2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis

Measuring physician adherence with gout quality indicators: a role for natural language processing

OBJECTIVE

To evaluate physician adherence with gout quality indicators (QIs) for medication use and monitoring, and behavioral modification (BM).

METHODS

Gout patients were assessed for the QIs as follows: QI 1: initial allopurinol dosage <300 mg/day for patients with chronic kidney disease (CKD); QI 2: uric acid within 6 months of allopurinol start; and QI 3: complete blood count and creatinine phosphokinase within 6 months of colchicine initiation. Natural language processing (NLP) was used to analyze clinical narrative data from electronic medical records (EMRs) of overweight (body mass index ≥28 kg/m(2) ) gout patients for BM counseling on gout-specific dietary restrictions, weight loss, and alcohol consumption (QI 4). Additional data included sociodemographics, comorbidities, and number of rheumatology and primary care visits. QI compliance versus noncompliance was compared using chi-square analyses and independent-groups t-test.

RESULTS

In 2,280 gout patients, compliance with QI was as follows: QI 1: 92.1%, QI 2: 44.8%, and QI 3: 7.7%. Patients compliant with QI 2 had more rheumatology visits at 3.5 versus 2.6 visits (P < 0.001), while those compliant with QI 3 had more CKD (P < 0.01). Of 1,576 eligible patients, BM counseling for weight loss occurred in 1,008 patients (64.0%), low purine diet in 390 (24.8%), alcohol abstention in 137 (8.7%), and all 3 elements in 51 patients (3.2%). Regular rheumatology clinic visits correlated with frequent advice on weight loss and gout-specific diet (P < 0.0001).

CONCLUSION

Rheumatology clinic attendance was associated with greater QI compliance. NLP proved a valuable tool for measuring BM as documented in the clinical narrative of EMRs.

Rilonacept for Gout Flare Prevention in Patients Receiving Uric Acid-lowering Therapy: Results of RESURGE, a Phase III, International Safety Study

Objective.

To evaluate the safety and efficacy of once-weekly subcutaneous rilonacept 160 mg for prevention of gout flares in patients initiating or continuing urate-lowering therapy (ULT).

Methods.

This phase III study was conducted in the United States, South Africa, Europe, and Asia. Adults (n = 1315, 18–80 yrs) with gout, who were initiating or continuing ULT, were randomized to treatment with weekly subcutaneous injections of rilonacept 160 mg or placebo for 16 weeks followed by a 4-week safety followup. The primary endpoint was safety, assessed by adverse events (AE) and laboratory values. Efficacy was a secondary endpoint.

Results.

Demographic and clinical characteristics were similar between treatments; predominantly male (87.8%), mean age 52.7 ± 11.3 years. Patients with ≥ 1 AE were 66.6% with rilonacept versus 59.1% placebo, with slightly more AE-related withdrawals with rilonacept (4.7% vs 3.0%) because of the greater incidence of injection site reactions (15.2% rilonacept, 3.3% placebo). Serious AE were similar in both groups, as were serious infections (0.9% placebo, 0.5% rilonacept); no tuberculosis or opportunistic infections occurred. Most common AE were headache, arthralgia, injection site erythema, accidental overdose, and pain in extremity. Of the 6 deaths, only 1 in the placebo group was considered treatment-related. At Week 16, rilonacept resulted in 70.3% fewer gout flares per patient (p < 0.0001), fewer patients with ≥ 1 and ≥ 2 gout flares (p < 0.0001), and 64.9% fewer gout flare days (p < 0.0001) relative to placebo.

Conclusion.

Weekly subcutaneous administration of rilonacept 160 mg showed no new safety signals. The safety profile was consistent with previous studies. Rilonacept also significantly reduced the risk of gout flares. Clinicaltrials.gov identifier NCT00856206; EudraCT No. 2008-007784-16.

Protocol of the Febuxostat versus Allopurinol Streamlined Trial (FAST): a large prospective, randomised, open, blinded endpoint study comparing the cardiovascular safety of allopurinol and febuxostat in the management of symptomatic hyperuricaemia

INTRODUCTION

Gout affects 2.5% of the UK's adult population and is now the most common type of inflammatory arthritis. The long-term management of gout requires reduction of serum urate levels and this is most often achieved with use of xanthine oxidase inhibitors, such as allopurinol. Febuxostat is the first new xanthine oxidase inhibitor since allopurinol and was licensed for use in 2008. The European Medicines Agency requested a postlicensing cardiovascular safety study of febuxostat versus allopurinol, which has been named the Febuxostat versus Allopurinol Streamlined trial (FAST).

