1
|
Sanchez C, Campeau A, Liu-Bryan R, Mikuls T, O'Dell J, Gonzalez D, Terkeltaub R. Sustained xanthine oxidase inhibitor treat to target urate lowering therapy rewires a tight inflammation serum protein interactome. Res Sq 2024:rs.3.rs-3770277. [PMID: 38260556 PMCID: PMC10802734 DOI: 10.21203/rs.3.rs-3770277/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background Effective xanthine oxidoreductase inhibition (XOI) urate-lowering treatment (ULT) to target significantly reduces gout flare burden and synovitis between 1-2 years therapy, without clearing all monosodium urate crystal deposits. Paradoxically, treat to target ULT is associated with increased flare activity for at least 1 year in duration on average, before gout flare burden decreases. Since XOI has anti-inflammatory effects, we tested for biomarkers of sustained, effective ULT that alters gouty inflammation. Methods We characterized the proteome of febuxostat-treated murine bone marrow macrophages. Blood samples (baseline and 48 weeks ULT) were analyzed by unbiased proteomics in febuxostat and allopurinol ULT responders from two, independent, racially and ethnically distinct comparative effectiveness trial cohorts (n=19, n=30). STRING-db and multivariate analyses supplemented determinations of significantly altered proteins via Wilcoxon matched pairs signed rank testing. Results The proteome of cultured IL-1b-stimulated macrophages revealed febuxostat-induced anti-inflammatory changes, including for classical and alternative pathway complement activation pathways. At 48 weeks ULT, with altered purine metabolism confirmed by serum metabolomics, serum urate dropped >30%, to normal (<6.8 mg/dL) in all the studied patients. Overall, flares declined from baseline. Treated gout patient sera and peripheral blood mononuclear cells (PBMCs) showed significantly altered proteins (p<0.05) in clustering and proteome networks. CRP was not a useful therapy response biomarker. By comparison, significant serum proteome changes included decreased complement C8 heterotrimer C8A and C8G chains essential for C5b-9 membrane attack complex assembly and function; increase in the NLRP3 inflammasome activation promoter vimentin; increased urate crystal phagocytosis inhibitor sCD44; increased gouty inflammation pro-resolving mediator TGFB1; decreased phagocyte-recruiting chemokine PPBP/CXCL7, and increased monocyte/macrophage-expressed keratin-related proteins (KRT9,14,16) further validated by PBMC proteomics. STRING-db analyses of significantly altered serum proteins from both cohorts revealed a tight interactome network including central mediators of gouty inflammation (eg, IL-1B, CXCL8, IL6, C5). Conclusions Rewiring of inflammation mediators in a tight serum protein interactome was a biomarker of sustained XOI-based ULT that effectively reduced serum urate and gout flares. Monitoring of the serum and PBMC proteome, including for changes in the complement pathway could help determine onset and targets of anti-inflammatory changes in response to effective, sustained XOI-based ULT.Trial Registration: ClinicalTrials.gov Identifier: NCT02579096.
Collapse
|
2
|
Stewart S, Gamble G, Doyle AJ, Son CN, Aati O, Latto K, Horne A, Stamp LK, Dalbeth N. The statistical challenge of analysing changes in dual energy computed tomography (DECT) urate volumes in people with gout. Semin Arthritis Rheum 2023; 63:152303. [PMID: 37939600 DOI: 10.1016/j.semarthrit.2023.152303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/12/2023] [Accepted: 10/31/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Dual energy computed tomography (DECT) allows direct visualization of monosodium urate crystal deposition in gout. However, DECT urate volume data are often highly skewed (mostly small volumes with the remainder considerably larger), making statistical analyses challenging in longitudinal research. The aim of this study was to explore the ability of various analysis methods to normalise DECT urate volume data and determine change in DECT urate volumes over time. METHODS Simulated datasets containing baseline and year 1 DECT urate volumes for 100 people with gout were created from two randomised controlled trials. Five methods were used to transform the DECT urate volume data prior to analysis: log-transformation, Box-Cox transformation, log(X-(min(X)-1)) transformation; inverse hyperbolic sine transformation, and rank order. Linear regression analyses were undertaken to determine the change in DECT urate volume between baseline and year 1. Cohen's d were calculated as a measure of effect size for each data treatment method. These analyses were then tested in a validation clinical trial dataset containing baseline and year 1 DECT urate volumes from 91 people with gout. RESULTS No data treatment method successfully normalised the distribution of DECT urate volumes. For both simulated and validation data sets, significant reductions in DECT urate volumes were observed between baseline and Year 1 across all data treatment methods and there were no significant differences in Cohen's d effect sizes. CONCLUSIONS Normalising highly skewed DECT urate volume data is challenging. Adopting commonly used transformation techniques may not significantly improve the ability to determine differences in measures of central tendency when comparing the change in DECT urate volumes over time.
