxylic acid scaffold. Moreover, lead compound 8 exhibited hypouricemic effect in potassium oxonate-hypoxanthine-induced hyperuricemic mice. These results promote the understanding of ligand-receptor interaction and might help to design more promising XO inhibitors.

Effectiveness of betel leaves (piper betle l.) and breadfruit leaves (Artocarpus atilis) in reducing uric acid levels in hyperuricemic male white rats (Rattus norvegicus)

Hyperuricemia is a condition where plasma uric acid is elevated. Prolonged elevated uric acid levels increase the risk of gout. Herbal medication is an alternative therapy for gout with minimum side effects. Betel (Piper betle) leaves and breadfruit (Artocarpus atilis) leaves contain natural substances that may reduce uric acid levels. The study aims to compare the effectiveness of betel leaves and breadfruit leaves extract in reducing plasma uric acid levels in hyperuricemic male white rats using a pre-and-post control group experimental research with 24 hyperuricemic male white rats divided into 4 groups. Negative control group were given normal feed and aquadest. Positive control group were given high-purine feed and aquadest. Group 1 and 2 were given high-purine feed and betel leaf extract of 332mg/200gBW and breadfruit leaf extract of 500mg/200gBW respectively. Data were analyzed using paired t-test. Postive control group showed uric acid level of 8.01mg/dl and 8.25mg/dl (pre and post-test respectively). Betel leaf extract group showed with post-test uric acid level of 2.02mg/dl from 8.09mg/dl, while breadfruit leaf extract group from 8.12mg/dl to 2.28mg/dl. Betel leaf and breadfruit leaf extract were effective in reducing uric acid levels in hyperuricemic male white rats.

Gout - asymptomatic hyperuricemia with/without asymptomatic monosodium urate crystal deposition: To be treated or not?

Elevation of serum uric acid level without clinically visible arthritis (known as asymptomatic hyperuricemia) is not traditionally considered to be gout disease, but only a possible cause of it, even though it may be accompanied by tissue uric acid crystal deposition. On the other hand, gout is traditionally recognized as recurrent, overt arthritis, visible only after a long period of time due to uric acid accumulation in joints. Advanced imaging techniques have substantially changed the perception of this problem, identifying gout as a low-grade chronic inflammatory disease from the very beginning, visible only by phases of acute arthritis attacks. According to ultrasonography, uric acid crystal hyperechoic aggregates (tophi) are seen not only in the symptomatic gout disease phase, but also in the preceding ? asymptomatic (latent) ? gout phase. New perception of the problem was approved by the recently described NETs (neutrophil extracellular traps) phenomenon. Also, hyperuricemia has recently been identified as a systemic disorder, responsible not only for the apparent gout arthritis, but also for the renal and cardiovascular disease occurrence and progression. Positive effect of urate-lowering therapy (xanthine oxidase inhibitors and uricosurics) on hypertension and chronic kidney disease indicates a possibility of its utility in asymptomatic hyperuricemia and asymptomatic gout therapy, apart from the use in clinically manifested gout treatment and for certain conditions, such as tumor lysis syndrome.

CARDIOVASCULAR DISEASES AT GOUT

The article covers data on the study of the main risk factors and the search for prognostic indicators of cardiovascular risk in gout, a modern understanding of the main mechanisms of influencing the risk of cardiovascular diseases. Data on the efficacy and safety of anti-rheumatic therapy in gout from the point of view of cardiovascular risk are presented.

Cardiovascular safety of febuxostat. Analysis of the CARES study

Gout is associated with the high frequency of comorbidities, among which there are cardiovascular disease and kidney diseases. In this case, cardiovascular mortality rates are in the first place among the causes of death in patients with gout and exceed the death rates in the population. This may be associated with the main signs of gout, such as a high serum uric acid (UA) level and its related chronic inflammation. Drug correction of hyperuricemia is the mainstay of gout therapy and it is supposed to be able to neutralize the negative effect of UA on the risk of its associated adverse events. Xanthine oxidase inhibitors (allopurinol and febuxostat) are first-line urate-lowering agents. Their effect on UA levels, comorbidities, long-term outcomes (including overall and cardiovascular mortality, development and progression of chronic kidney disease), and occurrence of adverse reactions is studied in large-scale studies, the results of which may affect the strategy of such therapy.The paper discusses the advantages and disadvantages of the CARES (Gout and Cardiovascular Morbidities) study that has compared the cardiovascular safety of allopurinol and febuxostat. The findings suggest that there is no substantial difference in the frequency of cardiovascular events with febuxostat and allopurinol, but at the same time these demonstrate a high risk for cardiovascular and overall mortality in the febuxostat group. Analysis of this paper cannot conclude that there is a greater cardiovascular risk with therapy with febuxostat; however, it shows that when compared with allopurinol, this risk may be higher. A more detailed study of this issue is required after obtaining the results of already started and planned investigations comparing the effects of allopurinol and febuxostat on the risk of adverse cardiovascular events in patients with asymptomatic hyperuricemia.

Recapture and improved outcome of pegloticase response with methotrexate–A report of two cases and review of the literature

IntroductionPegloticase is a PEGylated uric acid specific enzyme indicated for the treatment of refractory gout. Anti-pegloticase antibodies contribute to high discontinuation rates, increased risk of infusion reactions, and early loss of drug efficacy. ObjectiveTo describe the use of methotrexate to recapture function of pegloticase after development of anti-drug antibodies while treating gout. MethodsWe report two cases of using methotrexate as an adjunct to treatment with pegloticase for refractory tophaceous gout. We also present the results of a literature review on the use of concomitant immunosuppressive therapy with pegloticase to prevent anti-pegloticase antibody development. ResultsPatient A, a 55-year-old man with a history of tophaceous gout, was treated with pegloticase but developed high serum urate(sUA) levels prior to his third infusion. Adjunctive treatment with methotrexate restored pegloticase response and the patient's sUA levels decreased, and remained low for the remainder of his treatment.Patient B, a 36-year-old man with a history of tophaceous gout, was treated with pegloticase. Oral methotrexate was initiated at the first infusion. Low sUA levels were achieved but increased after a lapse in methotrexate compliance. Re-initiation of methotrexate restored pegloticase response and the patient tolerated subsequent infusions.Literature review identified three reports of successful use of concomitant pegloticase and immunosuppressive therapy for refractory tophaceous gout, including an open label trial with a subset of 7 transplant recipients, an additional case study of pegloticase treatment with one transplant recipient, and a case study of pegloticase administered with low-dose azathioprine. ConclusionProphylactic use of immunosuppressive therapy with pegloticase may enable sustained treatment and improve outcomes. Additionally, immunosuppressive therapy seems to show the ability to recapture pegloticase response after development of anti-drug antibodies. The use of immunosuppressants to prevent anti-drug antibody formation, recapture pegloticase efficacy, and reduce discontinuation rates warrants further study.