METHODS AND ANALYSIS

FAST is a cardiovascular safety study using the prospective, randomised, open, blinded endpoint design. FAST is recruiting in the UK and Denmark. Recruited patients are aged over 60 years, prescribed allopurinol for symptomatic hyperuricaemia and have at least one additional cardiovascular risk factor. After an allopurinol lead-in phase where the dose of allopurinol is optimised to achieve European League against Rheumatism (EULAR) urate targets (serum urate <357 µmol/L), patients are randomised to either continue optimal dose allopurinol or to use febuxostat. Patients are followed-up for an average of 3 years. The primary endpoint is first occurrence of the Anti-Platelet Trialists' Collaboration (APTC) cardiovascular endpoint of non-fatal myocardial infarction, non-fatal stroke or cardiovascular death. Secondary endpoints are all cause mortality and hospitalisations for heart failure, unstable, new or worsening angina, coronary or cerebral revascularisation, transient ischaemic attack, non-fatal cardiac arrest, venous and peripheral arterial vascular thrombotic event and arrhythmia with no evidence of ischaemia. The primary analysis is a non-inferiority analysis with a non-inferiority upper limit for the HR for the primary outcome of 1.3.

ETHICS AND DISSEMINATION

FAST (ISRCTN72443728) has ethical approval in the UK and Denmark, and results will be published in a peer reviewed journal.

TRIAL REGISTRATION NUMBER

FAST is registered in the EU Clinical Trials Register (EUDRACT No: 2011-001883-23) and International Standard Randomised Controlled Trial Number Register (ISRCTN No: ISRCTN72443728).

Association between periodontal disease and inflammatory arthritis reveals modulatory functions by melanocortin receptor type 3

Because there is clinical evidence for an association between periodontal disease and rheumatoid arthritis, it is important to develop suitable experimental models to explore pathogenic mechanisms and therapeutic opportunities. The K/BxN serum model of inflammatory arthritis was applied using distinct protocols, and modulation of joint disruption afforded by dexamethasone and calcitonin was established in comparison to the melanocortin (MC) receptor agonist DTrp(8)-γ-melanocyte stimulating hormone (MSH; DTrp). Wild-type and MC receptor type 3 (MC3)-null mice of different ages were also used. There was significant association between severity of joint disease, induced with distinct protocols and volumes of the arthritogenic K/BxN serum, and periodontal bone damage. Therapeutic treatment with 10 μg dexamethasone, 30 ng elcatonin, and 20 μg DTrp per mouse revealed unique and distinctive pharmacological properties, with only DTrp protecting both joint and periodontal tissue. Further analyses in nonarthritic animals revealed higher susceptibility to periodontal bone loss in Mc3r(-/-) compared with wild-type mice, with significant exacerbation at 14 weeks of age. These data reveal novel protective properties of endogenous MC3 on periodontal status in health and disease and indicate that MC3 activation could lead to the development of a new genus of anti-arthritic bone-sparing therapeutics.

Gout: joints and beyond, epidemiology, clinical features, treatment and co-morbidities

Gout is a common inflammatory arthritis precipitated by an inflammatory reaction to urate crystals in the joint. Gout is increasingly being recognised as a disease primarily of urate overload with arthritis being a consequence of this pathological accumulation. It is associated with a number of important co-morbidities including chronic kidney disease, obesity, diabetes and cardiovascular disease. The prevalence of gout is increasing around the world. Significant progress has been made in determining the genetic basis for both gout and hyperuricaemia. Environmental risk factors for gout have been identified as certain foods, alcohol and several medications. There is, however, little evidence that changing these environmental risks improves gout on an individual level. Treatment of gout encompasses two strategies: firstly treatment of inflammatory arthritis with non-steroidal anti-inflammatories, corticosteroids, colchicine or interleukin-1 inhibitors. The second and most important strategy is urate lowering, to a target of 0.36 mmol/L (6 mg/dL) or potentially lower in those with tophi (collections of crystalline urate subcutaneously). Along with urate lowering, adequate and prolonged gout flare prophylaxis is required to prevent the precipitation of acute attacks. Newer urate lowering agents are in development and have the potential to significantly expand the potential treatment options. Education of patients regarding the importance of life long urate lowering therapy and prophylaxis of acute attacks is critical to treatment success as adherence with medication is low in chronic diseases in general but especially in gout.

Treatment of nongout joint deposition diseases: an update

This update develops the actual therapeutic options in the management of the joint involvement of calcium pyrophosphate deposition disease (CPPD), basic calcium phosphate (BCP) deposition disease, hemochromatosis (HH), ochronosis, oxalosis, and Wilson's disease. Conventional pharmaceutical treatment provides benefits for most diseases. Anti-interleukine-1 (IL-1) treatment could provide similar results in CPPD than in gout flares. There is only limited evidence about the efficacy of preventive long-term colchicine intake, methotrexate, and hydroxychloroquine in chronic CPPD. Needle aspiration and lavage have satisfactory short and midterm results in BCP. Extracorporeal shockwave therapy has also proved its efficacy for high-doses regimes. Phlebotomy does not seem to have shown real efficacy on joint involvement in HH so far. Iron chelators' effects have not been assessed on joint involvement either, while IL-1 blockade may prove useful. NSAIDs have limited efficacy on joint involvement of oxalosis, while colchicine and steroids have not been assessed either. The use of nitisinone for ochronotic arthropathy is still much debated, but it could provide beneficial effects on joint involvement. The effects of copper chelators have not been assessed either in the joint involvement of Wilson's disease. NSAIDs should be avoided because of the liver affection they may worsen.

