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Schlesinger N, Pillinger MH, Simon LS, Lipsky PE. Interleukin-1β inhibitors for the management of acute gout flares: a systematic literature review. Arthritis Res Ther 2023; 25:128. [PMID: 37491293 PMCID: PMC10367374 DOI: 10.1186/s13075-023-03098-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/23/2023] [Indexed: 07/27/2023] Open
Abstract
OBJECTIVES The objective of this systematic review was to assess the effects of interleukin-1β (IL-1β) inhibitors on gout flares. METHODS Studies published between 2011 and 2022 that evaluated the effects of IL-1β inhibitors in adult patients experiencing gout flares were eligible for inclusion. Outcomes including pain, frequency and intensity of gout flares, inflammation, and safety were assessed. Five electronic databases (Pubmed/Medline, Embase, Biosis/Ovid, Web of Science and Cochrane Library) were searched. Two independent reviewers performed study screening, data extraction and risk of bias assessments (Cochrane Risk of Bias Tool 2 for randomised controlled trials [RCTs] and Downs and Black for non-RCTs). Data are reported as a narrative synthesis. RESULTS Fourteen studies (10 RCTs) met the inclusion criteria, with canakinumab, anakinra, and rilonacept being the three included IL-1β inhibitors. A total of 4367 patients with a history of gout were included from the 14 studies (N = 3446, RCTs; N = 159, retrospective studies [with a history of gout]; N = 762, post hoc analysis [with a history of gout]). In the RCTs, canakinumab and rilonacept were reported to have a better response compared to an active comparator for resolving pain, while anakinra appeared to be not inferior to an active comparator for resolving pain. Furthermore, canakinumab and rilonacept reduced the frequency of gout flares compared to the comparators. All three medications were mostly well-tolerated compared to their comparators. CONCLUSION IL-1β inhibitors may be a beneficial and safe medication for patients experiencing gout flares for whom current standard therapies are unsuitable. REVIEW PROTOCOL REGISTRATION PROSPERO ID: CRD42021267670.
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Affiliation(s)
- Naomi Schlesinger
- Division of the Rheumatology at the Spencer Fox Eccles School of Medicine, University of Utah, Harold J, Ardella T, and Helen T Stevenson Presidential Endowed Chair of Rheumatology, Salt Lake City, UT, 84132, USA.
| | - Michael H Pillinger
- The Division of Rheumatology, NYU Grossman School of Medicine, New York, USA
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Yip RM, Cheung TT, So H, Chan JP, Ho CT, Tsang HH, Yu CK, Wong PC. The Hong Kong Society of Rheumatology consensus recommendations for the management of gout. Clin Rheumatol 2023:10.1007/s10067-023-06578-9. [PMID: 37014501 DOI: 10.1007/s10067-023-06578-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/09/2023] [Accepted: 03/12/2023] [Indexed: 04/05/2023]
Abstract
Gout is one of the most common noncommunicable diseases in Hong Kong. Although effective treatment options are readily available, the management of gout in Hong Kong remains suboptimal. Like other countries, the treatment goal in Hong Kong usually focuses on relieving symptoms of gout but not treating the serum urate level to target. As a result, patients with gout continue to suffer from the debilitating arthritis, as well as the renal, metabolic, and cardiovascular complications associated with gout. The Hong Kong Society of Rheumatology spearheaded the development of these consensus recommendations through a Delphi exercise that involved rheumatologists, primary care physicians, and other specialists in Hong Kong. Recommendations on acute gout management, gout prophylaxis, treatment of hyperuricemia and its precautions, co-administration of non-gout medications with urate-lowering therapy, and lifestyle advice have been included. This paper serves as a reference guide to all healthcare providers who see patients who are at risk and are known to have this chronic but treatable condition.
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Affiliation(s)
- Ronald Ml Yip
- Tung Wah Group of Hospitals Integrated Diagnostic and Medical Centre, Kwong Wah Hospital, 25, Waterloo Road, Kowloon, Hong Kong.
| | - Tommy T Cheung
- Rheumatology Centre, Department of Medicine, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong
| | - Ho So
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
| | - Julia Ps Chan
- Rheumatology Centre, Department of Medicine, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong
| | - Carmen Tk Ho
- Division of Rheumatology and Clinical Immunology, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - Helen Hl Tsang
- Division of Rheumatology and Clinical Immunology, Queen Mary Hospital, Pok Fu Lam, Hong Kong
| | - Carrel Kl Yu
- Hong Kong Autoimmune and Rheumatic Diseases Centre, Central, Hong Kong
| | - Priscilla Ch Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Ma Liu Shui, Hong Kong
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Lian A, Shandilya A, Riordan J. A single-centre retrospective case series of Anakinra for incident calcium pyrophosphate deposition disease. Clin Rheumatol 2023:10.1007/s10067-023-06573-0. [PMID: 36913030 DOI: 10.1007/s10067-023-06573-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023]
Abstract
In this 2-year retrospective case series, we characterise the calcium pyrophosphate deposition disease (CPPD) inpatient cohort at a single centre and assess the efficacy and safety of anakinra in its treatment. Adult inpatients with CPPD between 1st September 2020 and 30th September 2022 were identified by ICD-10 codes and confirmed based on clinical diagnosis and either CPP crystals on aspirate or chondrocalcinosis on imaging. Charts were reviewed for demographic, clinical, biochemical data, treatment choice, and response. Response to treatment was determined from chart documentation and calculated from time of first CPPD treatment. Daily responses to anakinra were recorded if anakinra was used. Seventy patients accounting for 79 cases of CPPD were identified. Twelve cases received anakinra, whilst 67 cases received conventional therapy only. Patient receiving anakinra were predominantly male, had multiple comorbidities, and had higher CRPs and serum creatinine when compared to the non-anakinra group. Anakinra was rapidly effective with the mean time to substantial and complete response being 1.7 and 3.6 days respectively. Anakinra was well tolerated. This study adds to the small amount of retrospective data present about the use of anakinra in CPPD. We observed a rapid response to anakinra in our cohort with minimal adverse drug reactions. Key Points • Treatment of CPPD with anakinra appears to be rapidly efficacious without safety concerns.
