451
|
Franklin JM, Glynn RJ, Martin D, Schneeweiss S. Evaluating the Use of Nonrandomized Real-World Data Analyses for Regulatory Decision Making. Clin Pharmacol Ther 2019; 105:867-877. [PMID: 30636285 DOI: 10.1002/cpt.1351] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 11/25/2018] [Indexed: 12/27/2022]
Abstract
The analysis of longitudinal healthcare data outside of highly controlled parallel-group randomized trials, termed real-world evidence (RWE), has received increasing attention in the medical literature. In this paper, we discuss the potential role of RWE in drug regulation with a focus on the analysis of healthcare databases. We present several cases in which RWE is already used and cases in which RWE could potentially support regulatory decision making. We summarize key issues that investigators and regulators should consider when designing or evaluating such studies, and we propose a structured process for implementing analyses that facilitates regulatory review. We evaluate the empirical evidence base supporting the validity, transparency, and reproducibility of RWE from analysis of healthcare databases and discuss the work that still needs to be done to ensure that such analyses can provide decision-ready evidence on the effectiveness and safety of treatments.
Collapse
Affiliation(s)
- Jessica M Franklin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David Martin
- Office of Medical Policy, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
452
|
Perez-Gomez MV, Bartsch LA, Castillo-Rodriguez E, Fernandez-Prado R, Fernandez-Fernandez B, Martin-Cleary C, Gracia-Iguacel C, Ortiz A. Clarifying the concept of chronic kidney disease for non-nephrologists. Clin Kidney J 2019; 12:258-261. [PMID: 30976406 PMCID: PMC6452188 DOI: 10.1093/ckj/sfz007] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Indexed: 12/12/2022] Open
Abstract
Chronic kidney disease (CKD) expands the prior concept of chronic renal insufficiency by including patients with relatively preserved renal function, as assessed by the estimated glomerular filtration rate (eGFR), as even these early CKD stages are associated with an increased risk for all-cause death and cardiovascular death, CKD progression and acute kidney injury. A decreased eGFR (<60 mL/min/1.73 m2) is by itself diagnostic of CKD when persisting for >3 months. However, when eGFR is ≥60 mL/min/1.73 m2, an additional criterion is required to diagnose CKD. In a recent clinical trial published in The New England Journal of Medicine, all 6190 participants were reported to have CKD: 47% had Stages 1 and 2 CKD and 53% had Stage 3 CKD. This illustrates a widespread misunderstanding of the concept of CKD. Moreover, CKD categories in this study were assigned based on the estimated creatinine clearance. Since both estimated creatinine clearance and creatinine clearance overestimate eGFR, this illustrates another frequent misunderstanding: equating GFR with creatinine clearance. In this commentary, we clarify the concept of CKD and of CKD categories for non-nephrologists. Assigning a diagnosis of CKD to a patient with normal renal function and absence of other evidence of CKD may have negative consequences for the individual (e.g. insurance and others) as well as for the medical community at large by creating confusion about the concept.
Collapse
Affiliation(s)
- Maria Vanessa Perez-Gomez
- Department of Nephrology, Instituto de Investigacion Sanitaria de la Fundacion Jimenez Diaz, Madrid, Spain
| | | | | | - Raul Fernandez-Prado
- Department of Nephrology, Hospital Universitario Fundacion Jimenez Diaz, Madrid, Spain
| | | | - Catalina Martin-Cleary
- Department of Nephrology, Instituto de Investigacion Sanitaria de la Fundacion Jimenez Diaz, Madrid, Spain
| | - Carolina Gracia-Iguacel
- Department of Nephrology, Instituto de Investigacion Sanitaria de la Fundacion Jimenez Diaz, Madrid, Spain
| | - Alberto Ortiz
- Universidad Autonoma, Fundacion Jimenez Diaz, Madrid, Spain
| |
Collapse
|
453
|
Day RO, Lau W, Stocker SL, Aung E, Coleshill MJ, Schulz M, Bechara J, Carland JE, Graham GG, Williams KM, McLachlan AJ. Management of gout in older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Richard O. Day
- St Vincent's Hospital Clinical School; UNSW Medicine; Sydney Australia
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
| | - Wendy Lau
- Westmead Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | - Sophie L. Stocker
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | - Eindra Aung
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
| | - Mathew J. Coleshill
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | - Marcel Schulz
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | - Jacob Bechara
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | - Jane E. Carland
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | | | | | - Andrew J. McLachlan
- Sydney Pharmacy School; University of Sydney; Sydney Australia
- Department of Clinical Pharmacology; St Vincent's Hospital; Sydney Darlinghurst Australia
| |
Collapse
|
454
|
Cuenca JA, Balda J, Palacio A, Young L, Pillinger MH, Tamariz L. Febuxostat and Cardiovascular Events: A Systematic Review and Meta-Analysis. Int J Rheumatol 2019; 2019:1076189. [PMID: 30863448 PMCID: PMC6378016 DOI: 10.1155/2019/1076189] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/03/2019] [Accepted: 01/16/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Febuxostat is approved in the United States for the management of hyperuricemia in patients with gout. In November 2017 the FDA released a warning alert on a possible link between febuxostat and cardiovascular disease (CVD) reported in a single clinical trial. OBJECTIVE To conduct a systematic review and meta-analysis and assess the risk of major adverse cardiovascular events (MACE) in patients receiving febuxostat compared to a control group. METHODS We searched the MEDLINE and EMBASE database for studies published up until March 2018. We included randomized clinical trials (RCTs) that compared febuxostat to control groups including placebo and allopurinol. We calculated the pooled relative risk (RR) of MACE and cardiovascular disease (CVD) mortality with the corresponding 95% confidence intervals (CI). RESULTS Our search yielded 374 potentially relevant studies. Among the 25 RCTs included in the systematic review, 10 qualified for the meta-analysis. Among the 14,402 subjects included, the median age was 54 years (IQR 52-67) and 90% were male (IQR 82-96); 8602 received febuxostat, 5118 allopurinol, and 643 placebo. The pooled RR of MACE for febuxostat was 0.9; 95% CI 0.6-1.5 (p= 0.96) compared to the control. The RR of CV-related death for febuxostat was 1.29; 95% CI 1.01-1.66 (p=0.03). CONCLUSIONS Compared with other SU-lowering treatments, febuxostat does not increase or decrease the risk of cardiovascular disease but may increase the risk of CVD death. More RCTs measuring cardiovascular safety as a primary outcome are needed to adequately evaluate the risk of CVD with febuxostat.
