Efficacy of Canakinumab vs. triamcinolone acetonide according to multiple gouty arthritis-related health outcomes measures

Interleukin-1β inhibitors for the management of acute gout flares: a systematic literature review

OBJECTIVES

The objective of this systematic review was to assess the effects of interleukin-1β (IL-1β) inhibitors on gout flares.

METHODS

Studies published between 2011 and 2022 that evaluated the effects of IL-1β inhibitors in adult patients experiencing gout flares were eligible for inclusion. Outcomes including pain, frequency and intensity of gout flares, inflammation, and safety were assessed. Five electronic databases (Pubmed/Medline, Embase, Biosis/Ovid, Web of Science and Cochrane Library) were searched. Two independent reviewers performed study screening, data extraction and risk of bias assessments (Cochrane Risk of Bias Tool 2 for randomised controlled trials [RCTs] and Downs and Black for non-RCTs). Data are reported as a narrative synthesis.

RESULTS

Fourteen studies (10 RCTs) met the inclusion criteria, with canakinumab, anakinra, and rilonacept being the three included IL-1β inhibitors. A total of 4367 patients with a history of gout were included from the 14 studies (N = 3446, RCTs; N = 159, retrospective studies [with a history of gout]; N = 762, post hoc analysis [with a history of gout]). In the RCTs, canakinumab and rilonacept were reported to have a better response compared to an active comparator for resolving pain, while anakinra appeared to be not inferior to an active comparator for resolving pain. Furthermore, canakinumab and rilonacept reduced the frequency of gout flares compared to the comparators. All three medications were mostly well-tolerated compared to their comparators.

CONCLUSION

IL-1β inhibitors may be a beneficial and safe medication for patients experiencing gout flares for whom current standard therapies are unsuitable.

REVIEW PROTOCOL REGISTRATION

PROSPERO ID: CRD42021267670.

Efficacy and Safety of Pharmacologic Interventions in Patients Experiencing a Gout Flare: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To compare the relative efficacy and safety of pharmacologic antiinflammatory interventions for gout flares.

METHODS

We searched Ovid Medline, Embase, and Cochrane library for randomized controlled trials (RCTs) that compared pharmacologic antiinflammatory treatment of gout flares. We conducted a network meta-analysis (NMA) using a frequentist framework and assessed the certainty of evidence and made conclusions using the Grading of Recommendations Assessment, Development, and Evaluation for NMA.

RESULTS

In the 30 eligible RCTs, canakinumab provided the highest pain reduction at day 2 and at longest follow-up (mean difference relative to acetic acid derivative nonsteroidal antiinflammatory drugs [NSAIDs] -41.12 [95% confidence interval (95% CI) -53.36, -29.11] on a 0-100 scale at day 2, and mean difference -12.84 [95% CI -20.76, -4.91] at longest follow-up; both moderate certainty; minimum important difference -19). Intravenous or intramuscular corticosteroids were inferior to canakinumab but may be better than the other commonly used interventions (low to very low certainty). For joint tenderness, canakinumab may be the most effective intervention at day 2. Acetic acid derivative NSAIDs improved joint swelling better than ibuprofen NSAIDs at day 2 (mean difference -0.29 [95% CI -0.56, -0.02] on a 0-4 scale; moderate certainty) and improved patient global assessment (PtGA) greater than ibuprofen NSAIDs at the longest follow-up (mean difference -0.44 [95% CI -0.86, -0.02]; moderate).

CONCLUSION

Canakinumab may be superior to other alternatives and intravenous or intramuscular corticosteroids may be the second best in pain reduction. Acetic acid derivative NSAIDs may be superior to ibuprofen NSAIDs in improving joint swelling and PtGA.

Medications for gout and its comorbidities: mutual benefits?

PURPOSE OF REVIEW

To review recent literature with relevance to the management of multimorbid patients with gout, i.e., gout medication repurposed for comorbidities and vice versa.

RECENT FINDINGS

Adding to the previous success of interleukin-1 inhibition, two trials on low-dose colchicine's role in cardiovascular disease (CVD) demonstrated potential benefits in patients with or without gout. In Colchicine Cardiovascular Outcomes Trial, a composite CVD endpoint was reduced by 23% among patients who had experienced a recent myocardial infarction. In Low-Dose Colchicine 2, the composite CVD endpoint was reduced 31% among those with stable coronary artery disease. Use of urate-lowering therapy (ULT) for renal protection in patients without gout produced null results. Allopurinol did not benefit the glomerular filtration rate in two trials (Controlled trial of slowing of Kidney Disease progression From the Inhibition of Xanthine oxidase and Preventing Early Renal Function Loss) among patients with chronic kidney disease (with or without hyperuricemia, but not gout). SGLT-2 inhibitors, a medication recommended for patients with diabetes and CVD, diabetic kidney disease, or heart failure, demonstrated a protective effect against gout flares in a secondary trial analysis and a large observational study.

SUMMARY

The role of colchicine may expand beyond gout flare prevention to patients with existing CVD. The renal benefit of ULT among patients with gout remains unclear. SGLT-2 inhibitors may benefit diabetic patients who have gout as a comorbidity.

A Randomized, Phase II Study Evaluating the Efficacy and Safety of Anakinra in the Treatment of Gout Flares

OBJECTIVE

To evaluate the efficacy and safety of anakinra compared to triamcinolone in the treatment of gout flares.