Collapse
Affiliation(s)
- Sarah Stewart
- School of Clinical Sciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, 90 Akoranga Drive, Northcote Auckland 0627, New Zealand; Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand.
| | - Greg Gamble
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand
| | - Anthony J Doyle
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand; Te Whatu Ora Health New Zealand, Te Toka Tumai Auckland, Radiology, Private Bag 92 024, Auckland 1142, New Zealand
| | - Chang-Nam Son
- Department of Rheumatology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, 712 Dongil-ro, Uijeongbu 11749, South Korea
| | - Opetaia Aati
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand
| | - Kieran Latto
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand
| | - Anne Horne
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand
| | - Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, 2 Riccarton Avenue, Christchurch 8011, New Zealand
| | - Nicola Dalbeth
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland 1023, New Zealand
| |
Collapse
|
3
|
Abstract
Hyperuricemia with consequent monosodium urate crystal deposition leads to gout, characterized by painful, incapacitating inflammatory arthritis flares that are also associated with increased cardiovascular event and related mortality risk. This narrative review focuses on emerging pharmacologic urate-lowering treatment (ULT) and management strategies in gout. Undertreated, gout can progress to palpable tophi and joint damage. In oral ULT clinical trials, target serum urate of < 6.0 mg/dL can be achieved in ~ 80-90% of subjects, with flare burden reduction by 1-2 years. However, real-world ULT results are far less successful, due to both singular patient nonadherence and prescriber undertreatment, particularly in primary care, where most patients are managed. Multiple dose titrations commonly needed to optimize first-line allopurinol ULT monotherapy, and substantial potential toxicities and other limitations of approved, marketed oral monotherapy ULT drugs, promote hyperuricemia undertreatment. Common gout comorbidities with associated increased mortality (e.g., moderate-severe chronic kidney disease [CKD], type 2 diabetes, hypertension, atherosclerosis, heart failure) heighten ULT treatment complexity and emphasize unmet needs for better and more rapid clinically significant outcomes, including attenuated gout flare burden. The gout drug armamentarium will be expanded by integrating sodium-glucose cotransporter-2 (SGLT2) inhibitors with uricosuric and anti-inflammatory properties as well as clinically indicated antidiabetic, nephroprotective, and/or cardioprotective effects. The broad ULT developmental pipeline is loaded with multiple uricosurics that selectively target uric acid transporter 1 (URAT1). Evolving ULT approaches include administering selected gut anaerobic purine degrading bacteria (PDB), modulating intestinal urate transport, and employing liver-targeted xanthine oxidoreductase mRNA knockdown. Last, emerging measures to decrease the immunogenicity of systemically administered recombinant uricases should simplify treatment regimens and further improve outcomes in managing the most severe gout phenotypes.