Collapse
Affiliation(s)
| | - Javier Balda
- Universidad Catolica de Santiago de Guayaquil, Ecuador
| | - Ana Palacio
- Division of Population Health and Computational Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
- Veterans Affairs Medical Center, Miami, FL, USA
| | - Larry Young
- Veterans Affairs Medical Center, Miami, FL, USA
- Division of Rheumatology, University of Miami, USA
| | - Michael H. Pillinger
- Division of Rheumatology, New York University School of Medicine, USA
- Veterans Affairs Medical Center, New York, NY, USA
| | - Leonardo Tamariz
- Division of Population Health and Computational Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
- Veterans Affairs Medical Center, Miami, FL, USA
| |
Collapse
|
455
|
|
456
|
Pharmacological urate-lowering approaches in chronic kidney disease. Eur J Med Chem 2019; 166:186-196. [PMID: 30769179 DOI: 10.1016/j.ejmech.2019.01.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/20/2019] [Accepted: 01/20/2019] [Indexed: 02/05/2023]
Abstract
Chronic kidney disease (CKD) has become a global public health issue and uric acid (UA) remains a major risk factor of CKD. As the main organ for the elimination of UA, kidney owned a group of urate transporters in tubular epithelium. Kidney disease hampered the UA excretion, and the accumulation of serum UA in return harmed the renal function. Commercially, there are three kinds of agents targeting at urate-lowering, xanthine oxidoreductase inhibitor which prevents the production of UA, uricosuric which increases the concentration of UA in urine thus decreasing serum UA level, and uricase which converts UA to allantoin resulting in the dramatic decrement of serum UA. Of note, in patients with CKD, administration of above-mentioned agents, alone or combined, needs special attention. New evidence is emerging for the efficacy of several urate-lowering drugs for the treatment of hyperuricemia in patients with CKD. Besides, loads of novel and promising drug candidates and phytochemicals are in the different phases of research and development. As of today, there is insufficient evidence to recommend the widespread use of UA-lowering therapy to prevent or slow down the progression of CKD. The review summarized the evidence and perspectives about the treatment of hyperuricemia with CKD for medicinal chemist and nephrologist.
Collapse
|
457
|
Abeles AM, Pillinger MH. Limitations in Assessing Cardiovascular Risk of Febuxostat in Patients With Gout and Cardiovascular Morbidities: Comment on the Article by Choi et al. Arthritis Rheumatol 2019; 71:1023-1024. [PMID: 30657651 DOI: 10.1002/art.40838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
458
|
Arbel Y, Abuzeid W, Rosenson RS, Weisman A, Farkouh ME. Old Drugs for New Indications in Cardiovascular Medicine. Cardiovasc Drugs Ther 2019; 32:223-232. [PMID: 29633048 DOI: 10.1007/s10557-018-6785-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Inflammation participates in the initiation and progression of atherosclerotic cardiovascular disease, and it is a critical inciting factor leading to acute ischemic events. Evidence has shown that certain anti-inflammatory medications used to treat non-atherosclerotic inflammatory diseases reduce cardiovascular events. This article reviews evidence that commonly used anti-inflammatory therapies (colchicine, allopurinol, methotrexate), reduce cardiovascular events. We discuss potential mechanisms of action, efficacy, and safety of these therapies and propose a clinical trials design to investigate their efficacy.
Collapse
Affiliation(s)
- Yaron Arbel
- Department of Cardiology, Tel Aviv Medical Center, Tel Aviv, affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Wael Abuzeid
- Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre, Ontario, Canada, affiliated with the University of Toronto, Toronto, Ontario, Canada
| | - Robert S Rosenson
- Mount Sinai Icahn School of Medicine, Mount Sinai Hospital, New York, USA
| | - Alanna Weisman
- Division of Endocrinology & Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael E Farkouh
- Peter Munk Centre, Heart & Stroke Richard Lewar Centre of Excellence, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
459
|
Lee JW, Lee KH. Comparison of renoprotective effects of febuxostat and allopurinol in hyperuricemic patients with chronic kidney disease. Int Urol Nephrol 2019; 51:467-473. [PMID: 30604229 DOI: 10.1007/s11255-018-2051-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 12/07/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE This study aimed to compare the renoprotective effect between febuxostat and allopurinol in hyperuricemic patients with chronic kidney disease (CKD), about which limited data are available. METHODS 141 patients with stage 3 CKD and hyperuricemia were followed from June 2005 to April 2018. Thirty patients received febuxostat, 40 allopurinol and 71 conventional CKD management only (control group). We compared the mean serum uric acid levels, estimated glomerular filtration rate (eGFR) changes over time and renal survival time free from predefined renal disease progression among these 3 groups. RESULTS Overall, mean age was 62.6 ± 13.3 years, baseline eGFR 42.1 ± 8.8 mL/min/1.73 m2, and serum uric acid 8.6 ± 1.5 mg/dL without intergroup difference. During the observation period (55.9 ± 31.8 months), febuxostat group, compared to both allopurinol and control group, had significantly lower mean serum uric acid levels (5.7 ± 1.0 vs. 7.1 ± 1.2 vs. 8.0 ± 0.8 mg/dL, p < 0.001) and maintained significantly higher mean eGFR values consistently for 4 years. Febuxostat group had significantly longer renal survival time free from renal disease progression than allopurinol and control group (87.7 (95% CI 71.2-104.2) vs. 77.6 (95% CI 60.2-94.9) vs. 48.7 (95% CI 39.3-58.1) months, respectively, p < 0.001). Cox proportional hazard model analysis adjusting for potent confounders revealed that febuxostat, with control group as reference, significantly reduced the risk of renal disease progression by 74.3% (hazard ratio 0.257 (95% CI 0.072-0.912), p = 0.036), while allopurinol showed insignificant result. CONCLUSIONS Febuxostat seems to reduce serum uric acid level and to retard renal disease progression more effectively than allopurinol in hyperuricemic patients with CKD.
Collapse
Affiliation(s)
- Jang-Wook Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Kwang-Hoon Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea.
| |
Collapse
|
460
|
Be cautious when treating gout in patients with renal impairment. DRUGS & THERAPY PERSPECTIVES 2019. [DOI: 10.1007/s40267-018-0568-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
461
|
Jansen TLTA, Janssen M. Gout lessons from 2018: CARES, a direct comparison of febuxostat vs allopurinol, and CANTOS, IL1 blocker for cardiovascular risk minimisation. Clin Rheumatol 2018; 38:263-265. [PMID: 30542798 DOI: 10.1007/s10067-018-4396-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 12/04/2018] [Indexed: 11/29/2022]
Abstract
In the Cardiovascular Safety of Febuxostat and Allopurinol in Patients with Gout and Cardiovascular Morbidities (CARES) trial conducted by White et al. (March 29 issue from NEJM), all-cause mortality and cardiovascular mortality are found to be higher among patients randomly assigned to febuxostat compared to allopurinol, but significant flaws are a clear lack of treat to target strategy with more powered treatment in the febuxostat arm, dysbalance with cardiovascular risk factors selectively in again the febuxostat arm, and discontinuation of the trial regimen in over 50% of patients with discontinuation of follow-up in about 45%. With these flaws, conclusions such as febuxostat-associated higher mortality are potentially if not probably incorrect, and thus febuxostat to be used not as first-line therapy may well be an invalid consequence? The paper here describes potential lessons to be taken.