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Affiliation(s)
- Alwin Lian
- Department of Rheumatology, Wollongong Hospital, Wollongong, NSW, Australia.
| | - Apoorva Shandilya
- Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia
| | - John Riordan
- Department of Rheumatology, Wollongong Hospital, Wollongong, NSW, Australia
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Mohapatra A, Rajendrakumar SK, Chandrasekaran G, Revuri V, Sathiyamoorthy P, Lee YK, Lee JH, Choi SY, Park IK. Biomineralized Nanoscavenger Abrogates Proinflammatory Macrophage Polarization and Induces Neutrophil Clearance through Reverse Migration during Gouty Arthritis. ACS APPLIED MATERIALS & INTERFACES 2023; 15:3812-3825. [PMID: 36646643 DOI: 10.1021/acsami.2c19684] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The deposition of monosodium urate (MSU) crystals induces the overexpression of reactive oxygen species (ROS) and proinflammatory cytokines in residential macrophages, further promoting the infiltration of inflammatory leukocytes in the joints of gouty arthritis. Herein, a peroxidase-mimicking nanoscavenger was developed by forming manganese dioxide over albumin nanoparticles loaded with an anti-inflammatory drug, indomethacin (BIM), to block the secretion of ROS and COX2-induced proinflammatory cytokines in the MSU-induced gouty arthritis model. In the MSU-induced arthritis mouse model, the BIM nanoparticles alleviated joint swelling, which is attributed to the abrogation of ROS and inflammatory cytokine secretions from proinflammatory macrophages that induces neutrophil infiltration and fluid building up in the inflammation site. Further, the BIM nanoparticle treatment reduced the influx of macrophages and neutrophils in the injured region by blocking migration and inducing reverse migration in the zebrafish larva tail amputation model as well as in MSU-induced peritonitis and air pouch mouse models. Overall, the current strategy of employing biomineralized nanoscavengers for arthritis demonstrates clinical significance in dual blocking of peroxides and COX2 to prevent influx of inflammatory cells into the sites of inflammation.
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Affiliation(s)
- Adityanarayan Mohapatra
- Department of Biomedical Sciences and Center for Global Future Biomedical Scientists at Chonnam National University, Chonnam National University Medical School, Gwangju61469, Republic of Korea
| | - Santhosh Kalash Rajendrakumar
- Department of Biomedical Sciences and Center for Global Future Biomedical Scientists at Chonnam National University, Chonnam National University Medical School, Gwangju61469, Republic of Korea
- Department of Chemistry, University of Warwick, CoventryCV4 7AL, United Kingdom
| | - Gopalakrishnan Chandrasekaran
- Department of Biomedical Sciences and Center for Global Future Biomedical Scientists at Chonnam National University, Chonnam National University Medical School, Gwangju61469, Republic of Korea
| | - Vishnu Revuri
- Department of Green Bioengineering, Korea National University of Transportation, Chungju27470, Republic of Korea
| | - Padmanaban Sathiyamoorthy
- Department of Biomedical Sciences and Center for Global Future Biomedical Scientists at Chonnam National University, Chonnam National University Medical School, Gwangju61469, Republic of Korea
| | - Yong-Kyu Lee
- Department of Green Bioengineering, Korea National University of Transportation, Chungju27470, Republic of Korea
| | - Jae Hyuk Lee
- Department of Pathology, Chonnam National University Medical School, Gwangju61469, Republic of Korea
| | - Seok-Yong Choi
- Department of Biomedical Sciences and Center for Global Future Biomedical Scientists at Chonnam National University, Chonnam National University Medical School, Gwangju61469, Republic of Korea
| | - In-Kyu Park
- Department of Biomedical Sciences and Center for Global Future Biomedical Scientists at Chonnam National University, Chonnam National University Medical School, Gwangju61469, Republic of Korea
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Jeria-Navarro S, Gomez-Gomez A, Park HS, Calvo-Aranda E, Corominas H, Pou MA, Diaz-Torne C. Effectiveness and safety of anakinra in gouty arthritis: A case series and review of the literature. Front Med (Lausanne) 2023; 9:1089993. [PMID: 36714095 PMCID: PMC9877612 DOI: 10.3389/fmed.2022.1089993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023] Open
Abstract
Background Gout is the most common type of inflammatory arthritis. Nonsteroidal anti-inflammatory drugs, corticosteroids, and colchicine are the first-line agents, although they are contraindicated in many patients. Blockade of IL-1 with anakinra can be an alternative. Objective To present a case series of 10 difficult-to-treat gout patients treated with anakinra and perform a scoping review of the effectiveness and safety of anakinra in gout patients. Methods A total of 1,519 citations were screened. The reviewers ran a two-stage screening process by title/abstract and full-text reading. Thirty-eight articles finally met the selection criteria and were included for data extraction and synthesis. Experience in difficult-to treat and complex clinical scenarios, such as active infection, hemodialysis, and transplantation, were specifically described. Results The study sample comprised 551 patients, from whom 648 flares were finally analyzed. The mean age was 57.9 years, and 82.9% were men. The clinical presentation was polyarticular in 47.5% and tophaceous in 66.9%. Sixty-five patients with an active infection, 41 transplanted patients and 14 in haemodyalisis treated with anakinra are described. More than half of the patients had >1 associated comorbidity. Anakinra was effective both for flares (94%) and for long-term treatment (91%) and well tolerated. In the case of flares, 34 (6.7%) adverse effects were registered. Adverse events were more prevalent in long-term treatment. Conclusion Anakinra was effective and safe for management of gout flares in difficult-to-treat patients. It has been used in multiple complex scenarios, such as active infections, dialysis, transplantation, chronic kidney disease, and polyarticular gout. Anakinra has also proven effective as long-term treatment, although there are more concerns about its safety.
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Affiliation(s)
- Sicylle Jeria-Navarro
- Rheumatology Department, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alejandro Gomez-Gomez
- Rheumatology Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain,Crystal-induced Arthritis Study Group, Spanish Society of Rheumatology (GEACSER), Madrid, Spain
| | - Hye Sang Park
- Rheumatology Department, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Enrique Calvo-Aranda
- Crystal-induced Arthritis Study Group, Spanish Society of Rheumatology (GEACSER), Madrid, Spain,Rheumatology Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Hector Corominas
- Rheumatology Department, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Cesar Diaz-Torne
- Rheumatology Department, Hospital Universitari de la Santa Creu i Sant Pau, Barcelona, Spain,Crystal-induced Arthritis Study Group, Spanish Society of Rheumatology (GEACSER), Madrid, Spain,*Correspondence: Cesar Diaz-Torne ✉
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Nasonov EL, Eliseev MS. Resolution of the Council of Excperts (16th June, 2022): Therapy of gouty arthritis with an IL-1 inhibitor (anakinra). RHEUMATOLOGY SCIENCE AND PRACTICE 2022. [DOI: 10.47360/1995-4484-2022-638-641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Kim SK. The Mechanism of the NLRP3 Inflammasome Activation and Pathogenic Implication in the Pathogenesis of Gout. JOURNAL OF RHEUMATIC DISEASES 2022; 29:140-153. [PMID: 37475970 PMCID: PMC10324924 DOI: 10.4078/jrd.2022.29.3.140] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 07/22/2023]
Abstract
The NACHT, LRR, and PYD-domains-containing protein 3 (NLRP3) inflammasome is an intracellular multi-protein signaling platform that is activated by cytosolic pattern-recognition receptors such as NLRs against endogenous and exogenous pathogens. Once it is activated by a variety of danger signals, recruitment and assembly of NLRP3, ASC, and pro-caspase-1 trigger the processing and release of pro-inflammatory cytokines including interleukin-1β (IL-1β) and IL-18. Multiple intracellular and extracellular structures and molecular mechanisms are involved in NLRP3 inflammasome activation. Gout is an autoinflammatory disease induced by inflammatory response through production of NLRP3 inflammasome-mediated proinflammatory cytokines such as IL-1β by deposition of monosodium urate (MSU) crystals in the articular joints and periarticular structures. NLRP3 inflammasome is considered a main therapeutic target in MSU crystal-induced inflammation in gout. Novel therapeutic strategies have been proposed to control acute flares of gouty arthritis and prophylaxis for gout flares through modulation of the NLRP3/IL-1 axis pathway. This review discusses the basic mechanism of NLRP3 inflammasome activation and the IL-1-induced inflammatory cascade and explains the NLRP3 inflammasome-induced pathogenic role in the pathogenesis of gout.