Collapse
Affiliation(s)
- Robert Terkeltaub
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA, 92093, USA.
| |
Collapse
|
4
|
Laurent V, Jauffret C, Pacaud A, Ducoulombier V, Legrand J, Verdun S, Norberciak L, Budzik JF, Pascart T. Factors influencing the kinetics of MSU crystal depletion measured with dual-energy CT in patients with gout. RMD Open 2023; 9:e003725. [PMID: 37940341 PMCID: PMC10632919 DOI: 10.1136/rmdopen-2023-003725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/10/2023] [Indexed: 11/10/2023] Open
Abstract
OBJECTIVE To examine factors influencing the kinetics of monosodium urate (MSU) crystal dissolution measured with dual-energy computed tomography (DECT) during follow-up of patients with gout. METHODS Patients with a diagnosis of gout with baseline knees and feet DECT scans exhibiting MSU crystal volumes ≥0.1 cm3 and at least one follow-up DECT were included. Spearman's correlation coefficient was used to search for association between change from baseline MSU crystal volume at 6, 12, 18 and 24 months and serum urate (SU) level. Associations between percentage change from the baseline volume of MSU crystal deposits and explanatory variables were assessed using linear mixed models. RESULTS Sixty-two patients (age 67.3±12.8 years; 53 (85%) males) cumulating 104 follow-up DECT scans were included. Overall, SU target levels (<6.0 and <5.0 mg/dL) were achieved by 48 (77%) and 36 (58%) patients, respectively. There was a good correlation (r=0.66; p<0.0001) observed between SU level and percentage change in MSU crystal volume. The median decrease from baseline MSU crystal volume was greater in patients reaching the <5.0 mg/dL SU target than in those reaching ≥5.0 SU <6.0 mg/dL: -85% (95% CI: -94% to -72%) versus -40% (-57% to -22%; p<0.05) at 12 months. In multivariable analysis, time (in days) with a multilevel coefficient of -0.06 (95% CI: -0.08 to -0.03, p<0.001), hypertension (coefficient: 41.87, 95% CI: 16.38 to 67.18, p<0.01) and SU level <5.0 mg/dL (coefficient: -39.46, 95% CI: -70.93 to -8.34, p=0.02) were the only variables significantly associated with MSU crystal volume change. CONCLUSION In patients with DECT-measured MSU crystal deposition, reaching the <5.0 mg/dL SU target provides more extensive and rapid crystal dissolution than reaching the <6.0 mg/dL SU target.
Collapse
Affiliation(s)
- Victor Laurent
- Department of Rheumatology, Université Catholique de Lille, Lille, France
| | - Charlotte Jauffret
- Department of Rheumatology, Université Catholique de Lille, Lille, France
| | - Aurore Pacaud
- Department of Rheumatology, Université Catholique de Lille, Lille, France
| | | | - Julie Legrand
- Department of Radiology, Université Catholique de Lille, Lille, France
| | - Stéphane Verdun
- Research Department, Université Catholique de Lille, Lille, France
| | | | | | - Tristan Pascart
- Department of Rheumatology, Université Catholique de Lille, Lille, France
| |
Collapse
|
5
|
Abstract
Gout and hyperuricemia (HU) have generated immense attention due to increased prevalence. Gout is a multifactorial metabolic and inflammatory disease that occurs when increased uric acid (UA) induce HU resulting in monosodium urate (MSU) crystal deposition in joints. However, gout pathogenesis does not always involve these events and HU does not always cause a gout flare. Treatment with UA-lowering therapeutics may not prevent or reduce the incidence of gout flare or gout-associated comorbidities. UA exhibits both pro- and anti-inflammation functions in gout pathogenesis. HU and gout share mechanistic and metabolic connections at a systematic level, as shown by studies on associated comorbidities. Recent studies on the interplay between UA, HU, MSU and gout as well as the development of HU and gout in association with metabolic syndromes, non-alcoholic fatty liver disease (NAFLD), and cardiovascular, renal and cerebrovascular diseases are discussed. This review examines current and potential therapeutic regimens and illuminates the journey from disrupted UA to gout.