Collapse
|
462
|
The impact of xanthine oxidase (XO) on hemolytic diseases. Redox Biol 2018; 21:101072. [PMID: 30580157 PMCID: PMC6305892 DOI: 10.1016/j.redox.2018.101072] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/04/2018] [Accepted: 12/06/2018] [Indexed: 01/13/2023] Open
Abstract
Hemolytic diseases are associated with elevated levels of circulating free heme that can mediate endothelial dysfunction directly via redox reactions with biomolecules or indirectly by upregulating enzymatic sources of reactive species. A key enzymatic source of these reactive species is the purine catabolizing enzyme, xanthine oxidase (XO) as the oxidation of hypoxanthine to xanthine and subsequent oxidation of xanthine to uric acid generates superoxide (O2•-) and hydrogen peroxide (H2O2). While XO has been studied for over 120 years, much remains unknown regarding specific mechanistic roles for this enzyme in pathologic processes. This gap in knowledge stems from several interrelated issues including: 1) lethality of global XO deletion and the absence of tissue-specific XO knockout models have coalesced to relegate proof-of-principle experimentation to pharmacology; 2) XO is mobile and thus when upregulated locally can be secreted into the circulation and impact distal vascular beds by high-affinity association to the glycocalyx on the endothelium; and 3) endothelial-bound XO is significantly resistant (> 50%) to inhibition by allopurinol, the principle compound used for XO inhibition in the clinic as well as the laboratory. While it is known that circulating XO is elevated in hemolytic diseases including sickle cell, malaria and sepsis, little is understood regarding its role in these pathologies. As such, the aim of this review is to define our current understanding regarding the effect of hemolysis (free heme) on circulating XO levels as well as the subsequent impact of XO-derived oxidants in hemolytic disease processes.
Collapse
|
463
|
Tamargo J, Caballero R, Delpón E. New drugs in preclinical and early stage clinical development in the treatment of heart failure. Expert Opin Investig Drugs 2018; 28:51-71. [DOI: 10.1080/13543784.2019.1551357] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, CIBERCV, Madrid,
Spain
| | - Ricardo Caballero
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, CIBERCV, Madrid,
Spain
| | - Eva Delpón
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, CIBERCV, Madrid,
Spain
| |
Collapse
|
464
|
Burns RB, Smith CC, Shmerling RH, Tess A. How Would You Manage This Patient With Gout?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2018; 169:788-795. [PMID: 30508444 DOI: 10.7326/m18-2548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Gout is the most common form of inflammatory arthritis. In 2012, the American College of Rheumatology (ACR) issued a guideline, which was followed in 2017 by one from the American College of Physicians (ACP). The guidelines agree on treating acute gout with a corticosteroid, nonsteroidal anti-inflammatory drug, or colchicine and on not initiating long-term urate-lowering therapy (ULT) for most patients after a first gout attack and in those whose attacks are infrequent (<2 per year). However, they differ on treatment of both recurrent gout and problematic gout. The ACR advocates a "treat-to-target" approach, and the ACP did not find enough evidence to support this approach and offered an alternative strategy that bases intensity of ULT on the goal of avoiding recurrent gout attacks ("treat-to-avoid-symptoms") with no monitoring of urate levels. They also disagree on the role of a gout-specific diet. Here, a general internist and a rheumatologist discuss these guidelines; they debate how they would manage an acute attack of gout, if and when to initiate ULT, and the goals for ULT. Lastly, they offer specific advice for a patient who is uncertain about whether to begin this therapy.
Collapse
Affiliation(s)
- Risa B Burns
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., C.C.S., R.H.S., A.T.)
| | - C Christopher Smith
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., C.C.S., R.H.S., A.T.)
| | - Robert H Shmerling
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., C.C.S., R.H.S., A.T.)
| | - Anjala Tess
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.B.B., C.C.S., R.H.S., A.T.)
| |
Collapse
|
465
|
Stamp LK, Chapman PT, Barclay ML, Horne A, Frampton C, Tan P, Drake J, Dalbeth N. How much allopurinol does it take to get to target urate? Comparison of actual dose with creatinine clearance-based dose. Arthritis Res Ther 2018; 20:255. [PMID: 30446002 PMCID: PMC6240322 DOI: 10.1186/s13075-018-1755-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 10/29/2018] [Indexed: 01/13/2023] Open
Abstract
Objective Allopurinol dosing has frequently been limited based on creatinine clearance (CrCL), resulting in failure to achieve target serum urate (SU). The aim of this analysis was to determine how many milligrams of allopurinol above the recommended CrCL-based dose (R+) are required to achieve target SU and to investigate the factors that influence R+. Methods We analysed data from participants in a 24-month open, randomized, controlled, parallel-group, comparative clinical trial. Data obtained during the 12-month dose escalation (DE) phase of the study (year 1 for DE/DE and year 2 for control/DE) were combined. R+ dose was defined as the number of milligrams of allopurinol above the CrCL-based dose at the final visit. Results Of the 132 participants, R+ allopurinol dose at the final visit was ≤ 100 mg/day in 38 (28.8%), 101–200 mg/day in 46 (34.8%) and > 200 mg/day in 48 participants (37.1%). There was no significant difference between the R+ groups in the number of participants achieving target SU. There was an increase in plasma oxypurinol and a larger percentage and absolute change in SU as R+ increased. Multivariate analysis revealed CrCL, weight, baseline SU and allopurinol dose, were significantly positively associated with allopurinol dose at 12 months. There were no significant differences across R+ groups in renal or liver function adverse events, although there were numerically more serious adverse events in the higher R+ groups. Conclusion A wide range of R+ doses are required to achieve target SU. Four easily obtained clinical variables (baseline SU, CrCL, weight, and allopurinol dose) may be helpful to predict allopurinol dose. Trial registration ANZCTR, ACTRN12611000845932. Registered on 10 August 2011. Electronic supplementary material The online version of this article (10.1186/s13075-018-1755-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, P. O. Box 4345, Christchurch, 8140, New Zealand. .,Department of Rheumatology, Immunology and Allergy, Christchurch Hospital, Private Bag 4710, Christchurch, 8140, New Zealand.
| | - Peter T Chapman
- Department of Rheumatology, Immunology and Allergy, Christchurch Hospital, Private Bag 4710, Christchurch, 8140, New Zealand
| | - Murray L Barclay
- Department of Medicine, University of Otago, Christchurch, P. O. Box 4345, Christchurch, 8140, New Zealand.,Department of Clinical Pharmacology, Christchurch Hospital, Private Bag 4710, Christchurch, 8140, New Zealand
| | - Anne Horne
- Department of Medicine, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Christopher Frampton
- Department of Medicine, University of Otago, Christchurch, P. O. Box 4345, Christchurch, 8140, New Zealand
| | - Paul Tan
- Department of Medicine, University of Auckland, Private Bag 92019, Auckland, New Zealand
| | - Jill Drake
- Department of Medicine, University of Otago, Christchurch, P. O. Box 4345, Christchurch, 8140, New Zealand
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Private Bag 92019, Auckland, New Zealand
| |
Collapse
|
466
|
Stamp LK, Wright DFB, Dalbeth N. Restricting maintenance allopurinol dose according to kidney function in patients with gout is inappropriate! Br J Clin Pharmacol 2018; 85:1378-1379. [PMID: 30421456 DOI: 10.1111/bcp.13798] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 10/12/2018] [Indexed: 01/10/2023] Open
Affiliation(s)
- Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand
| | | | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
| |
Collapse
|
467
|
Dissociation between urate and blood pressure in mice and in people with early Parkinson's disease. EBioMedicine 2018; 37:259-268. [PMID: 30415890 PMCID: PMC6284456 DOI: 10.1016/j.ebiom.2018.10.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 10/05/2018] [Accepted: 10/12/2018] [Indexed: 02/02/2023] Open
Abstract
Background Epidemiological, laboratory and clinical studies have established an association between elevated urate and high blood pressure (BP). However, the inference of causality remains controversial. A naturally occurring antioxidant, urate may also be neuroprotective, and urate-elevating treatment with its precursor inosine is currently under clinical development as a potential disease-modifying strategy for Parkinson's disease (PD). Methods Our study takes advantage of a recently completed phase II trial evaluating oral inosine in de novo non-disabling early PD with no major cardiovascular and nephrological conditions, and of three lines of genetically engineered mice: urate oxidase (UOx) global knockout (gKO), conditional KO (cKO), and transgenic (Tg) mice with markedly elevated, mildly elevated, and substantially reduced serum urate, respectively, to systematically investigate effects of urate-modifying manipulation on BP. Findings Among clinical trial participants, change in serum urate but not changes in systolic, diastolic and orthostatic BP differed by treatment group. There was no positive correlation between urate elevations and changes in systolic, diastolic and orthostatic BP ((p = .05 (in inverse direction), 0.30 and 0.63, respectively)). Between UOx gKO, cKO, or Tg mice and their respective wildtype littermates there were no significant differences in systolic or diastolic BP or in their responses to BP-regulating interventions. Interpretation Our complementary preclinical and human studies of urate modulation in animal models and in generally healthy early PD do not support a hypertensive effect of urate elevation or an association between urate and BP. Fund U.S. Department of Defense, RJG Foundation, Michael J. Fox Foundation LEAPS program, National Institutes of Health, American Federation for Aging Research, Parkinson's Disease Foundation Advancing Parkinson's Therapies initiative.