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Affiliation(s)
- Seong-Kyu Kim
- Division of Rheumatology, Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea
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8
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Ahmed HMA, Sun D, Gaffo A. Factors Affecting Response to Anakinra in Crystalline Arthritis Flares. J Clin Rheumatol 2022; 28:196-200. [PMID: 35358118 DOI: 10.1097/rhu.0000000000001831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Interleukin 1 inhibition with anakinra has shown efficacy in the management of crystalline-induced arthritis (CIA) flares. Gout treatment guidelines recommend its use after contraindication or intolerance to first-line therapies. The aim of this study is to identify features associated with better response to anakinra when used to treat CIA flares. METHODS This is a medical record review study that included inpatients with acute CIA in whom anakinra was used between the years 2014 and 2019 at one tertiary center (University of Alabama at Birmingham). The primary end point was response to anakinra treatment defined as a decrease in the reported visual analog score of at least 50% within 48 hours of initiation of treatment. Demographic, clinical, and laboratory factors were compared, and factors found significant in bivariate analysis at a p value of less than 0.15 were tested in a multivariate logistic regression analysis for independent association with the response. RESULTS A total of 55 admission encounters were analyzed. The mean age was 60.1 years, 36 (66%) were men, and 31 (56%) were African Americans. Twenty-eight of 49 (57%) met the primary end point of response at 48 hours, but 52 of 55 (94.5%) ultimately responded to anakinra during hospital stay. Factors associated with response at 48 hours were race, reason for admission related to cardiac etiologies, not having failed steroids before trial of anakinra, and hospital admission within 48 hours of initiation of flare. On a multivariable logistic regression model, we could not find significant independent associations with response to anakinra. CONCLUSIONS Our study showed high response rates to anakinra. We could not identify factors associated with a more robust, early response. It is likely that anakinra is equally effective across a wide range of clinical scenarios.
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Affiliation(s)
| | - Dongmei Sun
- Division of Rheumatology and Clinical Immunology, University of Alabama at Birmingham
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9
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Lu Y, Fang L, Xu X, Wu Y, Li J. MicroRNA-142-3p facilitates inflammatory response by targeting ZEB2 and activating NF-κB signaling in gouty arthritis. Cell Cycle 2022; 21:805-819. [PMID: 35239453 PMCID: PMC8973338 DOI: 10.1080/15384101.2022.2031678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Gouty arthritis (GA) is caused by monosodium urate (MSU) crystal accumulation in the joints. MSU-mediated inflammation is an important inducing factor in gouty arthritis (GA). Recent studies have demonstrated that microRNAs can influence GA progression. Herein, the role and mechanism of miRNA-142-3p in GA were explored. To establish the in vitro and in vivo GA models, MSU was used to induce inflammatory response in human monocyte cell line THP-1 and male C57BL/6 mice. Protein levels, gene expression and proinflammatory cytokine secretion were respectively tested by Western blotting, RT-qPCR, and enzyme-linked immunosorbent assay (ELISA). Pathological changes in sagittal sections of ankle tissues were exhibited by hematoxylin-eosin (HE) staining. Binding relationship between miRNA-142-3p and zinc finger E-box binding homeobox 2 (ZEB2) was predicted and confirmed by bioinformatics analysis and luciferase reporter assay. In this study, MSU induced inflammatory response and upregulated miRNA-142-3p in THP-1 cells. Functionally, miRNA-142-3p knockdown inhibited inflammatory response in MSU-stimulated THP-1 cells and alleviated pathological symptoms of GA mice. Mechanically, miRNA-142-3p targeted ZEB2 in THP-1 cells. ZEB2 expression was elevated in MSU-administrated THP-1 cells and GA mice. ZEB2 downregulation reserved the inhibitory effect of miRNA-142-3p deficiency on inflammatory response in MSU-treated THP-1 cells. In addition, miRNA-142-3p activated NF-κB signaling by binding with ZEB2 in THP-1 cells upon MSU stimulation. Overall, miRNA-142-3p facilitates inflammatory response by targeting ZEB2 and activating NF-κB signaling in GA.
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Affiliation(s)
- Yao Lu
- Department of Rheumatology and Immunology, Zhoushan Hospital of Zhejiang Province, Zhoushan 316021, Zhejiang, China
| | - Li Fang
- Department of Rheumatology and Immunology, Zhoushan Hospital of Zhejiang Province, Zhoushan 316021, Zhejiang, China
| | - Xiangfeng Xu
- Department of Rheumatology and Immunology, Zhoushan Hospital of Zhejiang Province, Zhoushan 316021, Zhejiang, China,CONTACT Xiangfeng Xu Zhoushan Hospital of Zhejiang Province, No.739 Dingshen Road, Lincheng New District, Zhoushan, Zhejiang, China
| | - Yanying Wu
- Department of Rheumatology and Immunology, Zhoushan Hospital of Zhejiang Province, Zhoushan 316021, Zhejiang, China
| | - Jiajia Li
- Department of Rheumatology and Immunology, Zhoushan Hospital of Zhejiang Province, Zhoushan 316021, Zhejiang, China
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10
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Abstract
The incidence and prevalence of gout have increased, as have comorbid obesity, diabetes mellitus, hypertension, chronic kidney and cardiovascular disease. Gout is now the commonest type of inflammatory arthritis despite availability of safe, effective and potentially 'curative' urate-lowering drugs. Modern imaging studies show that gout is a chronic inflammatory crystal deposition disorder even at the first acute attack and they illuminate the need to eliminate urate crystals by continuing reduction of the serum urate below its solubility threshold. Clinical outcomes, adherence to therapy and quality of gout care in primary care and hospital practice can be greatly improved by better use of allopurinol and flare prophylaxis, greater patient engagement, education and follow-up, and by nurse-led models of care that employ a 'treat-to-target' principle (SUA< 360 or 300µmol/l). Advances in understanding the physiology and genetic control of urate transport in the kidney and gut have led to novel, more selective uricosuric drugs, and basic research on mediators of urate crystal-induced inflammation has pointed to alternative therapeutic targets for treating and preventing gout flares. Current guidelines for the management of gout and indications for the use of some more recently introduced drugs; febuxostat, lesinurad, pegloticase and interleukin-1 antagonists are also briefly reviewed.