Pharmacokinetics considerations for gout treatments

INTRODUCTION

Patients with gout often have comorbid conditions such as renal failure, cardiovascular disease and metabolic syndrome. The presence and required treatment of these conditions can make the treatment of gout challenging. Knowledge of the pharmacokinetics of the available drugs for the management of gout is mandatory.

AREAS COVERED

A MEDLINE PubMed search for articles published in English from January 1990 to January 2014 was completed using the terms: pharmacokinetics, colchicine, canakinumab, allopurinol, febuxostat, pegloticase, gout, toxicity, drug interaction.

EXPERT OPINION

Colchicine is a drug with a narrow therapeutic-toxicity window. Co-prescription with strong CYP3A4 or P-glycoprotein inhibitors can greatly modify its pharmacokinetics and is to be avoided. Elimination of canakinumab mainly occurs via intracellular catabolism, following receptor mediator endocytosis. Canakinumab appears to be a good alternative for patients with contraindications to colchicine, NSAIDs and corticosteroids. For patients with renal impairment, some authors recommend that the allopurinol maximum dosage should be adjusted to creatinine clearance. If the urate target cannot be achieved, the therapy should be switched to febuxostat, which is appropriate with mild-to-moderate renal failure. Anti-pegloticase antibodies affect the pharmacokinetics of the drug because they increase its clearance, with loss of pegloticase activity.

Comparison of intramuscular compound betamethasone and oral diclofenac sodium in the treatment of acute attacks of gout

INTRODUCTION

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for the treatment of acute gouty arthritis but have the risk of gastrointestinal bleeding and cardiovascular toxicity. Glucocorticoid was as effective as oral NSAIDs in the initial treatment of gout arthritis of patients intolerant of NSAIDs. However, whether glucocorticoid has the same or preferable effect as oral NSAIDs on patients with acute gouty arthritis irrespective of gastrointestinal and cardiovascular risks factor remains unknown. This study was to compare the efficacy, safety and tolerance of compound betamethasone (diprospan) 7 mg intramuscular injection (i.m.) once for all during the study with diclofenac sodium 75 mg twice a day in the treatment of acute gouty arthritis.

METHODS

Sixty patients with acute gouty arthritis were randomised (1 : 1) to receive compound betamethasone 7 mg i.m. once for all during the study or diclofenac sodium 75 mg twice a day for 7 days in this open-label study. Pain intensity, tenderness, swelling and global assessment of response to therapy were collected as end-points for the treatment.

RESULTS

The mean change in pain intensity from baseline to Day 3 and Day 7 in both treatment groups demonstrated that compound betamethasone had preferable efficacy over diclofenac sodium on Day 3 and comparable efficacy on Day 7. The compound betamethasone group had fewer adverse effects (AEs) than diclofenac sodium group. No statistically significant differences were observed about serum uric acid levels at different pain intensity at baseline.

CONCLUSIONS

A single dose of compound betamethasone may be better than diclofenac sodium for the treatment of acute gouty arthritis.

[Diagnosis and management of gout in Austria. Survey of current practice considering the EULAR recommendations]

BACKGROUND AND OBJECTIVES

Gout shows an increasing incidence and has become a major health problem in the Western world. Despite effective treatment options, neither diagnosis nor therapeutic efforts can be regarded sufficient to date. It was of interest to investigate current handling of gout among Austrian rheumatologists.

MATERIAL AND METHODS

In 2012, a survey of Austrian rheumatologists concerning diagnosis and management of hyperuricemia and gout was performed. With the consent of the Austrian Society of Rheumatology, 574 society members (343 via electronic mail, 23 via mail) were sent a questionnaire consisting of 17 questions. This is the first survey assessing the management of gout among Austrian rheumatologists.

RESULTS

The overall response rate was 22.1 %. Of all the contacted members (email and mail), 19.9 % answered the questionnaire electronically and only 5.6 % by mail. The adherence to the EULAR recommendations for gout ranged between 69 and 95 % (median 84 %).

CONCLUSION

Among Austrian rheumatologists, the knowledge about gout, its diagnostic and imaging procedures, management and therapeutic goals is good and mainly in line with current international recommendations. To improve the management of patients with gout and hyperuricemia, a more frequent referral to rheumatologists could be beneficial.