Collapse
|
468
|
Choi H, Neogi T, Stamp L, Dalbeth N, Terkeltaub R. New Perspectives in Rheumatology: Implications of the Cardiovascular Safety of Febuxostat and Allopurinol in Patients With Gout and Cardiovascular Morbidities Trial and the Associated Food and Drug Administration Public Safety Alert. Arthritis Rheumatol 2018; 70:1702-1709. [PMID: 29869840 PMCID: PMC6203619 DOI: 10.1002/art.40583] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 05/31/2018] [Indexed: 12/12/2022]
Abstract
Recently, the US Food and Drug Administration (FDA) issued a public safety alert, responding to the results of the now-published Cardiovascular Safety of Febuxostat and Allopurinol in Patients With Gout and Cardiovascular Morbidities (CARES) trial. The CARES trial showed no significant difference between allopurinol and febuxostat in the primary composite end point of cardiovascular (CV) events in subjects with gout and established CV comorbidities at baseline. However, there was a significantly increased risk of CV and all-cause mortality with febuxostat. Urate-lowering therapy (ULT) is central to the long-term management of gout, and xanthine oxidoreductase inhibitor (XOI) therapy is the consensus first-line approach. Allopurinol is generally the first XOI used, but febuxostat is an effective XOI option, and is commonly used when allopurinol is not tolerated. These data are further relevant since CV comorbidities are common in gout. Here, we examine why the CARES trial was done, and discuss other, ongoing comparative studies of febuxostat and allopurinol whose results are awaited. We assess the strengths and limitations of the CARES trial, and appraise the robustness and biologic plausibility of the results. The CARES trial does not prove that febuxostat raises CV mortality risk, but suggests greater risk with febuxostat than allopurinol. The CARES trial results do not support first-line use of febuxostat ULT, and raise questions about febuxostat placement at various pharmacologic ULT decision tree branches. Alternatives to febuxostat that are frequently effective include allopurinol dose escalation and uricosuric therapy alone or combined with allopurinol. The FDA safety alert highlights the need for shared ULT medical decision-making with gout patients, including discussion of the CV safety of febuxostat.
Collapse
Affiliation(s)
- Hyon Choi
- Professor of Medicine and Rheumatologist, Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Bulfinch 165, Boston, MA 02114
| | - Tuhina Neogi
- Professor of Medicine and Rheumatologist, Boston University School of Medicine, Clinical Epidemiology Unit, Suite X200, Boston, MA, 02118
| | - Lisa Stamp
- Professor of Medicine and Rheumatologist, Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand
| | - Nicola Dalbeth
- Professor of Medicine and Rheumatologist, Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Robert Terkeltaub
- Professor of Medicine and Rheumatologist, VA San Diego Healthcare System, San Diego, CA, Dept. of Medicine, University of California San Diego, La Jolla, CA
| |
Collapse
|
469
|
Robinson PC. Gout - An update of aetiology, genetics, co-morbidities and management. Maturitas 2018; 118:67-73. [PMID: 30415758 DOI: 10.1016/j.maturitas.2018.10.012] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/22/2018] [Accepted: 10/25/2018] [Indexed: 02/07/2023]
Abstract
Gout is an increasingly common chronic disorder of urate crystal deposition that manifests as flares of acute inflammatory arthritis. Hyperuricaemia is a prerequisite and a fifth of both men and woman are hyperuricaemic. The prevalence of gout is much lower than the prevalence of hyperuricaemia for reasons that are not currently clear. Gout is more common in men than women prior to menopause due to the uricosuric effects of oestrogen, but after menopause the incidence of gout rises substantially in women. Co-morbidities are an important issue in gout, with cardiovascular disease, diabetes mellitus, obesity and chronic kidney disease all common in patients with gout. Environmental factors like diet affect the incidence of gout but there is little evidence to support an emphasis on diet in treating established gout. The diagnosis of gout is often made without the use of joint aspiration and validated diagnostic rules are available for both primary and secondary care as well as classification criteria for research use. The overarching principle of the management of gout with pharmacotherapy is the need to reduce serum urate levels to below a target of 0.30 mmol/L or 0.36 mmol/L depending on whether it is tophaceous or non-tophaceous respectively. The use of allopurinol has been researched extensively and newer strategies for safer effective dosing are now recommended. Newer agents have been introduced for the treatment of gout, including febuxostat and lesinurad. A number of important questions in the field are under current investigation.
Collapse
Affiliation(s)
- Philip C Robinson
- University of Queensland School of Clinical Medicine, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, Brisbane, Queensland, 4006, Australia.
| |
Collapse
|
470
|
Neogi T, Dalbeth N. Patient education and engagement in treat-to-target gout care. Lancet 2018; 392:1379-1381. [PMID: 30343848 DOI: 10.1016/s0140-6736(18)32415-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 09/26/2018] [Indexed: 12/27/2022]
Affiliation(s)
- Tuhina Neogi
- Boston University School of Medicine, Clinical Epidemiology Unit, Boston, MA 02118, USA.
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
| |
Collapse
|
471
|
Chan CW, Yap YN. Pharmacotherapeutic management of gout in patients with cardiac disease. Expert Opin Pharmacother 2018; 19:2011-2018. [DOI: 10.1080/14656566.2018.1536747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Chun Wai Chan
- Department of Family Medicine, School of Medicine, International Medical University , Seremban, Negeri Sembilan Darul Khusus, Malaysia
| | - Ying Nee Yap
- School of Medicine, International Medical University , Kuala Lumpur, Malaysia
| |
Collapse
|
472
|
Affiliation(s)
- William B White
- University of Connecticut School of Medicine, Farmington, CT
| | | |
Collapse
|
473
|
Galindo T, Reyna J, Weyer A. Evidence for Transient Receptor Potential (TRP) Channel Contribution to Arthritis Pain and Pathogenesis. Pharmaceuticals (Basel) 2018; 11:E105. [PMID: 30326593 PMCID: PMC6315622 DOI: 10.3390/ph11040105] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 10/08/2018] [Accepted: 10/12/2018] [Indexed: 02/07/2023] Open
Abstract
Based on clinical and preclinical evidence, Transient Receptor Potential (TRP) channels have emerged as potential drug targets for the treatment of osteoarthritis, rheumatoid arthritis, and gout. This review summarizes the relevant data supporting a role for various TRP channels in arthritis pain and pathogenesis, as well as the current state of pharmacological efforts to ameliorate arthritis symptoms in patient populations.