Collapse
Affiliation(s)
- Wei-Zheng Zhang
- VIDRL, The Peter Doherty Institute, Melbourne, VIC, Australia.
| |
Collapse
|
6
|
Yuan H, Fan Y, Mou X, Qing Y, Yan X, Tang X, Yue W, Gu P, Yang Q, He Y. Musculoskeletal Ultrasound in Monitoring the Efficacy of Gout: A Prospective Study Based on Tophus and Double Contour Sign. Balkan Med J 2023; 40:104-110. [PMID: 36715053 PMCID: PMC9998831 DOI: 10.4274/balkanmedj.galenos.2022.2022-7-39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background In patients with gout receiving uric acid-lowering therapy, musculoskeletal ultrasound has the potential to observe changes in gout lesions. Aims To analyze the effectiveness of uric acid-lowering therapy in patients with gout over one year using musculoskeletal ultrasound as a monitoring technique. Study Design Prospective cohort study. Methods A total of 215 patients meeting the 1977 American College of Rheumatology gout classification criteria and treated with uric acid-lowering therapy were separated into two groups, treat-to-target and treat-to-non-target depending on the target serum urate levels. Lower extremity joints were evaluated by ultrasound before therapy (M0), as well as three (M3), six (M6), and twelve (M12) months after therapy. At various moments during uric acid-lowering therapy, the tophus size and the semiquantitative ultrasound scoring system of double contour sign were measured in the treat-to-target and treat-to-non-target groups. Results Ninety-five tophi (45 in treat-to-target and 50 in treat-to-non-target) and sixty-seven double contour sign (34 in treat-to-target and 33 in treat-to-non-target) were evaluated longitudinally. In both groups, the long diameter, short diameter, and area of tophus in treat-to-target decreased as the duration of uric acid-lowering treatment increased. Differences in the long diameter of tophus between M12 and M0, M3 and M6 were statistically significant (P < 0.05), while differences between the other time points were not significant (P > 0.05). No statistically significant differences were observed in the short diameter and the area of tophus between M0 and M3 (P > 0.05), while there were statistically significant differences between other periods (P < 0.05). In treat-to-non-target, the long diameter, short diameter, and area of tophus showed a slight increase at different uric acid-lowering therapy time points. The differences in the long diameter, short diameter, and area of tophus at different uric acid-lowering therapy time points were not significant (P > 0.05). The semiquantitative ultrasound scoring system of double contour sign of treat-to-target and treat-to-non-target showed a decreasing trend with increasing uric acid-lowering therapy time, with a more pronounced drop in treat-to-target than treat-to-non-target. In treat-to-target, the difference in the semiquantitative ultrasound scoring system of double contour sign at each uric acidlowering therapy time point was significant (P < 0.05). In treat-tonon- target, the difference in semiquantitative ultrasound scoring system of double contour sign scores between M0 and M3 was not statistically significant (P >0.05), but it was statistically significant for the remaining time points (P < 0.05). Conclusion After one year of uric acid-lowering therapy in patients with gout, an ultrasound indicated that the size of tophus and the semiquantitative ultrasound scoring system of double contour sign score decreased dramatically in the treat-to-target group. Semiquantitative ultrasound scoring system of double contour sign score was dramatically reduced in the treat-to-non-target group, but the size of the tophus remained the same. Therefore, musculoskeletal ultrasound is an effective tool to monitor the efficacy of uric acid-lowering therapy.
