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Dr. Abdellatif:
This is CME on ReachMD. I’m Dr. Abdul Abdellatif. Here with me today, Dr. John Botson, a rheumatologist from Alaska.
John, how do you manage our patients with uncontrolled gout more effectively nowadays?
Dr. Botson:
The important thing to realize is that gout is not a joint problem in itself. It’s a systemic inflammatory process very similar to diabetes or high cholesterol and coronary artery disease. It’s something that we not only need to treat the acute episodes and pain, but also, we need to treat the patient so that we can prevent these other comorbidities and cardiovascular risks, especially, from happening.
The first is the patient hurts, so you’ve got to treat their acute illness. And this one I say with a little grain of salt talking to a nephrologist, but we use things like NSAIDs and colchicine and prednisone unless there’s a reason they can’t. But we’re using these intermittently, hopefully only in the beginning until you can get the gout more in control and prevent them from getting to that uncontrolled stage. Many patients still blame themselves for flares, many providers still blame patients for flares when, really, we need to recognize that this is also a genetic disease. It’s something that you’re born with. Your diet plays a small role in this.
We really have a couple sort of standard medications that we’ve used for decades: uric acid-lowering agents, or xanthine oxidase inhibitors, as we call them, allopurinol, febuxostat. And these are agents that block an enzyme that prevents the uric acid levels from going up. So they’re bocking the xanthine oxidase. They work well in most patients. The side effect profile is generally pretty minimal. We do watch for some allergic reactions with allopurinol, and there was a recent concern about cardiovascular disease with the febuxostat that’s still under debate.
Uricosurics we do use occasionally. They’re not as widely used. They’re definitely not used in your population as a nephrologist. They have some small uric acid-lowering benefits. The patients that are really suffering are in those difficult-to-treat cases of refractory gout, or what we call uncontrolled gout. By definition, they failed uric acid-lowering agents, those xanthine oxidase inhibitors; they’ve either not tolerated or failed uricosurics or you can’t use them. We’ve got 1 drug FDA-approved right now and that’s pegloticase. It will lower the uric acid to undetectable, and it’s safe in patients with all stages of kidney disease. It’s not a corticosteroid, so even diabetics can use it. This uricase breaks down the serum uric acid into something called allantoin, which is really water soluble and freely excreted.
There was a recent trial that actually improved upon pegloticase in using a combination with methotrexate that stopped the antidrug antibodies from being developed and essentially improved its efficacy and its safety. So in rough numbers, almost doubling the efficacy and about 8 times the improvement in safety for this medication in combination.
So that’s really kind of set the bar now of where our treatment is. And so essentially, our goal in all these patients, whether we’re using a xanthine oxidase inhibitor or a uricase, is to get the serum uric acid below that solubility level. We often shoot for a level of 6. In patients that have severe gout we’ll shoot or a level of 5.
But ultimately, when we’re initiating treatment, lower is better for these patients to get them under control. And then once we’re sufficiently under control, then we use some of these other agents to move forward and to keep the patients at that level.
Dr. Abdellatif:
We actually took 20 patients of our kidney transplant patients who had had their transplant for at least a year in a steady state of immunosuppressive therapy, and we just gave them pegloticase based on protocol. And we were able to actually get 89% of these patients to respond to the treatment, and we were able to get them basically gout symptom free within 6 months of therapy, and we did not have even a significant infusion reaction or any cardiovascular events out of the greater than 200 infusions that we gave to our patients. So the drug does help our patients at all stages of kidney disease, normal dialysis, peritoneal dialysis, hemodialysis, even our transplant patients.
Well, this has been a brief and a great discussion. Unfortunately, our time is up. Thank you all for listening.
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