Collapse
Affiliation(s)
- Tabitha Galindo
- School of Physical Therapy and Athletic Training, Pacific University, Hillsboro, OR 97116, USA.
| | - Jose Reyna
- School of Physical Therapy and Athletic Training, Pacific University, Hillsboro, OR 97116, USA.
| | - Andy Weyer
- Biological Sciences Department, City College of San Francisco, San Francisco, CA 94112, USA.
| |
Collapse
|
474
|
Abstract
The definition of asymptomatic hyperuricemia remains unclear, as no consensus exists about the serum urate cutoff or the relevance of ultrasound findings. Comorbidities associated with hyperuricemia have increased in frequency over the past two decades. Hyperuricemia (and/or gout) may be a cause or a consequence of a comorbidity. Whereas epidemiological studies suggest that hyperuricemia may be linked to cardiovascular, metabolic, and renal comorbidities, Mendelian randomization studies have not provided proof that these links are causal. Discrepancies between findings from observational studies and clinical trials preclude the development of recommendations about the potential benefits of urate-lowering therapy (ULT) in individual patients with asymptomatic hyperuricemia. The risk/benefit ratio of ULT is unclear. The risk of developing gout, estimated at 50%, must be weighed against the risk of cutaneous and cardiovascular side effects of xanthine oxidase inhibitors. The need for optimal comorbidity management, in contrast, is universally accepted. Medications for comorbidities that elevate urate levels should be discontinued and replaced with medications that have the opposite effect. Therapeutic lifestyle changes, weight loss as appropriate, and sufficient physical activity are useful for improving general health. Whether ULT has beneficial effects on comorbidities will be known only when well-powered interventional trials with relevant primary endpoints are available.
Collapse
Affiliation(s)
- Gérard Chalès
- Faculté de Médecine de Rennes, 2, avenue du professeur Léon-Bernard, 35000 Rennes, France.
| |
Collapse
|
475
|
Katsiki N, Borghi C. The future of febuxostat after the Cardiovascular Safety of Febuxostat and Allopurinol in Patients with Gout and Cardiovascular Morbidities (CARES) trial: who CARES? Expert Opin Pharmacother 2018; 19:1853-1856. [DOI: 10.1080/14656566.2018.1532503] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Niki Katsiki
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| |
Collapse
|
476
|
Wu X, Li C. Fresh Perspectives on the CARES Trial and the Use of Febuxostat in an Asian Population: Comment on the Article by Choi et al. Arthritis Rheumatol 2018; 71:479-481. [PMID: 30294926 DOI: 10.1002/art.40741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Xinjiang Wu
- Qingdao University, Qingdao, China.,Medscience-Tech Institute for Non-communicable Diseases, Wuhan, China
| | - Changgui Li
- Qingdao University and Affiliated Hospital of Qingdao University, Qingdao, China
| |
Collapse
|
477
|
Coburn BW, Michaud K, Bergman DA, Mikuls TR. Reply. Arthritis Rheumatol 2018; 70:1697-1698. [DOI: 10.1002/art.40549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Brian W. Coburn
- Veterans Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center; Omaha NE
| | - Kaleb Michaud
- University of Nebraska Medical Center Omaha, NE and National Data Bank for Rheumatic Diseases; Wichita KS
| | | | - Ted R. Mikuls
- Veterans Affairs Nebraska-Western Iowa Health Care System and University of Nebraska Medical Center; Omaha NE
| |
Collapse
|
478
|
Bredemeier M. Mounting Evidence Indicates That Escalating Doses of Allopurinol Are Unnecessary for Cardiovascular Protection: Comment on the Article by Coburn et al. Arthritis Rheumatol 2018; 70:1696-1697. [DOI: 10.1002/art.40548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Markus Bredemeier
- Hospital Nossa Senhora da Conceição; Grupo Hospitalar Conceição; Porto Alegre Brazil
| |
Collapse
|
479
|
Kimura K, Hosoya T, Uchida S, Inaba M, Makino H, Maruyama S, Ito S, Yamamoto T, Tomino Y, Ohno I, Shibagaki Y, Iimuro S, Imai N, Kuwabara M, Hayakawa H, Ohtsu H, Ohashi Y. Febuxostat Therapy for Patients With Stage 3 CKD and Asymptomatic Hyperuricemia: A Randomized Trial. Am J Kidney Dis 2018; 72:798-810. [PMID: 30177485 DOI: 10.1053/j.ajkd.2018.06.028] [Citation(s) in RCA: 215] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 06/19/2018] [Indexed: 02/07/2023]
Abstract
RATIONALE & OBJECTIVE Epidemiologic and clinical studies have suggested that urate-lowering therapy may slow the progression of chronic kidney disease (CKD). However, definitive evidence is lacking. STUDY DESIGN Randomized, double-blind, placebo-controlled trial. SETTING & PARTICIPANTS 467 patients with stage 3 CKD and asymptomatic hyperuricemia at 55 medical institutions in Japan. INTERVENTION Participants were randomly assigned in a 1:1 ratio to receive febuxostat or placebo for 108 weeks. OUTCOMES The primary end point was the slope (in mL/min/1.73m2 per year) of estimated glomerular filtration rate (eGFR). Secondary end points included changes in eGFRs and serum uric acid levels at 24, 48, 72, and 108 weeks of follow-up and the event of doubling of serum creatinine level or initiation of dialysis therapy. RESULTS Of 443 patients who were randomly assigned, 219 and 222 assigned to febuxostat and placebo, respectively, were included in the analysis. There was no significant difference in mean eGFR slope between the febuxostat (0.23±5.26mL/min/1.73m2 per year) and placebo (-0.47±4.48mL/min/1.73m2 per year) groups (difference, 0.70; 95% CI, -0.21 to 1.62; P=0.1). Subgroup analysis demonstrated a significant benefit from febuxostat in patients without proteinuria (P=0.005) and for whom serum creatinine concentration was lower than the median (P=0.009). The incidence of gouty arthritis was significantly lower (P=0.007) in the febuxostat group (0.91%) than in the placebo group (5.86%). Adverse events specific to febuxostat were not observed. LIMITATIONS GFR was estimated rather than measured, and patients with stages 4 and 5 CKD were excluded. CONCLUSIONS Compared to placebo, febuxostat did not mitigate the decline in kidney function among patients with stage 3 CKD and asymptomatic hyperuricemia. FUNDING Funded by Teijin Pharma Limited. TRIAL REGISTRATION Registered at the UMIN (University Hospital Medical Information Network) Clinical Trials Registry with study number UMIN000008343.