Collapse
Affiliation(s)
- Hongmei Yuan
- Department of Ultrasound, Sichuan Key Laboratory of Medical Imaging, Affiliated Hospital of North Sichuan Medical College, Sichuan, China
| | - Yuhong Fan
- Department of Ultrasound, Sichuan Key Laboratory of Medical Imaging, Affiliated Hospital of North Sichuan Medical College, Sichuan, China,Department of Ultrasound Diagnosis, Daping Hospital, Army Medical University, Chongqing, China
| | - Xurong Mou
- Department of Ultrasound, Sichuan Key Laboratory of Medical Imaging, Affiliated Hospital of North Sichuan Medical College, Sichuan, China
| | - Yufeng Qing
- Department of Rheumatology, Affiliated Hospital of North Sichuan Medical College, Sichuan, China
| | - Xiang Yan
- Department of Ultrasound, Sichuan Key Laboratory of Medical Imaging, Affiliated Hospital of North Sichuan Medical College, Sichuan, China
| | - Xuemei Tang
- Department of Ultrasound, Sichuan Key Laboratory of Medical Imaging, Affiliated Hospital of North Sichuan Medical College, Sichuan, China
| | - Wensheng Yue
- Department of Ultrasound, Sichuan Key Laboratory of Medical Imaging, Affiliated Hospital of North Sichuan Medical College, Sichuan, China
| | - Peng Gu
- Department of Ultrasound, Sichuan Key Laboratory of Medical Imaging, Affiliated Hospital of North Sichuan Medical College, Sichuan, China
| | - Qibin Yang
- Department of Rheumatology, Affiliated Hospital of North Sichuan Medical College, Sichuan, China
| | - Yonglong He
- Department of Rheumatology, Affiliated Hospital of North Sichuan Medical College, Sichuan, China
| |
Collapse
|
7
|
Lee ZC, Santosa A, Khor AYK, Sriranganathan MK. The Singapore Experience With Uncontrolled Gout: Unmet Needs in the Management of Patients. Cureus 2023; 15:e36682. [PMID: 36987445 PMCID: PMC10039979 DOI: 10.7759/cureus.36682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Gout is the most common type of inflammatory arthritis, and its impact on cardiovascular health and quality of life is often underestimated. The prevalence and incidence of gout are increasing globally. Further, ischemic heart disease (IHD) and chronic kidney disease (CKD) are prevalent in gout patients. Some unmet needs for gout management include physicians' low initiation rate of urate-lowering therapy (ULT) and poor treatment adherence in patients with gout. There is also a lack of randomized controlled trials that establish safe doses of acute and long-term treatment for gout, particularly in patients with IHD and stage 4 CKD and above (including end-stage renal failure). Furthermore, there is also a lack of studies showing optimal serum uric acid (SUA) target and validated clinical outcome measures, including disease activity and remission criteria for gout tailored to treat-to-target approaches and the high cost of newer gout medications. The causal relationship between asymptomatic hyperuricemia or gout with comorbidities such as IHD and CKD has yet to be fully elucidated. There is a pressing need for collaborative international efforts to address the overall suboptimal management of gout.
Collapse
|
8
|
Saffarzadeh M, Haydar SMA, Shojania K, Ouellette H, Nicolaou S, Murray N. Assessing tophaceous spinal gout treatment response using dual-energy CT as a point-of-care imaging modality: case report. Skeletal Radiol 2022. [PMID: 36562821 DOI: 10.1007/s00256-022-04260-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
We describe a case of chronic tophaceous gout affecting the spine, hands, elbows, feet, and knees in a 67-year-old man with serum urate levels at 549 µmol/L whose response to treatment was successfully mapped using dual-energy computed tomography (DECT). The patient presented with exacerbation of acute-on-chronic lumbar back pain. He had received a diagnosis of gout 3 years prior to this presentation yet was not on any urate-lowering therapy. The patient received febuxostat 80 mg and colchicine 0.3 mg once daily and underwent DECT to assess baseline monosodium urate (MSU) burden. At baseline, MSU deposits were seen in the hands, elbows, feet, knees, and lumbar spine including the left L5-S1 facet joint encroaching onto the neural foramen. After 2.5 years of treatment, serum urate level was within the target range (< 360 µmol/L), and the patient underwent a follow-up DECT that revealed almost full resolution of MSU deposition in the spine, including the MSU-burdened facet joint and neural foramen in the lumbar spine, in addition to all the affected peripheral joints. This case is the first report of radiological evidence of nearly complete resolution of MSU deposits in spinal gout on DECT after urate-lowering therapy treatment, which demonstrates the utility of this imaging modality as a non-invasive investigational point-of-care imaging modality for mapping treatment response and identifying the etiology of back pain in a patient with chronic tophaceous spinal gout.