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Affiliation(s)
- George Nuki
- University of Edinburgh, Institute for Genetics and Molecular Medicine, Western General Hospital, Edinburgh, EH4 2XU, UK,
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Russell MD, Clarke BD, Roddy E, Galloway JB. Improving outcomes for patients hospitalised with gout: a systematic review. Rheumatology (Oxford) 2021; 61:90-102. [PMID: 34247233 PMCID: PMC8742824 DOI: 10.1093/rheumatology/keab539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Objectives Hospital admissions for gout flares have increased dramatically in recent years, despite widely available, effective medications for the treatment and prevention of flares. We conducted a systematic review to evaluate the effectiveness and implementation of interventions in patients hospitalized for gout flares. Methods A search was conducted in MEDLINE, Embase and the Cochrane library, from database inception to 8 April 2021, using the terms ‘gout’ and ‘hospital’ and their synonyms. Studies were included if they evaluated the effectiveness and/or implementation of interventions during hospital admissions or emergency department attendances for gout flares. Risk of bias assessments were performed for included studies. Results Nineteen articles were included. Most studies were small, retrospective analyses performed in single centres, with concerns for bias. Eleven studies (including five randomized controlled trials) reported improved patient outcomes following pharmacological interventions with known efficacy in gout, including allopurinol, prednisolone, NSAIDs and anakinra. Eight studies reported improved outcomes associated with non-pharmacological interventions: inpatient rheumatology consultation and a hospital gout management protocol. No studies to date have prospectively evaluated strategies designed to prevent re-admissions of patients hospitalized for gout flares. Conclusion There is an urgent need for high-quality, prospective studies of strategies for improving uptake of urate-lowering therapies in hospitalized patients, incorporating prophylaxis against flares and treat-to-target optimization of serum urate levels. Such studies are essential if the epidemic of hospital admissions from this treatable condition is to be countered.
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Affiliation(s)
- Mark D Russell
- Centre for Rheumatic Disease, King's College London, London, UK
| | | | - Edward Roddy
- School of Medicine, Keele University, Keele, UK.,Haywood Academic Rheumatology Centre, Midland Partnership NHS Foundation Trust, Stoke-on-Trent, UK
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12
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Galozzi P, Bindoli S, Luisetto R, Sfriso P, Ramonda R, Scanu A, Oliviero F. Regulation of crystal induced inflammation: current understandings and clinical implications. Expert Rev Clin Immunol 2021; 17:773-787. [PMID: 34053376 DOI: 10.1080/1744666x.2021.1937129] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Accumulation of abnormal crystals in the body, derived from endogenous or exogenous materials can drive a wide spectrum of inflammatory disease states. It is well established that intra-articular deposition of monosodium urate (MSU) and calcium pyrophoshate (CPP) crystals contributes to joint destruction through pro-inflammatory processes.Areas covered: This review will focus on current understanding and recent novelty about the mechanisms and the clinical implications of the inflammation induced by MSU and CPP crystals.Expert opinion: Advances in molecular biology reveal that at the base of the inflammatory cascade, stimulated by MSU or CPP crystals, there are many complex cellular mechanisms mainly involving the NLRP3 inflammasome, the hallmark of autoinflammatory syndromes. The extensive studies carried out through in vitro and in vivo models along with a better clinical definition of the disease has led to an optimized use of existing drugs and the introduction of novel therapeutic strategies. In particular, the identification of IL-1 as the most important target in gout and pseudogout has made it possible to expand the pharmacological indications of anti-IL-1 biological drugs, opening new therapeutic perspectives for patients.
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Affiliation(s)
- Paola Galozzi
- Rheumatology Unit, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Sara Bindoli
- Rheumatology Unit, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Roberto Luisetto
- Department of Surgery, Oncology and Gastroenterology-DISCOG, University of Padova, Padova, Italy
| | - Paolo Sfriso
- Rheumatology Unit, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Roberta Ramonda
- Rheumatology Unit, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Anna Scanu
- Rheumatology Unit, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Francesca Oliviero
- Rheumatology Unit, Department of Medicine - DIMED, University of Padova, Padova, Italy
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13
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Pisaniello HL, Fisher MC, Farquhar H, Vargas-Santos AB, Hill CL, Stamp LK, Gaffo AL. Efficacy and safety of gout flare prophylaxis and therapy use in people with chronic kidney disease: a Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN)-initiated literature review. Arthritis Res Ther 2021; 23:130. [PMID: 33910619 PMCID: PMC8080370 DOI: 10.1186/s13075-021-02416-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 01/04/2021] [Indexed: 12/27/2022] Open
Abstract
Gout flare prophylaxis and therapy use in people with underlying chronic kidney disease (CKD) is challenging, given limited treatment options and risk of worsening renal function with inappropriate treatment dosing. This literature review aimed to describe the current literature on the efficacy and safety of gout flare prophylaxis and therapy use in people with CKD stages 3-5. A literature search via PubMed, the Cochrane Library, and EMBASE was performed from 1 January 1959 to 31 January 2018. Inclusion criteria were studies with people with gout and renal impairment (i.e. estimated glomerular filtration rate (eGFR) or creatinine clearance (CrCl) < 60 ml/min/1.73 m2), and with exposure to colchicine, interleukin-1 inhibitors, non-steroidal anti-inflammatory drugs (NSAIDs), and glucocorticoids. All study designs were included. A total of 33 studies with efficacy and/or safety analysis stratified by renal function were reviewed-colchicine (n = 20), anakinra (n = 7), canakinumab (n = 1), NSAIDs (n = 3), and glucocorticoids (n = 2). A total of 58 studies reported these primary outcomes without renal function stratification-colchicine (n = 29), anakinra (n = 10), canakinumab (n = 6), rilonacept (n = 2), NSAIDs (n = 1), and glucocorticoids (n = 10). Most clinical trials excluded study participants with severe CKD (i.e. eGFR or CrCl of < 30 mL/min/1.73 m2). Information on the efficacy and safety outcomes of gout flare prophylaxis and therapy use stratified by renal function is lacking. Clinical trial results cannot be extrapolated for those with advanced CKD. Where possible, current and future gout flare studies should include patients with CKD and with study outcomes reported based on renal function and using standardised gout flare definition.
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Affiliation(s)
- Huai Leng Pisaniello
- Discipline of Medicine, Faculty of Health and Medical Sciences, the University of Adelaide, Adelaide, South Australia, Australia
| | - Mark C Fisher
- Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA.,Prima CARE, Fall River, MA, USA
| | - Hamish Farquhar
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | - Catherine L Hill
- Discipline of Medicine, Faculty of Health and Medical Sciences, the University of Adelaide, Adelaide, South Australia, Australia.,Rheumatology Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Angelo L Gaffo
- Division of Rheumatology and Clinical Immunology, University of Alabama, 1720 2nd Avenue South, Birmingham, AL, 35294, USA. .,Birmingham VA Medical Center, Birmingham, USA.