METHODS

Patients for whom nonsteroidal antiinflammatory drugs and colchicine were not suitable treatments were enrolled in this multicenter, randomized, double-blind study with follow-up for up to 2 years. The study was designed to assess superiority of anakinra (100 or 200 mg/day for 5 days) over triamcinolone (40 mg in a single injection) for the primary end point of changed patient-assessed pain intensity in the most affected joint (scored on a visual analog scale of 0-100) from baseline to 24-72 hours. Secondary outcome measures included: safety, immunogenicity, and patient- and physician-assessed global response.

RESULTS

One hundred sixty-five patients were randomized to receive anakinra (n = 110) or triamcinolone (n = 55). The median age was 55 years (range 25-83), 87% were men, the mean disease duration was 8.7 years, and the mean number of self-reported flares during the prior year was 4.5. A total of 301 flares were treated (214 with anakinra; 87 with triamcinolone). Anakinra in both doses and triamcinolone provided clinically meaningful reduction in patient-assessed pain intensity in the first and subsequent flares. For the first flare, the mean decline in pain intensity from baseline to 24-72 hours for total anakinra and triamcinolone was -41.2 and -39.4, respectively (P = 0.688). Anakinra performed better than triamcinolone for most secondary end points. There were no unexpected safety findings. The presence of antidrug antibodies was not associated with adverse events or altered pain reduction.

CONCLUSION

Anakinra was not superior to triamcinolone for the primary end point, but had comparable efficacy in pain reduction and was favored for most secondary end points. Anakinra is an effective option for gout flares when conventional therapy is unsuitable.

Effect of canakinumab on clinical and biochemical parameters in acute gouty arthritis: a meta-analysis

BACKGROUND

Targeted anti-IL-1β therapy may be a valuable option for the management of gouty arthritis. The present meta-analysis has evaluated the effect of canakinumab, an anti-IL-1β monoclonal antibody in gouty arthritis.

METHODS

A standard meta-analysis protocol was developed and after performing a comprehensive literature search in MEDLINE, Cochrane, and International Clinical Trial Registry Platform (ICTRP), reviewers assessed eligibility and extracted data from three relevant articles. A random-effects model was used to estimate the pooled effect size as the mean difference in Visual Analouge Scale (VAS) score, serum hsCRP, serum Amyloid A, and risk ratio for global assessment between the groups. Quality assessment was done using the risk of bias assessment tool and summary of findings was prepared using standard Cochrane methodology with GradePro GDT.

RESULTS

Treatment with canakinumab showed a mean reduction of VAS score by 14.59 mm [95% CI - 19.42 to - 9.77], serum hsCRP by 15.36 mg/L [95% CI 1.62-29.11], serum Amyloid A by 67.18 mg/L [95% CI 17.06-117.31], and improvement in patient global assessment (RR = 1.478; 95% CI 1.29-1.67) and physician global assessment (RR = 1.44; 95% CI 1.28-1.61). The probability that future studies may have a mean difference in VAS score less than zero has been calculated to be 27.3% using a cumulative distribution function (CDF) calculator.

CONCLUSION

This meta-analysis shows the beneficial effect of canakinumab over triamcinolone by reducing VAS score, serum hsCRP, serum amyloid A, and improvement in global assessments in acute gouty arthritis.

2020 American College of Rheumatology Guideline for the Management of Gout

OBJECTIVE

To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.

METHODS

Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional.

RESULTS

Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended.

CONCLUSION

Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.

2020 American College of Rheumatology Guideline for the Management of Gout

OBJECTIVE

To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.

METHODS

Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional.

RESULTS

Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended.

CONCLUSION

Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.

[The NLRP3 inflammasome: Physiopathology and therapeutic application]

The innate immune system constitutes the first line of host defense against pathogens. "Nonself", such as exogenous particles or pathogens, triggers an inflammatory response. Inflammasomes are molecular platforms activated upon cellular infection or stress that trigger the maturation of proinflammatory cytokines such as IL-1β. Activation of the NLRP3 inflammasome pathway, the most extensively studied, appears to be the corner stone of many inflammatory diseases, including Crohn's disease, rheumatoid arthritis and gout. Cryopyrine-associated periodic syndromes (CAPS) are NLRP3 inflammasome-associated diseases. Canakinumab (Ilaris(®)) is the only drug approved for CAPS treatment in France. Targeted therapy against NLRP3 inflammasome and IL-1β might be the new anti-inflammatory drugs.

Control of autoimmune CNS inflammation by astrocytes

Multiple sclerosis is a neurologic disease caused by immune cell infiltration into the central nervous system, resulting in gray and white matter inflammation, progressive demyelination, and neuronal loss. Astrocytes, the most abundant cell population in the central nervous system (CNS), have been considered inert scaffold or housekeeping cells for many years. However, recently, it has become clear that this cell population actively modulates the immune response in the CNS at multiple levels. While being exposed to a plethora of cytokines during ongoing autoimmune inflammation, astrocytes modulate local CNS inflammation by secreting cytokines and chemokines, among other factors. This review article gives an overview of the most recent understanding about cytokine networks operational in astrocytes during autoimmune neuroinflammation and highlights potential targets for immunomodulatory therapies for multiple sclerosis.