The emerging role of biotechnological drugs in the treatment of gout

One of the most important therapeutic advances obtained in the field of rheumatology is the availability of the so-called bio(techno)logical drugs, which have deeply changed treatment perspectives in diseases such as rheumatoid arthritis and ankylosing spondylitis. According to the steadily increasing attention on gout, due to well-established prognostic and epidemiology implications, in the last 5 years, the same change of perspective has been observed also for this disease. In fact, several bio(techno)logical agents have been investigated both for the management of the articular gout symptoms, targeting mainly interleukin-1β, as well as urate-lowering therapies such as recombinant uricases. Among the IL-1β inhibitors, the majority of studies involve drugs such as anakinra, canakinumab, and rilonacept, but other compounds are under development. Moreover, other potential targets have been suggested, as, for example, the TNF alpha and IL-6, even if data obtained are less robust than those of IL-1β inhibitors. Regarding urate-lowering therapies, the recombinant uricases pegloticase and rasburicase clearly showed their effectiveness in gout patients. Also in this case, new compounds are under development. The aim of this review is to focus on the various aspects of different bio(techno)logical drugs in gouty patients.

Optimizing current treatment of gout

Gout is the most common inflammatory arthritis worldwide. Although effective treatments exist to eliminate sodium urate crystals and to 'cure' the disease, the management of gout is often suboptimal. This article reviews available treatments, recommended best practice and barriers to effective care, and how these barriers might be overcome. To optimize the management of gout, health professionals need to know not only how to treat acute attacks but also how to up-titrate urate-lowering therapy against a specific target level of serum uric acid that is below the saturation point for crystal formation. Current perspectives are changing towards much earlier use of urate-lowering therapy, even at the time of first diagnosis of gout. Holistic assessment and patient education are essential to address patient-specific risk factors and ensuring adherence to individualized therapy. Shared decision-making between a fully informed patient and practitioner greatly increases the likelihood of curing gout.

Rhabdomyolysis associated with initiation of febuxostat therapy for hyperuricaemia in a patient with chronic kidney disease

WHAT IS KNOWN AND OBJECTIVE

Febuxostat is now recommended as the first-line pharmacological urate-lowering therapy for gout in the American College of Rheumatology guidelines. There is no case of rhabdomyolysis associated with febuxostat among reported side effects of the drug. Our objective is to report on a case of rhabdomyolysis associated with initiation of febuxostat in a patient with chronic kidney disease (CKD).

CASE SUMMARY

A 73-year-old male patient visited our emergency room due to progressive weakness in both lower extremities starting 3 days earlier. Ten days before presentation, his primary physician had changed his prescription from allopurinol to febuxostat (80 mg) because of poor control of uric acid levels. There was tenderness in both thighs. Initial creatinine kinase (CK) was 7652 U/L (0-170 U/L), and a bone scan using (99m) Tc-HDP revealed strong uptake in soft tissues in both thighs and buttocks. Electromyography (EMG) and nerve conduction velocity (NCV) showed abnormal spontaneous activities (ASA), suggesting myopathy, not nerve damage. On day 7 of admission, after conservative management and febuxostat withdrawal, he could walk on the ward. He is being followed in our clinic as an outpatient with no sequelae.

WHAT IS NEW AND CONCLUSION

This report is first case of rhabdomyolysis associated with initiation of febuxostat. Febuxostat should be withdrawn when rhabdomyolysis is confirmed.

Canakinumab: a guide to its use in acute gouty arthritis flares

Canakinumab (Ilaris®), an anti-interleukin-1β monoclonal antibody, is a novel approach to treat acute gouty arthritis flares in a targeted population of patients in whom treatment options are limited. Relative to on-demand treatment with intramuscular triamcinolone acetonide 40 mg, on-demand treatment with subcutaneous canakinumab 150 mg significantly relieved the pain and inflammation of a new gout flare, and reduced the risk of new flares in patients with acute gouty arthritis flares in whom standard treatment with non-steroidal anti-inflammatories and/or colchicine was inappropriate. Canakinumab has an acceptable tolerability profile in this difficult-to-treat population. The increased risk of infections and neutropenia associated with canakinumab treatment can be minimized by following the recommended precautions.

The degree of asymptomatic hyperuricemia and the risk of gout. A retrospective analysis of a large cohort

This study was conducted to examine the relationship between the degree of asymptomatic hyperuricemia and the development of gout, in men and women. The database of a screening center was searched for all subjects with asymptomatic hyperuricemia (>7.0 mg/dl men, >5.6 mg/dl women) during 2000-2012. We included men and women without previous diagnosis of gout, and a follow-up of at least 5 years. The risk of gout was analyzed in relation to the degree of hyperuricemia at the first visit. Of the 5,234 subjects who matched the inclusion criteria, 4,241 were normouricemic at their first visit and 993 were hyperuricemic. The mean follow up period was 7.5 years. Gout was diagnosed at the last visit in 34 subjects; four in the normouricemia group and 30 in the hyperuricemia group (0.1 % vs. 3.0 %, p < 0.001). Only one woman developed gout. The odds ratio (OR) for developing gout was 32 times higher in the hyperuricemic group than in the normouricemic group. The OR to develop gout was 11.2 (confidence interval [CI] 3.6-35.2) in men with mild hyperuricemia compared to 107.1 (CI 34.2-334.9) in men with moderate hyperuricemia, and 624.8 (CI 134.0-2,913.1) in men with severe hyperuricemia. Multivariate analysis of uric acid levels, thiazide use, regular alcohol consumption and estimated glomerular filtration rate (eGFR) showed that only the level of uric acid retained statistically significant for increasing the risk of gout. There is a strong association between the absolute level of uric acid and the risk to develop gout, strikingly so for men with severe hyperuricemia. Monitoring is recommended for that group, which poses the greatest risk to develop gout.