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14
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Saag KG, Khanna PP, Keenan RT, Ohlman S, Osterling Koskinen L, Sparve E, Åkerblad AC, Wikén M, So A, Pillinger MH, Terkeltaub R. A Randomized, Phase II Study Evaluating the Efficacy and Safety of Anakinra in the Treatment of Gout Flares. Arthritis Rheumatol 2021; 73:1533-1542. [PMID: 33605029 DOI: 10.1002/art.41699] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 02/11/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of anakinra compared to triamcinolone in the treatment of gout flares. METHODS Patients for whom nonsteroidal antiinflammatory drugs and colchicine were not suitable treatments were enrolled in this multicenter, randomized, double-blind study with follow-up for up to 2 years. The study was designed to assess superiority of anakinra (100 or 200 mg/day for 5 days) over triamcinolone (40 mg in a single injection) for the primary end point of changed patient-assessed pain intensity in the most affected joint (scored on a visual analog scale of 0-100) from baseline to 24-72 hours. Secondary outcome measures included: safety, immunogenicity, and patient- and physician-assessed global response. RESULTS One hundred sixty-five patients were randomized to receive anakinra (n = 110) or triamcinolone (n = 55). The median age was 55 years (range 25-83), 87% were men, the mean disease duration was 8.7 years, and the mean number of self-reported flares during the prior year was 4.5. A total of 301 flares were treated (214 with anakinra; 87 with triamcinolone). Anakinra in both doses and triamcinolone provided clinically meaningful reduction in patient-assessed pain intensity in the first and subsequent flares. For the first flare, the mean decline in pain intensity from baseline to 24-72 hours for total anakinra and triamcinolone was -41.2 and -39.4, respectively (P = 0.688). Anakinra performed better than triamcinolone for most secondary end points. There were no unexpected safety findings. The presence of antidrug antibodies was not associated with adverse events or altered pain reduction. CONCLUSION Anakinra was not superior to triamcinolone for the primary end point, but had comparable efficacy in pain reduction and was favored for most secondary end points. Anakinra is an effective option for gout flares when conventional therapy is unsuitable.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Robert Terkeltaub
- San Diego VA Healthcare Service and University of California San Diego, La Jolla
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15
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Malcova H, Milota T, Strizova Z, Cebecauerova D, Striz I, Sediva A, Horvath R. Interleukin-1 Blockade in Polygenic Autoinflammatory Disorders: Where Are We now? Front Pharmacol 2021; 11:619273. [PMID: 33708123 PMCID: PMC7941751 DOI: 10.3389/fphar.2020.619273] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/16/2020] [Indexed: 12/14/2022] Open
Abstract
Polygenic autoinflammatory diseases (AIDs), such as systemic juvenile idiopathic arthritis (sJIA), adult-onset Still's disease, Kawasaki disease, idiopathic recurrent pericarditis (IRP), Behçet’s Syndrome, Crystal-induced arthropatihes such as gout or Calcium pyrophosphate deposition disease are characterized by the overexpression of inflammasome-associated genes, leading to a dysregulation of the innate immune response. The IL-1 cytokine family (IL-1α, IL-1β, IL-1Ra, IL-18, IL-36Ra, IL-36α, IL-37, IL-36β, IL-36g, IL-38, IL-33) was defined to be principally responsible for the inflammatory nature of polygenic AIDs. Several clinical trials were initiated, and IL-1 blockade has been proven to cause a rapid reduction of clinical symptoms and normalization of laboratory parameters in the majority of cases. Randomized, placebo-controlled, clinical trials, together with registry-based clinical trials and open-label, retrospective and prospective observational studies, supported the efficacy and safety of IL-1 inhibitors in the treatment of polygenic AIDs. Most of the current data are focused on the therapeutic use of anakinra, an IL-1 receptor antagonist, canakinumab, an anti-IL-1β monoclonal antibody, and rilonacept, a soluble decoy receptor. However, other promising agents, such as gevokizumab, IL-1β blocking monoclonal antibody, tadekinig alfa, a human recombinant IL-18-binding protein, and tranilast, an analog of a tryptophan metabolite, are currently being tested. Anakinra, canakinumab and rilonacept caused impressive improvements in both systemic and musculoskeletal symptoms. Furthermore, the anti-IL-1 therapy allowed corticosteroid tapering and, in some cases, even withdrawal. This article reviews the current IL-1 inhibitors and the results of all clinical trials in which they have been tested for the management of broad spectrum of polygenic AIDs.
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Affiliation(s)
- Hana Malcova
- Department of Paediatric and Adult Rheumatology, University Hospital Motol, Prague, Czechia
| | - Tomas Milota
- Department of Paediatric and Adult Rheumatology, University Hospital Motol, Prague, Czechia.,Department of Immunology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Zuzana Strizova
- Department of Immunology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Dita Cebecauerova
- Department of Paediatric and Adult Rheumatology, University Hospital Motol, Prague, Czechia
| | - Ilja Striz
- Department of Clinical Immunology and Allergology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Anna Sediva
- Department of Immunology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Rudolf Horvath
- Department of Paediatric and Adult Rheumatology, University Hospital Motol, Prague, Czechia
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16
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Latourte A, Pascart T, Flipo RM, Chalès G, Coblentz-Baumann L, Cohen-Solal A, Ea HK, Grichy J, Letavernier E, Lioté F, Ottaviani S, Sigwalt P, Vandecandelaere G, Richette P, Bardin T. 2020 Recommendations from the French Society of Rheumatology for the management of gout: Management of acute flares. Joint Bone Spine 2020; 87:387-393. [PMID: 32422339 DOI: 10.1016/j.jbspin.2020.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/07/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To develop French Society of Rheumatology-endorsed recommendations for the management of gout flares. METHODS These evidence-based recommendations were developed by 9 rheumatologists (academic or community-based), 3 general practitioners, 1 cardiologist, 1 nephrologist and 1 patient, using a systematic literature search, one physical meeting to draft recommendations and 2 Delphi rounds to finalize them. RESULTS A set of 4 overarching principles and 4 recommendations was elaborated. The overarching principles emphasize the importance of patient education, including the need to auto-medicate for gout flares as early as possible, if possible within the first 12h after the onset, according to a pre-defined treatment. Patients must know that gout is a chronic disease, often requiring urate-lowering therapy in addition to flare treatment. Comorbidities and the risk of drug interaction should be screened carefully in every patient as they may contraindicate some anti-inflammatory treatments. Colchicine must be early prescribed at the following dosage: 1mg then 0.5mg one hour later, followed by 0.5mg,2 to 3 times/day over the next days. In case of diarrhea, which is the first symptom of colchicine poisoning, dosage must be reduced. Colchicine dosage must also be reduced in patients with chronic kidney disease or taking drugs, which interfere with its metabolism. Other first-line treatment options are systemic/intra-articular corticosteroids, or non-steroidal anti-inflammatory agents (NSAIDs). IL-1 inhibitors can be considered as a second-line option in case of failure, intolerance or contraindication to colchicine, corticosteroids and NSAIDs. They are contraindicated in cases of infection and neutrophil blood count should be monitored. CONCLUSION These recommendations aim to provide strategies for the safe use of anti-inflammatory agents, in order to improve the management of gout flares.