Collapse
Affiliation(s)
| | - Tatsuo Hosoya
- Division of Chronic Kidney Disease Therapeutics, The Jikei University, Tokyo, Japan
| | - Shunya Uchida
- Department of Internal Medicine, Teikyo University, Tokyo, Japan
| | - Masaaki Inaba
- Department of Metabolism, Endocrinology, and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | | | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Sadayoshi Ito
- Department of Nephrology, Hypertension, and Endocrinology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tetsuya Yamamoto
- Health Evaluation Center, Osaka Gyoumeikan Hospital, Osaka, Japan
| | - Yasuhiko Tomino
- Department of Nephrology, Juntendo University School of Medicine, Tokyo, Japan
| | - Iwao Ohno
- Division of General Medicine, Department of Internal Medicine, The Jikei University, Tokyo, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Satoshi Iimuro
- Teikyo Academic Research Center, Teikyo University, Tokyo, Japan
| | - Naohiko Imai
- Division of Nephrology and Hypertension, Kawasaki Municipal Tama Hospital, Kawasaki, Japan
| | - Masanari Kuwabara
- Department of Cardiology, Toranomon Hospital, Tokyo, Japan; Division of Renal Disease and Hypertension, University of Colorado Denver School of Medicine, Denver, CO
| | - Hiroshi Hayakawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University, Tokyo, Japan
| | - Hiroshi Ohtsu
- Center for Clinical Science, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yasuo Ohashi
- Department of Integrated Science and Engineering for Sustainable Society, Chuo University, Tokyo, Japan
| | | |
Collapse
|
480
|
Guo W, Zhao M, Tan W, Zheng L, Tao K, Chen L, Wang M, Chen D, Fan X. Base-Promoted Metal-/Oxidant-Free Three-Component Tandem Annulation: A Strategy for the Construction of 2,4,5-Trisubstituted Thiazoles via C−N Bond Cleavage of Amidines. ASIAN J ORG CHEM 2018. [DOI: 10.1002/ajoc.201800417] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Wei Guo
- Key Laboratory of Organo-pharmaceutical Chemistry of Jiangxi Province; Gannan Normal University; Ganzhou 341000 P. R. China
| | - Mingming Zhao
- Key Laboratory of Organo-pharmaceutical Chemistry of Jiangxi Province; Gannan Normal University; Ganzhou 341000 P. R. China
| | - Wen Tan
- Key Laboratory of Organo-pharmaceutical Chemistry of Jiangxi Province; Gannan Normal University; Ganzhou 341000 P. R. China
| | - Lvyin Zheng
- Key Laboratory of Organo-pharmaceutical Chemistry of Jiangxi Province; Gannan Normal University; Ganzhou 341000 P. R. China
| | - Kailiang Tao
- Key Laboratory of Organo-pharmaceutical Chemistry of Jiangxi Province; Gannan Normal University; Ganzhou 341000 P. R. China
| | - Luyan Chen
- Key Laboratory of Organo-pharmaceutical Chemistry of Jiangxi Province; Gannan Normal University; Ganzhou 341000 P. R. China
| | - Mingfeng Wang
- Key Laboratory of Organo-pharmaceutical Chemistry of Jiangxi Province; Gannan Normal University; Ganzhou 341000 P. R. China
| | - Deliang Chen
- Key Laboratory of Organo-pharmaceutical Chemistry of Jiangxi Province; Gannan Normal University; Ganzhou 341000 P. R. China
| | - Xiaolin Fan
- Key Laboratory of Organo-pharmaceutical Chemistry of Jiangxi Province; Gannan Normal University; Ganzhou 341000 P. R. China
| |
Collapse
|
481
|
Pagidipati NJ, Clare RM, Keenan RT, Chiswell K, Roe MT, Hess CN. Association of Gout With Long-Term Cardiovascular Outcomes Among Patients With Obstructive Coronary Artery Disease. J Am Heart Assoc 2018; 7:e009328. [PMID: 30369327 PMCID: PMC6201404 DOI: 10.1161/jaha.118.009328] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/03/2018] [Indexed: 12/15/2022]
Abstract
Background Epidemiological studies demonstrating a relationship between gout and cardiovascular disease are older and predate modern cardiovascular preventive therapy. We assessed the contemporary association between gout and cardiovascular disease in patients with obstructive coronary artery disease. Methods and Results Data were from the Duke Databank for Cardiovascular Diseases, which followed up patients undergoing cardiac catheterization with obstructive coronary artery disease at Duke University Medical Center (1998-2013). We assessed the relationship between gout diagnosis at baseline or during follow-up and the primary composite outcome of cardiovascular death, myocardial infarction, or stroke, adjusting for differences in baseline clinical factors. Secondary end points included cardiovascular death and all-cause mortality. New, postbaseline, gout diagnosis was included as a time-dependent covariate. Among 17 201 patients, 1406 (8.2%) had baseline gout and a high burden of cardiovascular risk factors, but high rates of optimal medical therapy. Over a median follow-up of 6.4 years, gout diagnosis at time of catheterization was not associated with the primary outcome (hazard ratio [95% confidence interval], 1.05 [0.96-1.15]; P=0.31) or cardiovascular death (hazard ratio [95% confidence interval], 1.10 [0.99-1.22]; P=0.08), but was associated with increased all-cause mortality (hazard ratio [95% confidence interval], 1.13 [1.05-1.23]; P=0.002). After including new, postbaseline, gout diagnosis, the instantaneous risk of the primary outcome was significantly associated with prior gout diagnosis (hazard ratio [95% confidence interval], 1.15 [1.07-1.25]; P=0.0004). Conclusions A clinical history of gout is associated with worse outcomes in a contemporary population of patients with obstructive coronary artery disease. This increased risk exists despite high levels of optimal baseline cardiovascular disease medical therapy, suggesting that residual cardiovascular risk is not addressed by standard medical therapy.
Collapse
Affiliation(s)
- Neha J. Pagidipati
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
| | - Robert M. Clare
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
| | - Robert T. Keenan
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
| | - Karen Chiswell
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
| | - Matthew T. Roe
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNC
| | - Connie N. Hess
- University of Colorado School of MedicineAuroraCO
- CPC Clinical ResearchAuroraCO
| |
Collapse
|
482
|
Abstract
INTRODUCTION Febuxostat is a potent non-purine selective xanthine oxidase inhibitor approved by the FDA in 2009 for management of hyperuricemia in people with gout. Areas covered: The authors summarize the pre-clinical studies and pivotal randomized controlled trials of febuxostat when used as a treatment for hyperuricaemia in gout Expert opinion: Febuxostat has clinical efficacy in serum urate lowering, and long-term use leads to improved outcomes such as gout flare frequency and tophus burden. Recently published post-approval placebo-controlled trials have demonstrated urate-lowering efficacy and safety of febuxostat in patients with chronic kidney disease, and reduced frequency of gout flares in people with early onset of gout. In November 2017, the FDA issued a drug safety communication based on the preliminary results of the CARES trial. This cardiovascular safety study of 6190 patients with gout and established cardiovascular disease comparing febuxostat and allopurinol showed no difference in the primary endpoint (a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or unstable angina with urgent revascularization), but did report higher all-cause mortality (hazard ratio 1.22) and cardiovascular mortality (hazard ratio 1.34) with febuxostat. Based on currently available data, it seems likely that allopurinol, rather than febuxostat, will remain first line urate-lowering therapy for people with gout.
