Conventional oral urate-lowering therapies frequently to fail to achieve target serum uric acid (sUA) levels in patients with chronic kidney disease and uncontrolled refractory gout. This can lead to increased urate burden and complications, including worsening kidney disease, cardiovascular events, and metabolic syndrome. Tune in to find out how to incorporate targeted therapies when managing uncontrolled refractory gout and improve your patients’ quality of life.
Center of the Target: Which Patients Are Most Likely to Develop Gout?
Center of the Target: Which Patients Are Most Likely to Develop Gout?
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This is CME on ReachMD. I’m Dr. Rick Johnson, and today we’re going to talk about the center of the target. Who are your most likely patients that need treatment for their gout?
Abdul, can you provide a case of a patient who could benefit from some of these newer uric acid-lowering therapies?
Thank you, Richard. Actually, I’m going to talk about my first patient that I treated with the new therapies available for treatment of uncontrolled gout. I had a patient of 82-year-old referred to me with chronic kidney disease stage 3, GFR in the mid-20s. And the reason the patient was referred to me was to manage his chronic kidney disease, kind of talk to them about the future of dialysis and what are the implications of progression of renal failure. However, when the patient actually presented to me, he was brought in the room by his son in a wheelchair, and when I tried to shake hands with the patient, actually he could not shake hands with me. I ask him, “Why?” He goes, “Because I am in pain.” And I ask him, “Why you are in pain?” He goes, “Because I have gout.” And I look at his hands and I see tophaceous gout everywhere on his hands. And he goes, oh, it’s also on my legs, on my feet. I look at his knees, his feet, it was just a striking picture for me to have a patient with that advanced disease that no one has offered him the most advanced therapy we have to treat uncontrolled gout. The patient told me he has been on allopurinol, he has been on febuxostat, he has been on colchicine, NSAIDS, steroids, anything that exists to treat gout, and he said, “Nothing works for me, so I just bear the pain. And whenever I have a bad flare, I go to the doctor to get some steroid shots.” Well, fortunately, now we do have an option for this patient. I treated that patient. Within 2 months of being on pegloticase therapy IV infusion, he was able to come back to see me, walking with a cane into the office, and that was, you know, an amazing feeling, that you had helped a patient who’s almost, you know, lost his functional capacity because of uncontrolled gout. So we do have therapies to treat these patients.
The guidelines tell us you have to target a uric acid of less than 6. And the reason for that is because anything above 6 precipitates in the body, forms crystals, eventually forms those tophi. However, when it’s below 6, the uric acid dissolves in the blood and it gets eliminated by the kidney.
In patients with chronic kidney disease, it’s very hard to control that because most of them do not get to target on oral urate therapies, and really, maybe 25% of those patients may get to target on urate-lowering therapy. Therefore, you know, pegloticase is an option for these patients. And the patient does not have to get to that complicated a state of health before they are offered this therapy. A patient who has one tophi on their joint and they are still having a flare and uric acid above 6, and these patients qualify for this therapy. We can help patients maintain quality of life by treating them earlier than waiting until they become disabled. The benefit of lowering uric acid [is] not only to control the pain and acute gout flares, but we want those patients to be able to function as they would like to.
So this poor guy who had been attempted to be managed with standard therapy, no one ever thought of giving him pegloticase until he walked in to see you, and then you give him this therapy. And the point is that when you lower the uric acid down to 2 or 3, or even 1, that that allows those crystals to dissolve so much faster, and suddenly he’s walking.
Abdul, do you want to say any final words?
I bet you a lot of that inflammation and these crystals building everywhere has been maybe a factor in his progression of his kidney disease, as well as his heart disease.
If you can target the uric acid levels less than 6, you’re not going to only benefit the reduction in arthritis and joint pains of acute gout, but you might actually improve the long-term survival of your patient.
It was a great little, quick talk, and thank you for listening.
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In accordance with the ACCME Standards for Integrity and Independence, Global Learning Collaborative (GLC) requires that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any ineligible company. GLC mitigates all conflicts of interest to ensure independence, objectivity, balance, and scientific rigor in all its educational programs.
Richard Johnson, MD
Professor of Medicine
University of Colorado
Anschutz Medical Campus
Research: National Institute of Health
Ownership Interest: Colorado Research Partners, XORTX Therapeutics
Receives Royalties: Elsevier, BenBella Books
Consulting Fees: Dinora, Horizon Pharma
Abdul A. Abdellatif, MD, FASN
Division of Nephrology
Baylor College of Medicine and CLS Health
No relevant relationships reported
John K. Botson, MD, RPh
Director of Rheumatology
Orthopedic Physicians Alaska
Research: Horizon Therapeutics
Patent Holder: Horizon Therapeutics
Consulting Fee: AbbVie, Amgen, Eli Lilly, Horizon Therapeutics, Novartis
Brittany Weber, MD, PhD
Director, Cardio-Rheumatology Clinic
Associate Physician, Prevention Cardiology & Cardiovascular Imaging
Brigham and Women’s Hospital
Research: AHA, NIH
Consulting Fees:, Agepha, Horizon Therapeutics, Kiniksa, Novo Nordisk
- Cindy Davidson has nothing to disclose.
- Hany Ibrahim, MD, has nothing to disclose.
- Samantha Keehn has nothing to disclose.
- John Maeglin has nothing to disclose.
- Brian McDonough has nothing to disclose.
- Tim Person has nothing to disclose.
After participating in this educational activity, participants should be better able to:
- Discuss the pathophysiology and prevalence of high uric acid levels and uncontrolled gout in patients with renal disease and the contribution of chronic gout to chronic kidney disease (CKD) progression, associated comorbidities, and increased mortality
- Apply knowledge of available diagnostic tools to identify patients with elevated serum uric acid (sUA) levels early in the progression of CKD to initiate proper urate-lowering therapy (ULT) and reduce urate burden
- Summarize the limitations of standard ULT options in patients with CKD
- Incorporate emerging urate-lowering therapies, including pegloticase-methotrexate combined therapy and clinical trial evidence, into clinical practice in the treatment of appropriate patients with uncontrolled gout
- Discuss gout as an independent risk factor for CVD and its association with CVD morbidity and mortality, necessitating early screening and treatment to attain target sUA levels
This activity is designed to meet the educational needs of nephrologists, rheumatologists, cardiologists, primary care physicians, and others who encounter, diagnose, and treat gout.
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Global Learning Collaborative (GLC) designates this enduring activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Global Learning Collaborative (GLC) designates this activity for 1.0 nursing contact hour. Nurses should claim only the credit commensurate with the extent of their participation in the activity.
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This activity is supported by an independent educational grant from Horizon Therapeutics, USA, Inc.
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