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Affiliation(s)
- Augustin Latourte
- Service de rhumatologie, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; Inserm U1132 BIOSCAR, université de Paris, Paris, France
| | - Tristan Pascart
- Service de rhumatologie, université de Lille, GH de l'institut catholique de Lille, Lille, France; EA4490, physiopathologie des maladies osseuses inflammatoires, université de Lille, Lille, France
| | - René-Marc Flipo
- Service de rhumatologie, université de Lille, CHU de Lille, Lille, France
| | | | | | - Alain Cohen-Solal
- Service de cardiologie, hôpital Lariboisière, AP-HP, Paris, France; Inserm U942 MASCOT, université de Paris, Paris, France
| | - Hang-Korng Ea
- Service de rhumatologie, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; Inserm U1132 BIOSCAR, université de Paris, Paris, France
| | | | - Emmanuel Letavernier
- Service de physiologie, hôpital Tenon, AP-HP, Paris, France; Inserm U1155, UPMC Université Paris 6, Sorbonne Universités, Paris, France
| | - Frédéric Lioté
- Service de rhumatologie, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; Inserm U1132 BIOSCAR, université de Paris, Paris, France
| | | | - Pierre Sigwalt
- Service de rhumatologie, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; Inserm U1132 BIOSCAR, université de Paris, Paris, France
| | | | - Pascal Richette
- Service de rhumatologie, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; Inserm U1132 BIOSCAR, université de Paris, Paris, France
| | - Thomas Bardin
- Service de rhumatologie, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; Inserm U1132 BIOSCAR, université de Paris, Paris, France.
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17
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Oliviero F, Bindoli S, Scanu A, Feist E, Doria A, Galozzi P, Sfriso P. Autoinflammatory Mechanisms in Crystal-Induced Arthritis. Front Med (Lausanne) 2020; 7:166. [PMID: 32426360 PMCID: PMC7203538 DOI: 10.3389/fmed.2020.00166] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/14/2020] [Indexed: 12/12/2022] Open
Abstract
Crystal-induced arthritides have been classified as “type-1 autoinflammatory diseases” for their main features which resemble those of the monogenic autoinflammatory syndromes. They are in fact characterized by spontaneous onset, recurrence of the episodes, self-limitation and resolution, inflammasome activation with huge production of IL-1β and a prevalent involvement of the innate immune system. The term “auto” refers also to the induction of IL-1β gene expression, processing and secretion by IL-1β itself. The concept of autoinflammation in crystal-induced arthritis has been finally reinforced by the efficacy of IL-1 blockade in treating acute and chronic state of this disease. The aim of this article is to review the autoinflammatory mechanisms in crystal-induced arthritis, considering both clinical and molecular aspects.
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Affiliation(s)
- Francesca Oliviero
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Sara Bindoli
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Anna Scanu
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Eugen Feist
- Department of Rheumatology, Cooperation Partner of the Otto-von-Guericke, University Magdeburg, Helios Clinic, Vogelsang-Gommern, Germany
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Paola Galozzi
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Paolo Sfriso
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
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18
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Sharma E, Pedersen B, Terkeltaub R. Patients Prescribed Anakinra for Acute Gout Have Baseline Increased Burden of Hyperuricemia, Tophi, and Comorbidities, and Ultimate All-Cause Mortality. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2019; 12:1179544119890853. [PMID: 31839715 PMCID: PMC6902385 DOI: 10.1177/1179544119890853] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 11/01/2019] [Indexed: 12/22/2022]
Abstract
Objective: The interleukin-1 (IL-1) receptor antagonist anakinra is an effective, off-label option in acute gout flares, when conventional therapy options are narrowed. We performed a retrospective, randomized, case-controlled study to gain clinical insight on baseline factors for gout patients most likely to receive anakinra, and ultimate mortality of those who received anakinra. Methods: Of 1451 gout patients seen between January 2003 and January 2015 in a Veterans Affairs (VA) rheumatology group practice, under stringent managed care principles, 13 (100% male), who received anakinra at least once for flares, were compared with 1:4 age- and sex-matched gout controls. Each patient’s first rheumatology encounter was studied by factor analysis for variables associated with later anakinra. Results: At baseline, patients that received anakinra had higher urate burden (palpable tophi [10/13] vs controls [16/52], P = .003), serum urate ([10.6 mg/dL] vs controls [7.6 mg/dL], P < .0001), and East Asian descent ([7/13] vs [16/52], P = .041). The anakinra group had higher ultimate all-cause mortality ([6/13] vs controls [7/52], relative risk [RR] = 3.43, 95% confidence interval [CI] = 1.39-8.48, P = .0076). Factor analysis showed baseline visit palpable tophus and statin use to be most strongly associated with later anakinra use. Increased mortality of anakinra users, as per a factorial analysis, was linked more strongly to comorbidities than to anakinra. Conclusions: At baseline rheumatology gout encounter, higher urate, palpable tophi, statin prescription, and East Asian descent were associated with later anakinra use for flares. Mortality was more closely associated to the presence of comorbidities at baseline rheumatology visit than to anakinra prescription.
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Affiliation(s)
- Ena Sharma
- Department of Medicine, San Diego Veterans Affairs Healthcare System, San Diego, CA, USA.,Division of Rheumatology, Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Brian Pedersen
- Department of Medicine, San Diego Veterans Affairs Healthcare System, San Diego, CA, USA.,Division of Rheumatology, Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Robert Terkeltaub
- Department of Medicine, San Diego Veterans Affairs Healthcare System, San Diego, CA, USA.,Division of Rheumatology, Allergy & Immunology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
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19
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Desmarais J, Schwab P. Gout Management in Chronic Kidney Disease: Pearls and Pitfalls. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2019. [DOI: 10.1007/s40674-019-00132-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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20
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Pascart T, Lioté F. Gout: state of the art after a decade of developments. Rheumatology (Oxford) 2019; 58:27-44. [PMID: 29547895 DOI: 10.1093/rheumatology/key002] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Indexed: 02/06/2023] Open
Abstract
This review article summarizes the relevant English literature on gout from 2010 through April 2017. It emphasizes that the current epidemiology of gout indicates a rising prevalence worldwide, not only in Western countries but also in Southeast Asia, in close relationship with the obesity and metabolic syndrome epidemics. New pathogenic mechanisms of chronic hyperuricaemia focus on the gut (microbiota, ABCG2 expression) after the kidney. Cardiovascular and renal comorbidities are the key points to consider in terms of management. New imaging tools are available, including US with key features and dual-energy CT rendering it able to reveal deposits of urate crystals. These deposits are now included in new diagnostic and classification criteria. Overall, half of the patients with gout are readily treated with allopurinol, the recommended xanthine oxidase inhibitor (XOI), with prophylaxis for flares with low-dose daily colchicine. The main management issues are related to patient adherence, because gout patients have the lowest rate of medication possession ratio at 1 year, but they also include clinical inertia by physicians, meaning XOI dosage is not titrated according to regular serum uric acid level measurements for targeting serum uric acid levels for uncomplicated (6.0 mg/dl) and complicated gout, or the British Society for Rheumatology recommended target (5.0 mg/dl). Difficult-to-treat gout encompasses polyarticular flares, and mostly patients with comorbidities, renal or heart failure, leading to contraindications or side effects of standard-of-care drugs (colchicine, NSAIDs, oral steroids) for flares; and tophaceous and/or destructive arthropathies, leading to switching between XOIs (febuxostat) or to combining XOI and uricosurics.