Collapse
Affiliation(s)
- Philip C Robinson
- a Royal Brisbane Hospital , University of Queensland Faculty of Medicine , Brisbane , Queensland , Australia.,b Department of Rheumatology , Royal Brisbane & Women's Hospital , Brisbane , Queensland , Australia
| | - Nicola Dalbeth
- c Bone and Joint Research Group, Department of Medicine , University of Auckland , Auckland , New Zealand.,d Department of Rheumatology , Auckland District Health Board , Auckland , New Zealand
| |
Collapse
|
483
|
|
484
|
Mukri MNA, Kong WY, Mustafar R, Shaharir SS, Shah SA, Abdul Gafor AH, Mohd R, Abdul Cader R, Kamaruzaman L. Role of febuxostat in retarding progression of diabetic kidney disease with asymptomatic hyperuricemia: A 6-months open-label, randomized controlled trial. EXCLI JOURNAL 2018; 17:563-575. [PMID: 30108461 PMCID: PMC6088214 DOI: 10.17179/excli2018-1256] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/12/2018] [Indexed: 11/10/2022]
Abstract
Introduction: Hyperuricemia is associated with chronic kidney disease (CKD) progression and poor cardiovascular outcomes. We studied the effect of febuxostat on estimated glomerular filtration rate (eGFR), proteinuria and monitored the safety profile of the medication. Material and Methods: This is a prospective open-label, randomized study in CKD stage 3 and 4 patients with diabetic nephropathy and asymptomatic hyperuricemia. Patients were randomized into febuxostat 40 mg daily and no treatment group using block randomization method and were followed up for 6 months. Their usual care for diabetes mellitus, hypertension and dyslipidemia were continued in the study. Blood and urine investigations were monitored at baseline, 3 months and 6 months. Results: The eGFR in febuxostat group was stabilized at 6 months with no significant reduction [26.2 (IQR 14.30) at baseline to 26.3 (IQR 15.2) ml/min/1.73 m2]. Whereas, there was a significant reduction of the eGFR in no treatment group from 28.2 (IQR 17.9) to 27.6 (IQR 19.3) ml/min/1.73 m2 (p value < 0.01). We found the HbA1c (glycosylated hemoglobin) was significantly increased in febuxostat group from 7.2 ± 0.5 % at baseline to 7.6 ± 1.4 at 6 months (p value 0.04) but no significant change of HbA1c in the no treatment group. Proteinuria level was unchanged in both groups. The commonest adverse event was joint pain. Conclusions: Febuxostat was able to preserve eGFR in CKD patients with diabetic nephropathy and this effect was beyond glycemic control. Increment of HbA1c level in febuxostat group needs further larger trials.
Collapse
Affiliation(s)
- Mohd Noor Azreey Mukri
- Nephrology Unit, Department of Medicine, National University of Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, Cheras 56000, Kuala Lumpur, Malaysia
| | - Wei-Yen Kong
- Nephrology Unit, Department of Medicine, National University of Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, Cheras 56000, Kuala Lumpur, Malaysia
| | - Ruslinda Mustafar
- Nephrology Unit, Department of Medicine, National University of Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, Cheras 56000, Kuala Lumpur, Malaysia
| | - Syahrul Sazliyana Shaharir
- Rheumatology Unit, Department of Medicine, National University of Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, Cheras 56000, Kuala Lumpur, Malaysia
| | - Shamsul Azhar Shah
- Department of Community Health, UKM Medical Molecular Biology Institute, Jalan Yaakob Latif, Bandar Tun Razak, Cheras 56000, Kuala Lumpur, Malaysia
| | - Abdul Halim Abdul Gafor
- Nephrology Unit, Department of Medicine, National University of Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, Cheras 56000, Kuala Lumpur, Malaysia
| | - Rozita Mohd
- Nephrology Unit, Department of Medicine, National University of Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, Cheras 56000, Kuala Lumpur, Malaysia
| | - Rizna Abdul Cader
- Nephrology Unit, Department of Medicine, National University of Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, Cheras 56000, Kuala Lumpur, Malaysia
| | - Lydia Kamaruzaman
- Nephrology Unit, Department of Medicine, National University of Malaysia, Jalan Yaakob Latif, Bandar Tun Razak, Cheras 56000, Kuala Lumpur, Malaysia
| |
Collapse
|
485
|
Vanholder R, Van Laecke S, Glorieux G, Verbeke F, Castillo-Rodriguez E, Ortiz A. Deleting Death and Dialysis: Conservative Care of Cardio-Vascular Risk and Kidney Function Loss in Chronic Kidney Disease (CKD). Toxins (Basel) 2018; 10:E237. [PMID: 29895722 PMCID: PMC6024824 DOI: 10.3390/toxins10060237] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/11/2018] [Indexed: 02/07/2023] Open
Abstract
The uremic syndrome, which is the clinical expression of chronic kidney disease (CKD), is a complex amalgam of accelerated aging and organ dysfunctions, whereby cardio-vascular disease plays a capital role. In this narrative review, we offer a summary of the current conservative (medical) treatment options for cardio-vascular and overall morbidity and mortality risk in CKD. Since the progression of CKD is also associated with a higher cardio-vascular risk, we summarize the interventions that may prevent the progression of CKD as well. We pay attention to established therapies, as well as to novel promising options. Approaches that have been considered are not limited to pharmacological approaches but take into account lifestyle measures and diet as well. We took as many randomized controlled hard endpoint outcome trials as possible into account, although observational studies and post hoc analyses were included where appropriate. We also considered health economic aspects. Based on this information, we constructed comprehensive tables summarizing the available therapeutic options and the number and kind of studies (controlled or not, contradictory outcomes or not) with regard to each approach. Our review underscores the scarcity of well-designed large controlled trials in CKD. Nevertheless, based on the controlled and observational data, a therapeutic algorithm can be developed for this complex and multifactorial condition. It is likely that interventions should be aimed at targeting several modifiable factors simultaneously.
Collapse
Affiliation(s)
- Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Steven Van Laecke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Griet Glorieux
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Francis Verbeke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | | | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, 28040 Madrid, Spain.
| |
Collapse
|
486
|
Cardiovascular safety of febuxostat and allopurinol. Drug Ther Bull 2018; 56:63. [PMID: 29875169 DOI: 10.1136/dtb.2018.5.0630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
|
487
|
McHugh J. Surprising safety outcomes of urate-lowering therapy. Nat Rev Rheumatol 2018; 14:320. [DOI: 10.1038/s41584-018-0007-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
488
|
Benn CL, Dua P, Gurrell R, Loudon P, Pike A, Storer RI, Vangjeli C. Physiology of Hyperuricemia and Urate-Lowering Treatments. Front Med (Lausanne) 2018; 5:160. [PMID: 29904633 PMCID: PMC5990632 DOI: 10.3389/fmed.2018.00160] [Citation(s) in RCA: 145] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 05/08/2018] [Indexed: 12/18/2022] Open
Abstract
Gout is the most common form of inflammatory arthritis and is a multifactorial disease typically characterized by hyperuricemia and monosodium urate crystal deposition predominantly in, but not limited to, the joints and the urinary tract. The prevalence of gout and hyperuricemia has increased in developed countries over the past two decades and research into the area has become progressively more active. We review the current field of knowledge with emphasis on active areas of hyperuricemia research including the underlying physiology, genetics and epidemiology, with a focus on studies which suggest association of hyperuricemia with common comorbidities including cardiovascular disease, renal insufficiency, metabolic syndrome and diabetes. Finally, we discuss current therapies and emerging drug discovery efforts aimed at delivering an optimized clinical treatment strategy.