Collapse
|
9
|
Stamp LK, Dalbeth N. Critical appraisal of serum urate targets in the management of gout. Nat Rev Rheumatol 2022. [PMID: 35974164 DOI: 10.1038/s41584-022-00816-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2022] [Indexed: 11/08/2022]
Abstract
Gout management involves two broad aspects: treatment of gout flares to provide rapid symptomatic relief and long-term urate-lowering therapy to lower serum urate sufficiently to prevent gout flares from occurring. All of the major rheumatology societies recommend a target serum urate of <5 mg/dl (<0.30 mmol/l) or <6 mg/dl (<0.36 mmol/l), both of which are below the point of saturation for urate and therefore lead to monosodium urate crystal dissolution. In this Review, we describe the rationale for treat-to-target urate approach in the long-term management of gout and the current evidence and controversy around the appropriate serum urate targets.
Collapse
|
10
|
Sivera F, Andres M, Dalbeth N. A glance into the future of gout. Ther Adv Musculoskelet Dis 2022; 14:1759720X221114098. [PMID: 35923650 PMCID: PMC9340313 DOI: 10.1177/1759720x221114098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 06/29/2022] [Indexed: 12/03/2022] Open
Abstract
Gout is characterized by monosodium urate (MSU) crystal deposits in and within joints. These deposits result from persistent hyperuricaemia and most typically lead to recurrent acute inflammatory episodes (gout flares). Even though some aspects of gout are well characterized, uncertainties remain; this upcoming decade should provide further insights into many of these uncertainties. Synovial fluid analysis allows for the identification of MSU crystals and unequivocal diagnosis. Non-invasive methods for diagnosis are being explored, such as Raman spectroscopy and imaging modalities. Both ultrasound and dual-energy computed tomography (DECT) allow the detection of MSU crystals; this not only provides a mean of diagnosis, but also has furthered gout knowledge defining the presence of a preclinical deposition in asymptomatic hyperuricaemia. Scientific consensus establishes the beginning of gout as the beginning of symptoms (usually the first flare), but the concept is currently under review. For effective long-term gout management, the main goal is to promote crystal dissolution treatment by reducing serum urate below 6 mg/dL (or 5 mg/dL if faster crystal dissolution is required). Current urate-lowering therapies' (ULTs) options are limited, with allopurinol and febuxostat being widely available, and probenecid, benzbromarone, and pegloticase available in some regions. New xanthine oxidase inhibitors and, especially, uricosurics inhibiting urate transporter URAT1 are under development; it is probable that the new decade will see a welcomed increase in the gout therapeutic armamentarium. Cardiovascular and renal comorbidities are common in gout patients. Studies determining whether optimal treatment of gout will positively impact these comorbidities are currently lacking, but will hopefully be forthcoming. Overall, the single change that will most impact gout management is greater uptake of international rheumatology society recommendations. Innovative strategies, such as nurse-led interventions based on these recommendations have recently demonstrated treatment success for people with gout.
Collapse
Affiliation(s)
- Francisca Sivera
- Rheumatology Unit, Hospital General
Universitario Elda, Ctra Sax s/n, Elda 03600, Alicante, Spain
- Department Medicine, Universidad Miguel
Hernandez, Elche, Spain
| | - Mariano Andres
- Department Medicine, Universidad Miguel
Hernandez, Elche, Spain
- Rheumatology Unit, Hospital General
Universitario Alicante, Alicante, Spain
- Alicante Institute of Sanitary and Biomedical
Research (ISABIAL), Alicante, Spain
| | | |
Collapse
|
11
|
Hammer HB, Rollefstad S, Semb AG, Jensen G, Karoliussen LF, Terslev L, Haavardsholm EA, Kvien TK, Uhlig T. Urate crystal deposition is associated with inflammatory markers and carotid artery pathology in patients with intercritical gout: results from the NOR-Gout study. RMD Open 2022; 8:rmdopen-2022-002348. [PMID: 35863863 PMCID: PMC9310249 DOI: 10.1136/rmdopen-2022-002348] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 06/29/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Gout is of unknown reason associated with cardiovascular disease. Ultrasound is sensitive for detecting crystal deposition and plasma calprotectin is a sensitive inflammatory marker. This study explores the associations between crystal deposition, inflammation and carotid artery pathology. METHOD A cross-sectional analysis of baseline assessments from the NOR-Gout study was undertaken. Crystal deposition was assessed by ultrasound (double contour, tophi, aggregates) and dual-energy CT (DECT) and laboratory assessments included plasma calprotectin. The carotid arteries were bilaterally examined for carotid intima-media thickness (cIMT) and presence of plaques. Spearman correlations, Mann-Whitney tests and linear regression analyses were used to explore associations between crystal deposition, inflammatory markers,and carotid pathology. RESULTS 202 patients with intercritical gout (95.5% men, mean (SD) age 56.5 (13.8) years, disease duration 7.9 (7.7) years) were included. Calprotectin was correlated with all scores of crystal deposition by ultrasound (r=0.26-0.32, p<0.001) and DECT (r=0.15, p<0.05). cIMT was correlated with sum score aggregates (r=0.18-0.22, p<0.05). Patients with large tophi had higher levels of calprotectin as well as more frequent carotid plaque (p<0.05). CONCLUSIONS Study findings point towards crystal deposition contributing to subclinical inflammation with subsequent vascular implications. However, future longitudinal studies are needed to confirm such causal relationships.