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Affiliation(s)
- Tristan Pascart
- EA 4490, Lille University, Lille, France.,Service de Rhumatologie, Hôpital Saint-Philibert, Lomme, France
| | - Frédéric Lioté
- UFR de Médecine, University of Paris Diderot, USPC, France.,INSERM, UMR 1132 Bioscar (Centre Viggo Petersen), France.,Service de Rhumatologie (Centre Viggo Petersen), Pôle Appareil Locomoteur, Hôpital Lariboisière (AP-HP), Paris, France
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21
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Keenan RT. Is It Time for Gout Flare Treatment to Move into the 21st Century? J Rheumatol 2019; 46:667-669. [PMID: 31262752 DOI: 10.3899/jrheum.181249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Robert T Keenan
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
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22
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Narang RK, Dalbeth N. Management of complex gout in clinical practice: Update on therapeutic approaches. Best Pract Res Clin Rheumatol 2019; 32:813-834. [PMID: 31427057 DOI: 10.1016/j.berh.2019.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Increasing therapeutic options are available for gout management. Anti-inflammatory agents are used in the acute management of gout flares, and interleukin-1 inhibitors are effective for those unable to take conventional anti-inflammatory treatments. Lowering of serum urate remains the cornerstone of effective long-term management. Allopurinol is the first-line urate-lowering therapy, and a gradual dose-escalation strategy to serum urate target is recommended. Febuxostat and lesinurad have been approved more recently. In a large cardiovascular outcomes trial, higher all-cause and cardiovascular mortality was observed with febuxostat than with allopurinol. Lesinurad should be co-prescribed with a xanthine oxidase inhibitor, and close monitoring of kidney function is required. Evidence for non-pharmacological management is limited, but personalised lifestyle modification may reduce associated cardiovascular risk. In this review, we discuss current principles in the gout management paradigm, consider strategies for managing complex, clinical scenarios, and review emerging therapies.
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Affiliation(s)
- Ravi K Narang
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand.
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23
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24
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Liew JW, Gardner GC. Use of Anakinra in Hospitalized Patients with Crystal-associated Arthritis. J Rheumatol 2019; 46:1345-1349. [PMID: 30647192 DOI: 10.3899/jrheum.181018] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE In this retrospective observational study, we assess the efficacy and safety of the interleukin 1 receptor antagonist anakinra in medically complex, hospitalized patients with acute gout and calcium pyrophosphate crystal arthritis. METHODS Adult inpatients treated with anakinra from 2014 to 2017 were identified for inclusion. Charts were reviewed for demographics, comorbidities, laboratory data, pain scores, joint involvement, prior treatment, dosing and response to anakinra, concurrent infections, and surgical interventions. Response to anakinra treatment was determined from review of provider documentation, as well as recorded pain scores on a numeric scale. RESULTS We identified 100 individuals accounting for 115 episodes of arthritis. This population was 82% male, with an average age of 60 years. Comorbidities included renal disease (45%) and history of organ transplantation (14%). Twenty-nine episodes of arthritis occurred in the perioperative setting. Concurrent infection was present in 34 episodes. Eighty-six episodes of arthritis had partial or complete response to anakinra within 4 days of treatment initiation; 66 episodes had partial or complete response within 1 day of anakinra administration. Anakinra was well tolerated. CONCLUSION To our knowledge, this is the largest observational study of anakinra use in the inpatient setting for the acute treatment of crystal-associated arthritis. We observed a rapid response to anakinra, with 75% of episodes significantly improving or completely resolving within 4 days of the first dose. Our data also support the use of this biologic agent in individuals with infections, as well as perioperative individuals and immunosuppressed transplant recipients.
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Affiliation(s)
- Jean W Liew
- From the Division of Rheumatology, Department of Medicine, University of Washington, Seattle, Washington, USA. .,J.W. Liew, MD, Division of Rheumatology, Department of Medicine, University of Washington; G.C. Gardner, MD, Division of Rheumatology, Department of Medicine, University of Washington.
| | - Gregory C Gardner
- From the Division of Rheumatology, Department of Medicine, University of Washington, Seattle, Washington, USA.,J.W. Liew, MD, Division of Rheumatology, Department of Medicine, University of Washington; G.C. Gardner, MD, Division of Rheumatology, Department of Medicine, University of Washington
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25
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Desmarais J, Chu CQ. Utility of Anakinra in Acute Crystalline Diseases: A Retrospective Study Comparing a University Hospital with a Veterans Affairs Medical Center. J Rheumatol 2018; 46:748-750. [PMID: 30442822 DOI: 10.3899/jrheum.180393] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of anakinra in inpatient management of acute gout and pseudogout. METHODS Hospitalized patients with acute gout (n = 77) or pseudogout (n = 11) or both (n = 3) were analyzed for response to anakinra and adverse effects. RESULTS Half of all patients had comorbidities limiting the treatment choice. Anakinra was well tolerated, and 92% of gout flares and 79% of pseudogout flares responded to treatment. CONCLUSION Anakinra is an effective and safe treatment for acute gout and pseudogout in hospitalized patients, particularly in those with comorbidities.