Collapse
Affiliation(s)
| | - Pinky Dua
- Pfizer Ltd., Cambridge, United Kingdom
| | | | | | - Andrew Pike
- DMPK, Oncology, IMED Biotech Unit, AstraZeneca, Cambridge, United Kingdom
| | - R Ian Storer
- IMED Biotech Unit, Medicinal Chemistry, Discovery Sciences, AstraZeneca, Cambridge, United Kingdom
| | | |
Collapse
|
489
|
Klein RW, Kabadi S, Cinfio FN, Bly CA, Taylor DC, Szymanski KA. Budget impact of adding lesinurad for second-line treatment of gout: a US health plan perspective. J Comp Eff Res 2018; 7:807-816. [PMID: 29792516 DOI: 10.2217/cer-2017-0103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Aim: To estimate budget impact of adopting lesinurad as add-on to allopurinol for urate-lowering therapy in gout. Methods: A budget impact model was developed for a US payer perspective, using a Markov model to estimate costs, survival and discontinuation in a one-million-member health plan. The population included patients failing first-line gout therapy, followed for 5 years. Results: Incremental costs of adding lesinurad versus no lesinurad were US$241,907 and US$1,098,220 in first and fifth years, respectively. Cumulative 5-year incremental cost was US$3,633,440. Estimated incremental mean cost per treated patient with gout per year was US$112. The mean per-member per-month cost increased by US$0.06. Conclusion: Initiating lesinurad would result in an incremental per-member per-month cost of US$0.06 over 5 years.
Collapse
Affiliation(s)
- Robert W Klein
- Medical Decision Modeling, Inc., 3500 DePauw Blvd #1037, Indianapolis, IN 46268, USA
| | - Shaum Kabadi
- AstraZeneca LP, 101 Orchard Ridge Drive, Gaithersburg, MD 20878, USA
| | - Frank N Cinfio
- Medical Decision Modeling, Inc., 201 N. Illinois #1175, Indianapolis, IN 46204, USA
| | - Christopher A Bly
- Medical Decision Modeling, Inc., 201 N. Illinois #1175, Indianapolis, IN 46204, USA
| | - Douglas Ca Taylor
- Ironwood Pharmaceuticals, 301 Binney Street, Cambridge, MA 02142, USA
| | | |
Collapse
|
490
|
Hashimoto T, Ako J. Report of the Annual Scientific Session of the American College of Cardiology (ACC) 2018, Orlando. Circ J 2018; 82:1491-1496. [PMID: 29709996 DOI: 10.1253/circj.cj-18-0405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The 67thAnnual Scientific Session and Expo of the American College of Cardiology (ACC) were held at the Orange County Convention Center, Orlando, from March 10-12, 2018. This meeting offered 2,700 accepted abstracts presented in oral and poster sessions by 2,100 experts and 37 Late-Breaking Clinical Trials and Featured Clinical Research presentations. This report introduces the key presentations and highlights from the ACC 2018 Scientific Session.
Collapse
Affiliation(s)
- Takuya Hashimoto
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| |
Collapse
|
491
|
Jordan A, Gresser U. Side Effects and Interactions of the Xanthine Oxidase Inhibitor Febuxostat. Pharmaceuticals (Basel) 2018; 11:ph11020051. [PMID: 29799494 PMCID: PMC6027216 DOI: 10.3390/ph11020051] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/21/2018] [Accepted: 05/21/2018] [Indexed: 12/15/2022] Open
Abstract
The paper addresses the safety of febuxostat and summarizes reports on side effects and interactions of febuxostat published by the cut-off date (last day of literature search) of 20 March 2018. Publications on side effects and the interactions of febuxostat were considered. Information concerning the occurrence of side effects and interactions in association with the treatment with febuxostat was collected and summarized in the review. The incidence of severe side effects was much less frequent than mild side effects (1.2–3.8% to 20.1–38.7%). The rate and range of febuxostat side effects are low at doses of up to 120 mg and only increase with a daily dose of over 120 mg. The publications reveal no age-dependent increase in side effects for febuxostat. In patients with impaired renal function, no increase in adverse events is described with a dose of up to 120 mg of febuxostat per day. Patients with impaired liver function had no elevated risk for severe side effects. A known allopurinol intolerance increases the risk of skin reactions during treatment with febuxostat by a factor of 3.6. No correlation between treatment with febuxostat and agranulocytosis has been confirmed. Possible interactions with very few medications (principally azathioprine) are known for febuxostat. Febuxostat is well tolerated and a modern and safe alternative to allopurinol therapy.
Collapse
Affiliation(s)
- Andreas Jordan
- Internal Medicine, Medical Faculty, Ludwig Maximilians University of Munich, 80539 Munich, Germany.
| | - Ursula Gresser
- Internal Medicine, Medical Faculty, Ludwig Maximilians University of Munich, 80539 Munich, Germany.
| |
Collapse
|
492
|
Ndrepepa G. Uric acid and cardiovascular disease. Clin Chim Acta 2018; 484:150-163. [PMID: 29803897 DOI: 10.1016/j.cca.2018.05.046] [Citation(s) in RCA: 260] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 05/23/2018] [Indexed: 12/22/2022]
Abstract
Uric acid (UA) is an end product of purine metabolism in humans and great apes. UA acts as an antioxidant and it accounts for 50% of the total antioxidant capacity of biological fluids in humans. When present in cytoplasm of the cells or in acidic/hydrophobic milieu in atherosclerotic plaques, UA converts into a pro-oxidant agent and promotes oxidative stress and through this mechanism participates in the pathophysiology of human disease including cardiovascular disease (CVD). Most epidemiological studies but not all of them suggested the existence of an association between elevated serum UA level and CVD, including coronary heart disease (CHD), stroke, congestive heart failure, arterial hypertension and atrial fibrillation as well as an increased risk for mortality due to CVD in general population and subjects with confirmed CHD. Evidence available also suggests an association between elevated UA and traditional cardiovascular risk factors, metabolic syndrome, insulin resistance, obesity, non-alcoholic fatty liver disease and chronic kidney disease. Experimental and clinical studies have evidenced several mechanisms through which elevated UA level exerts deleterious effects on cardiovascular health including increased oxidative stress, reduced availability of nitric oxide and endothelial dysfunction, promotion of local and systemic inflammation, vasoconstriction and proliferation of vascular smooth muscle cells, insulin resistance and metabolic dysregulation. Although the causality in the relationship between UA and CVD remains unproven, UA may be pathogenic and participate in the pathophysiology of CVD by serving as a bridging mechanism mediating (enabling) or potentiating the deleterious effects of cardiovascular risk factors on vascular tissue and myocardium.
Collapse
Affiliation(s)
- Gjin Ndrepepa
- Department of Adult Cardiology, Deutsches Herzzentrum München, Technische Universität, Munich, Germany.
| |
Collapse
|
493
|
Safety and Efficacy of Benzbromarone and Febuxostat in Hyperuricemia Patients with Chronic Kidney Disease: A Prospective Pilot Study. Clin Exp Nephrol 2018; 22:1324-1330. [DOI: 10.1007/s10157-018-1586-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 04/28/2018] [Indexed: 01/22/2023]
|
494
|
Schlimpert V. [Not Available]. MMW Fortschr Med 2018; 160:14. [PMID: 29619724 DOI: 10.1007/s15006-018-0351-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
|