Collapse
Affiliation(s)
- Hilde Berner Hammer
- Dept of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway .,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Silvia Rollefstad
- Peventive Cardio-Rheuma clinic, Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Anne Grete Semb
- Peventive Cardio-Rheuma clinic, Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Gro Jensen
- Clinical chemical laboratory, Diakonhjemmet Hospital, Oslo, Norway
| | | | - L Terslev
- Center for Rheumatology and Spine Diseases, Rigshospitalet, Kobenhavn, Denmark
| | - Espen A Haavardsholm
- Dept of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tore K Kvien
- Dept of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Till Uhlig
- Dept of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
12
|
Uhlig T, Karoliussen LF, Sexton J, Kvien TK, Haavardsholm EA, Perez-Ruiz F, Hammer HB. One- and 2-year flare rates after treat-to-target and tight-control therapy of gout: results from the NOR-Gout study. Arthritis Res Ther 2022; 24:88. [PMID: 35443675 PMCID: PMC9020166 DOI: 10.1186/s13075-022-02772-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 03/30/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To explore the frequency and predictors of flares over 2 years during a treat-to-target strategy with urate-lowering therapy (ULT) in patients with gout. METHODS In the treat-to-target, tight control NOR-Gout study patients started ULT with escalating doses of allopurinol. Flares were recorded over 2 years. Baseline predictors of flares during months 9-12 in year 1 and during year 2 were analyzed by multivariable logistic regression. RESULTS Of 211 patients included (mean age 56.4 years, disease duration 7.8 years, 95% males), 81% (150/186) of patients experienced at least one gout flare during the first year and 26% (45/173) during the second year. The highest frequency of flares in the first year was seen during months 3-6 (46.8% of patients). Baseline crystal depositions detected by ultrasound and by dual-energy computed tomography (DECT) were the only variables which predicted flares both during the first period of interest at months 9-12 (OR 1.033; 95% CI 1.010-1.057, and OR 1.056; 95% CI 1.007-1.108) and also in year 2. Baseline subcutaneous tophi (OR 2.42, 95% CI 1.50-5.59) and prior use of colchicine at baseline (OR 2.48, 95% CI 1.28-4.79) were independent predictors of flares during months 9-12, whereas self-efficacy for pain was a protective predictor (OR 0.98 per unit, 95% CI 0.964-0.996). CONCLUSIONS In patients with gout, flares remain frequent during the first year of a treat-to-target ULT strategy, especially during months 3-6, but are much less frequent during year 2. Baseline crystal depositions predict flares over 2 years, supporting ULT early during disease course. TRIAL REGISTRATION ACTRN12618001372279.