Multinational evidence-based recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion of a broad panel of rheumatologists in the 3e initiative

We aimed to develop evidence-based multinational recommendations for the diagnosis and management of gout. Using a formal voting process, a panel of 78 international rheumatologists developed 10 key clinical questions pertinent to the diagnosis and management of gout. Each question was investigated with a systematic literature review. Medline, Embase, Cochrane CENTRAL and abstracts from 2010-2011 European League Against Rheumatism and American College of Rheumatology meetings were searched in each review. Relevant studies were independently reviewed by two individuals for data extraction and synthesis and risk of bias assessment. Using this evidence, rheumatologists from 14 countries (Europe, South America and Australasia) developed national recommendations. After rounds of discussion and voting, multinational recommendations were formulated. Each recommendation was graded according to the level of evidence. Agreement and potential impact on clinical practice were assessed. Combining evidence and clinical expertise, 10 recommendations were produced. One recommendation referred to the diagnosis of gout, two referred to cardiovascular and renal comorbidities, six focused on different aspects of the management of gout (including drug treatment and monitoring), and the last recommendation referred to the management of asymptomatic hyperuricaemia. The level of agreement with the recommendations ranged from 8.1 to 9.2 (mean 8.7) on a 1-10 scale, with 10 representing full agreement. Ten recommendations on the diagnosis and management of gout were established. They are evidence-based and supported by a large panel of rheumatologists from 14 countries, enhancing their utility in clinical practice.

Clinical and health care use characteristics of patients newly starting allopurinol, febuxostat, and colchicine for the treatment of gout

OBJECTIVE

Gout is a common form of inflammatory arthritis with an increasing prevalence in developed countries. It is well known that many patients with gout have significant comorbidities and high health care utilization. We aimed to describe the clinical characteristics and health care utilization patterns in patients with gout who were newly prescribed allopurinol, febuxostat, or colchicine.

METHODS

We used US insurance claims data (2009-2011) to conduct a population-based cohort study.

RESULTS

There were 25,051 allopurinol, 4,288 febuxostat, and 6,238 colchicine initiators. The mean age was 53 years and 83-87% were men. More than one-half of the patients had hypertension and hyperlipidemia, 20% had diabetes mellitus, and 10% had cardiovascular disease. The mean uric acid level was similar across the groups at baseline, ranging from 8.1-8.5 mg/dl. Compared with allopurinol or colchicine initiators, febuxostat initiators had more comorbidities and greater health care utilization, including outpatient, inpatient, or emergency room visits, both at baseline and during followup. Use of gout-related drugs such as opioids, steroids, and nonsteroidal antiinflammatory drugs was most common in febuxostat initiators and least common in colchicine initiators. The median daily doses at both the start and end of treatment were 300 mg for allopurinol, 40 mg for febuxostat, and 1.2 mg for colchicine. The doses of allopurinol and febuxostat were rarely increased during followup.

CONCLUSION

Patients who started allopurinol, febuxostat, or colchicine for gout generally had hyperuricemia and multiple comorbidities. Febuxostat initiators had more comorbidities and greater use of health care resources and gout-related drugs than the other groups. Overall, the doses of allopurinol or febuxostat remained unchanged over time.

Canakinumab for gout: a specific, patient-profiled indication

The role of interleukin-1 (IL-1) in inflammation induced by crystals, and especially by monosodium urate crystals (MSUCs), has raised much interest in both basic and clinical investigation. Several drugs have been developed, and more are still in development, to block IL-1 driven inflammation, though to date only canakinumab (blocking IL-1β) has been labelled, yet limited to the European Union, with a restricted indication to treat episodes of acute inflammation (EAIs) in patients with gout in whom other therapeutic choices are unacceptable. Other medications developed for IL-1 blocking, such as anakinra and rilonacept, have been tested in gout patients in clinical trials, but lack label approval and may be further restricted to orphan indication in gout. Notwithstanding, the use of IL-1 blockade to prevent EAIs in gout looks promising, but no drug has yet obtained approval for such an indication.

Effect of pegloticase on renal function in patients with chronic kidney disease: a post hoc subgroup analysis of 2 randomized, placebo-controlled, phase 3 clinical trials

BACKGROUND

Pegloticase is approved in the US for treatment of refractory chronic gout. Since chronic kidney disease (CKD) is common in these patients, we conducted a post-hoc analysis of 2 replicate phase 3 trials and the subsequent open-label extension study to determine the effects of pegloticase on renal function in patients with CKD stages 3 and 4, as well as the effects of renal dysfunction on pegloticase efficacy and safety.

FINDINGS

Patients with renal insufficiency were randomized to pegloticase 8 mg every 2 weeks (n = 42), pegloticase 8 mg every 4 weeks (n = 41), or placebo (n = 20) for 6 months as defined by the study protocols. Renal function was assessed by estimated glomerular filtration rate (eGFR). All patients completing the randomized trials could participate in an open-label extension study for a further 2.5 years. Uric acid response, the primary end point in the trials, was plasma uric acid <6.0 mg/dl for 80% of months 3 and 6.Mean eGFR in both pegloticase dosing cohorts remained constant over the randomized treatment phase and long-term open-label extension study. The number of patients achieving uric acid response was similar across CKD stages (32% stage 1, 23% stage 2, 35% stage 3, and 39% stage 4, respectively, P = 0.3). There was no difference in the pegloticase safety profile based on CKD stage.

CONCLUSIONS

Pegloticase treatment does not impact eGFR in CKD patients and response to pegloticase is independent of CKD stage.

TRIAL REGISTRATION

Clinical trial identifier: NCT00325195.

Recommendations for screening and detection of connective tissue disease-associated pulmonary arterial hypertension

OBJECTIVE

Pulmonary arterial hypertension (PAH) affects up to 15% of patients with connective tissue diseases (CTDs). Previous recommendations developed as part of larger efforts in PAH did not include detailed recommendations for patients with CTD-associated PAH. Therefore, we sought to develop recommendations for screening and early detection of CTD-associated PAH.

METHODS

We performed a systematic review of the literature on the screening and diagnosis of PAH in CTD. Using the RAND/University of California, Los Angeles consensus methodology, we developed case scenarios followed by 2 stages of voting. First, international experts from a variety of specialties voted anonymously on the appropriateness of each case scenario. The experts then met face-to-face to discuss and resolve discrepant votes to arrive at consensus recommendations.

RESULTS

The key recommendation stated that all patients with systemic sclerosis (SSc) should be screened for PAH. In addition, patients with mixed connective tissue disease or other CTDs with scleroderma features (scleroderma spectrum disorders) should be screened for PAH. It was recommended that screening pulmonary function tests (PFTs) with single-breath diffusing capacity for carbon monoxide, transthoracic echocardiogram, and measurement of N-terminal pro-brain natriuretic peptide (NT-proBNP) be performed in all patients with SSc and scleroderma spectrum disorders. In patients with SSc and scleroderma spectrum disorders, transthoracic echocardiogram and PFTs should be performed annually. The full screening panel (transthoracic echocardiogram, PFTs, and measurement of NT-proBNP) should be performed as soon as any new signs or symptoms are present.

CONCLUSION

We provide consensus-based, evidence-driven recommendations for screening and early detection of CTD-associated PAH. It is our hope that these recommendations will lead to earlier detection of CTD-associated PAH and ultimately improve patient outcomes.

Improvement in the management of gout is vital and overdue: an audit from a UK primary care medical practice

Background

Gout is estimated to affect 1.4% of adults in the UK. Appropriate and timely management is essential to reduce the risk of further flares, complications, and to reduce cardiovascular disease risk. The British Society for Rheumatology and British Health Professionals in Rheumatology (BSR/BHPR) and the European League Against Rheumatism (EULAR) have published guidance regarding the management of gout, thereby providing standards against which performance can be measured. This audit was designed to assess the extent to which patients diagnosed with gout in one primary care medical practice in North Staffordshire, UK, are managed in accordance with current best practice guidelines, and to identify strategies for improvement where appropriate.

Methods

Audit criteria were derived from the EULAR and BSR/BHPR guidelines; standards were set arbitrarily, but with consideration of patient comorbidity and other factors which may influence concordance. An electronic search of the practice records was performed to identify adults with a diagnosis of gout. Medical record review with a descriptive analysis was undertaken to assess the extent to which medical management adhered to the predefined standards.

Results

Of the total ≥18 year-old practice population (n = 8686), 305 (3%) patient records included a diagnosis of gout. Of these, 74% (n = 226) had an electronic record of serum uric acid (SUA), and 11% (n = 34) and 53% (n = 162) a measure of estimated glomerular filtration rate (eGFR) ever and serum glucose since diagnosis respectively. 34% (n = 105) of patients had ever taken urate-lowering therapy with 25% (n = 77) currently prescribed this at the time of data extraction. Dose adjustment and monitoring of treatment according to SUA was found to be inadequate. Provision of lifestyle advice and consideration of comorbidities was also lacking.

Conclusions

The primary care management of gout in this practice was not concordant with national and international guidance, a finding consistent with previous studies. This demonstrates that the provision of guidelines alone is not sufficient to improve the quality of gout management and we identify possible strategies to increase guideline adherence.

Lifestyle interventions for acute gout

BACKGROUND

Although lifestyle interventions are often recommended in the management of chronic gout, the evidence from trial data of the benefits and safety of using lifestyle interventions for treating acute gout attacks have not previously been examined in a systematic review.

OBJECTIVES

The objective of this systematic review was to evaluate the benefits and safety of lifestyle interventions for the treatment of people with acute gout.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE for studies (up to 5 April 2013). We also searched the 2010 to 2011 American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) abstracts and performed a handsearch of the reference lists of included articles.