Collapse
Affiliation(s)
- Till Uhlig
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway. .,Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Lars F Karoliussen
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway
| | - Joe Sexton
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway
| | - Tore K Kvien
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Espen A Haavardsholm
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Fernando Perez-Ruiz
- Osakidetza, OSI EE-Cruces, Division of Rheumatology, Cruces University Hospital, Baracaldo, Spain.,Biocruces-Bizkaia Health Research Institute, Baracaldo, Spain.,Medicine Department, Medicine School, University of the Basque Country, Leioa, Spain
| | - Hilde Berner Hammer
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Box 23, Vinderen, N-0319, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW To give an overview of what can reasonably be considered as known about dual-energy computed tomography (DECT) in crystal-related arthropathies, and what still needs to be explored. RECENT FINDINGS Recent studies suggest an overall superiority of DECT over ultrasound in gout in terms of sensitivity (89 vs. 84%) and specificity (91 vs. 84%), except in early disease. Additional studies are needed to optimize DECT postprocessing settings in order to improve the specificity of the technique and eliminate all artifacts. Evidence has been controversial concerning DECT's ability to detect monosodium urate (MSU) crystal deposits on vessel walls, or whether or not MSU-coded plaques are artifacts. DECT can be used to monitor MSU crystal depletion during urate-lowering treatment; MSU crystal volume is associated with cardiovascular risk and disease activity. There are some reports on calcium-containing crystal deposition diseases (calcium pyrophosphate and basic calcium phosphate) demonstrating that DECT can characterize and discriminate between the different types of crystals. SUMMARY Our knowledge about the use of DECT in crystal-related arthropathies continues to expand. Some unknowns have been clarified but there's still lots to learn, particularly concerning gout management and the potential use of DECT in calcium-containing crystal-related arthropathies.
Collapse
Affiliation(s)
- Tristan Pascart
- Department of Rheumatology, Lille Catholic Hospitals
- MabLab UR4490, University Lille, ULCO
| | - Jean-François Budzik
- MabLab UR4490, University Lille, ULCO
- Department of Diagnostic and Interventional Imaging, Lille Catholic Hospitals, University of Lille, Lille, France
| |
Collapse
|
14
|
Weaver JS, Vina ER, Munk PL, Klauser AS, Elifritz JM, Taljanovic MS. Gouty Arthropathy: Review of Clinical Manifestations and Treatment, with Emphasis on Imaging. J Clin Med 2021; 11:jcm11010166. [PMID: 35011907 PMCID: PMC8745871 DOI: 10.3390/jcm11010166] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/16/2021] [Accepted: 12/26/2021] [Indexed: 12/22/2022] Open
Abstract
Gout, a crystalline arthropathy caused by the deposition of monosodium urate crystals in the articular and periarticular soft tissues, is a frequent cause of painful arthropathy. Imaging has an important role in the initial evaluation as well as the treatment and follow up of gouty arthropathy. The imaging findings of gouty arthropathy on radiography, ultrasonography, computed tomography, dual energy computed tomography, and magnetic resonance imaging are described to include findings of the early, acute and chronic phases of gout. These findings include early monosodium urate deposits, osseous erosions, and tophi, which may involve periarticular tissues, tendons, and bursae. Treatment of gout includes non-steroidal anti-inflammatories, colchicine, glucocorticoids, interleukin-1 inhibitors, xanthine oxidase inhibitors, uricosuric drugs, and recombinant uricase. Imaging is critical in monitoring response to therapy; clinical management can be modulated based on imaging findings. This review article describes the current standard of care in imaging and treatment of gouty arthropathy.
Collapse
Affiliation(s)
- Jennifer S. Weaver
- Department of Radiology, University of New Mexico, Albuquerque, NM 87131, USA;
- Correspondence:
| | - Ernest R. Vina
- Department of Medicine, University of Arizona Arthritis Center, Tucson, AZ 85724, USA;
| | - Peter L. Munk
- Department of Radiology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada;
- Department of Radiology, Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
| | - Andrea S. Klauser
- Radiology Department, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria;
| | - Jamie M. Elifritz
- Departments of Radiology and Pathology, University of New Mexico, Albuquerque, NM 87131, USA;
- New Mexico Office of the Medical Investigator, Albuquerque, NM 87131, USA
| | - Mihra S. Taljanovic
- Department of Radiology, University of New Mexico, Albuquerque, NM 87131, USA;
- Departments of Medical Imaging and Orthopaedic Surgery, University of Arizona, Tucson, AZ 85721, USA
| |
Collapse
|