SELECTION CRITERIA

Studies were included if they were randomised or quasi-randomised controlled trials which compared lifestyle interventions to another therapy (active or placebo) in patients with acute gout. Outcomes of interest were the change in participant-reported pain in the target joint(s), target joint inflammation and function, health-related quality of life (HRQoL), patient global assessment, study participant withdrawals due to adverse events (AEs) and serious adverse events (SAEs).

DATA COLLECTION AND ANALYSIS

Two review authors independently applied methods recommended by The Cochrane Collaboration for the selection, appraisal, data collection and synthesis of studies. We assessed the quality of the body of evidence for each outcome using the GRADE approach.

MAIN RESULTS

Only one study (19 participants) at high risk of bias was included in the review. Patients were randomised to receive oral prednisolone and colchicine with or without concomitant topical ice therapy. Topical ice therapy provided significant additional benefit over oral prednisolone and colchicine alone with respect to pain, but did not significantly reduce swelling during acute gout episodes. Mean pain reduction with standard medical treatment was 4.4 cm on a 0 to 10 cm visual analogue scale (VAS) after one week; the addition of topical ice reduced pain by an additional 3.33 cm (95% CI 5.84 to 0.82), or an absolute reduction of 33% (8% to 58% reduction). Joint swelling was reduced by a mean of 3.8 cm in the standard medical treatment group; the addition of topical ice therapy did not reduce swelling significantly (mean difference (MD) 2.07 cm, 95% CI -1.56 to 5.70). Target joint function, HRQoL, patient global assessment, study participant withdrawals due to AEs and SEAs were not reported in this study.

AUTHORS' CONCLUSIONS

There is low quality evidence, from a single trial at high risk of bias, that the addition of topical ice therapy to oral prednisolone and colchicine for oligoarticular attacks of acute gout results in significantly greater pain reduction at one week.

As compared to allopurinol, urate-lowering therapy with febuxostat has superior effects on oxidative stress and pulse wave velocity in patients with severe chronic tophaceous gout

We prospectively evaluated whether an effective 12-month uric acid-lowering therapy (ULT) with the available xanthine oxidase (XO) inhibitors allopurinol and febuxostat in patients with chronic tophaceous gout has an impact on oxidative stress and/or vascular function. Patients with chronic tophaceous gout who did not receive active ULT were included. After clinical evaluation, serum uric acid levels (SUA) and markers of oxidative stress were measured, and carotid-femoral pulse wave velocity (cfPWV) was assessed. Patients were then treated with allopurinol (n = 9) or with febuxostat (n = 8) to target a SUA level ≤ 360 μmol/L. After 1 year treatment, the SUA levels, markers of oxidative stress and the cfPWV were measured again. Baseline characteristics of both groups showed no significant differences except a higher prevalence of moderate impairment of renal function (estimated glomerular filtration rate <60 ml/min) in the febuxostat group. Uric acid lowering with either inhibitors of XO resulted in almost equally effective reduction in SUA levels. The both treatment groups did not differ in their baseline cfPWV (allopurinol group: 14.1 ± 3.4 m/s, febuxostat group: 13.7 ± 2.7 m/s, p = 0.80). However, after 1 year of therapy, we observed a significant cfPWV increase in the allopurinol group (16.8 ± 4.3 m/s, p = 0.001 as compared to baseline), but not in the febuxostat patients (13.3 ± 2.3 m/s, p = 0.55). Both febuxostat and allopurinol effectively lower SUA levels in patients with severe gout. However, we observed that febuxostat also appeared to be beneficial in preventing further arterial stiffening. Since cardiovascular events are an important issue in treating patients with gout, this unexpected finding may have important implications and should be further investigated in randomized controlled trials.

3,4-Dihydroxy-5-nitrobenzaldehyde (DHNB) is a potent inhibitor of xanthine oxidase: a potential therapeutic agent for treatment of hyperuricemia and gout

Hyperuricemia, excess of uric acid in the blood, is a clinical problem that causes gout and is also considered a risk factor for cardiovascular disease. The enzyme xanthine oxidase (XO) produces uric acid during the purine metabolism; therefore, discovering novel XO inhibitors is an important strategy to develop an effective therapy for hyperuricemia and gout. We found that 3,4-dihydroxy-5-nitrobenzaldehyde (DHNB), a derivative of the natural substance protocatechuic aldehyde, potently inhibited XO activity with an IC₅₀ value of 3 μM. DHNB inhibited XO activity in a time-dependent manner, which was similar to that of allopurinol, a clinical XO inhibitory drug. DHNB displayed potent mixed-type inhibition of the activity of XO, and showed an additive effect with allopurinol at the low concentration. Structure-activity relationship studies of DHNB indicated that the aldehyde moiety, the catechol moiety, and nitration at C-5 were required for XO inhibition. DHNB interacted with the molybdenum center of XO and was slowly converted to its carboxylic acid at a rate of 10⁻¹⁰ mol/L/s. In addition, DHNB directly scavenged free radical DPPH and ROS, including ONOO⁻ and HOCl. DHNB effectively reduced serum uric acid levels in allantoxanamide-induced hyperuricemic mice. Furthermore, mice orally given a large dose (500 mg/kg) of DHNB did not show any side effects, while 42% of allopurinol (500 mg/kg)-treated mice died and their offspring lost their fur. Thus, DHNB could be an outstanding candidate for a novel XO inhibitory drug that has potent activity and low toxicity, as well as antioxidant activity and a distinct chemical structure from allopurinol.

The kidney in hyperuricemia and gout

PURPOSE OF REVIEW

Gout is a painful inflammatory arthritis associated with hyperuricemia, with a prevalence of almost 10 million in the USA. Reduced renal excretion of urate is the underlying hyperuricemic mechanism in the vast majority of gout patients; most of the genes that affect serum urate level (SUA) encode urate transporters or associated regulatory proteins. Acquired influences can also modulate SUA and renal urate excretion, sometimes precipitating acute gout. Coincidentally, the prevalence of renal comorbidities in gout - hypertension, chronic kidney disease (CKD), and nephrolithiasis - is very high.

RECENT FINDINGS

Recent advances in genetics and molecular physiology have greatly enhanced the understanding of renal reabsorption and secretion of filtered urate. Moreover, baseline SUA appears to be set by the net balance of absorption and secretion across epithelial cells in the kidney and intestine. There have also been substantial advances in the management of gout in patients with CKD.

SUMMARY

The stage is set for an increasingly molecular understanding of baseline and regulated urate transport by the kidney and intestine. The increasing prevalence of gout with CKD will be balanced by an expanding spectrum of therapeutic options for this important disease.

Adrenocorticotropic hormone: A powerful but underappreciated therapeutic tool for acute crystal induced arthritis?

Treatment of acute gout is not always an easy task since patients usually have multiple comorbidities that preclude the use of nonsteroidal anti-inflammatory drugs and colchicine, the most widely used therapeutic tools. Adrenocorticotropic hormone (ACTH) has long been used in the treatment of acute gout and several studies have shown that it is highly effective and exhibits an excellent safety profile. ACTH belongs to a family of proteins called melanocortins; these molecules have strong anti-inflammatory properties and serve as natural inhibitors of inflammatory responses. We have recently reported that treatment of acute gout with 100 IU of synthetic ACTH is highly effective and associates with negligible side effects. It is note worthy that ACTH did not associate with significant “steroid related” side effects such as hypertension, hyperglycemia and hypokalemia. ACTH appears as a powerful and easy to use therapeutic tool for patients with multiple comorbidities. We believe that the role of ACTH as a treatment for acute gout should be reappraised, especially in light of new experimental data indicating that ACTH has pleiotropic anti-inflammatory properties and is not just a hormone that stimulates the release of steroids.

Personalizing guidelines for diabetes management: twilight or dawn of the expert?

BACKGROUND

This opinion article on the management of type 2 diabetes considers the old and new format of guidelines and critical changes in the character of such guidelines. We highlight limitations of the guidelines and make recommendations for how treatment can be more personalised.

DISCUSSION

Published guidelines for the management of adult-onset non-insulin requiring diabetes have adopted a formulaic approach to patient management that can be overseen centrally and delivered by personnel with limited training. Recently, guidelines have taken a patient-centered, multiple risk-factor approach. Importantly, local funding issues are considered, but drive the final action and not the decision-making process. The nature of the disease can be determined by laboratory tests, including screening for diabetes-associated autoantibodies. The strategy remains step-up, with intensification of drug or insulin dose. As with past guidelines, there is an assumption that in each patient with type 2 diabetes, metformin is used initially, but targets and therapies then veer in different directions to create a matrix of options based on the features and responses of each individual. Factors to consider include: (A)ge, (B)ody weight, (C)omplications and co-morbidities, Diabetes (D)uration and (E)xpense, but also patient preference and patient response.

SUMMARY

Guidelines for the management of type 2 diabetes have important limitations and a patient-centered, multiple target, multiple therapy approach is proposed.

How to manage patients with gout

OBJECTIVES

Recently, after almost 50 years of dormancy, new therapeutic agents for the management of gout have entered the market or are in clinical development. In this article, the current guidelines for the diagnosis and management of gout are reviewed.

METHODS

Key papers for inclusion were identified by a PubMed search, and articles were selected according to their relevance for the topic, according to the authors' judgment.

RESULTS AND CONCLUSIONS

Although our therapeutic arsenal is strong, and effective gout management with urate lowering therapy improves many patient-reported outcomes in clinical trials, major gaps exist in patient understanding of disease and adherence to long-term therapy. Research is required to identify the optimal models of care for patients with gout. However, quality of care in gout can be enhanced through better gout-centered education. To properly manage gout, education of the gout patient is critical, since only the patient who understands their gout will stay with their medication long-term.