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Affiliation(s)
- Julianna Desmarais
- From the Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University; Rheumatology Section, Veterans Affairs (VA) Portland Health Care System, Portland, Oregon, USA. .,J. Desmarais, MD, Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University; C.Q. Chu, MD, PhD, Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University, and Rheumatology Section, VA Portland Health Care System.
| | - Cong-Qiu Chu
- From the Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University; Rheumatology Section, Veterans Affairs (VA) Portland Health Care System, Portland, Oregon, USA.,J. Desmarais, MD, Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University; C.Q. Chu, MD, PhD, Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University, and Rheumatology Section, VA Portland Health Care System
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26
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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
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27
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Thomas M, Forien M, Palazzo E, Dieudé P, Ottaviani S. Efficacy and tolerance of anakinra in acute calcium pyrophosphate crystal arthritis: a retrospective study of 33 cases. Clin Rheumatol 2018; 38:425-430. [DOI: 10.1007/s10067-018-4272-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/08/2018] [Accepted: 08/20/2018] [Indexed: 12/20/2022]
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Marchetti C, Swartzwelter B, Koenders MI, Azam T, Tengesdal IW, Powers N, de Graaf DM, Dinarello CA, Joosten LAB. NLRP3 inflammasome inhibitor OLT1177 suppresses joint inflammation in murine models of acute arthritis. Arthritis Res Ther 2018; 20:169. [PMID: 30075804 PMCID: PMC6091035 DOI: 10.1186/s13075-018-1664-2] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 07/09/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Activation of the NLRP3 inflammasome in gout amplifies the inflammatory response and mediates further damage. In the current study, we assessed the therapeutic effect of OLT1177, an orally active NLRP3 inflammasome inhibitor that is safe in humans, in murine acute arthritis models. METHODS Zymosan or monosodium urate (MSU) crystals were injected intra-articularly (i.a.) into mouse knee joints to induce reactive or gouty arthritis. Joint swelling, articular cell infiltration, and synovial cytokines were evaluated 25 hours and 4 hours following zymosan or MSU challenge, respectively. OLT1177 was administrated intraperitoneally by oral gavage or in the food by an OLT1177-enriched diet. RESULTS OLT1177 reduced zymosan-induced joint swelling (p < 0.001), cell influx (p < 0.01), and synovial levels of interleukin (IL)-1β, IL-6, and chemokine (C-X-C motif) ligand 1 (CXCL1) (p < 0.05), respectively, when compared with vehicle-treated mice. Plasma OLT1177 levels correlated (p < 0.001) dose-dependently with reduction in joint inflammation. Treatment of mice with OLT1177 limited MSU crystal articular inflammation (p > 0.0001), which was associated with decreased synovial IL-1β, IL-6, myeloperoxidase, and CXCL1 levels (p < 0.01) compared with vehicle-treated mice. When administrated orally 1 hour after MSU challenge, OLT1177 reduced joint inflammation, processing of IL-1β, and synovial phosphorylated c-Jun N-terminal kinase compared with the vehicle group. Mice were fed an OLT1177-enriched diet for 3 weeks and then challenged i.a. with MSU crystals. Joint swelling, synovial IL-1β, and expression of Nlrp3 and Il1b were significantly reduced in synovial tissues in mice fed an OLT1177-enriched diet when compared with the standard diet group. CONCLUSIONS Oral OLT1177 is highly effective in ameliorating reactive as well as gouty arthritis.
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Affiliation(s)
- Carlo Marchetti
- Department of Medicine, University of Colorado Denver, Aurora, CO USA
| | | | - Marije I. Koenders
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tania Azam
- Department of Medicine, University of Colorado Denver, Aurora, CO USA
| | - Isak W. Tengesdal
- Department of Medicine, University of Colorado Denver, Aurora, CO USA
- Department of Internal Medicine and Radboud Institute of Molecular Life Sciences (RIMLS), Radboud University Medical Center, Geert Grooteplein Zuid 8, 6525 GA Nijmegen, The Netherlands
| | - Nick Powers
- Department of Medicine, University of Colorado Denver, Aurora, CO USA
| | - Dennis M. de Graaf
- Department of Medicine, University of Colorado Denver, Aurora, CO USA
- Department of Internal Medicine and Radboud Institute of Molecular Life Sciences (RIMLS), Radboud University Medical Center, Geert Grooteplein Zuid 8, 6525 GA Nijmegen, The Netherlands
| | - Charles A. Dinarello
- Department of Medicine, University of Colorado Denver, Aurora, CO USA
- Department of Internal Medicine and Radboud Institute of Molecular Life Sciences (RIMLS), Radboud University Medical Center, Geert Grooteplein Zuid 8, 6525 GA Nijmegen, The Netherlands
| | - Leo A. B. Joosten
- Department of Medicine, University of Colorado Denver, Aurora, CO USA
- Department of Internal Medicine and Radboud Institute of Molecular Life Sciences (RIMLS), Radboud University Medical Center, Geert Grooteplein Zuid 8, 6525 GA Nijmegen, The Netherlands
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Davies K, Bukhari MAS. Recent pharmacological advances in the management of gout. Rheumatology (Oxford) 2018; 57:951-958. [PMID: 28968896 DOI: 10.1093/rheumatology/kex343] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Indexed: 01/10/2023] Open
Abstract
Gout is the most common cause of inflammatory arthritis worldwide, and reports show that despite availability of therapies, management is still suboptimal. The new EULAR 2016 recommendations for the treatment of gout highlight the huge development in gout therapies, and the number of drugs being trialled only continues to increase. A clinical review of the evidence that underlies the recommendations from EULAR can reveal possible gaps in the literature and avenues for future research into gout therapies.
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Affiliation(s)
- Kristen Davies
- Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Marwan A S Bukhari
- Faculty of Health and Medicine, Lancaster University, Lancaster, UK.,Department of Rheumatology, University Hospitals of Morecambe Bay NHS Foundation Trust, Royal Lancaster Infirmary, Lancaster, UK
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Abstract
Background Autoinflammatory diseases are distinct from autoimmune diseases. Whereas autoinflammatory diseases are due to dysfunctional T-cells and B-cells, autoinflammatory diseases are due to overproduction of macrophage cytokines particularly interleukin-1 beta (IL-1β). A causative role for IL-1 in autoinflammatory diseases is derived from clinical studies blocking the IL-1 receptor or neutralizing monoclonal antibodies or soluble receptors. Methods A review was performed of clinical trials in autoinflammatory diseases using the IL-1 receptor antagonist (anakinra), the soluble IL-1 receptor (rilonacept), antibodies to IL-1β (canakinumab, gevokizumab) and anti-IL-1α (xilonix). Findings Anakinra blocks the IL-1 Receptor type 1 (IL-1R1) and therefore blocks the activities of both IL-1α and IL-1β. Off-label use of anakinra is common for a broad spectrum of inflammatory diseases. Neutralization of IL-1β is used to treat hereditary autoinflammatory diseases but also atherosclerosis. Rilonacept reduces arterial wall inflammation in patients with chronic kidney disease. Neutralization of IL-1α has prolonged life in patients with advanced metastatic colorectal cancer. Compared to other cytokine blocking therapies, reducing the activities of IL-1 has an excellent safety record. Conclusions Blocking IL-1 therapies can be used to treat a wide-spectrum of acute and chronic inflammatory diseases.
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Winthrop KL, Mariette X, Silva JT, Benamu E, Calabrese LH, Dumusc A, Smolen JS, Aguado JM, Fernández-Ruiz M. ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies: an infectious diseases perspective (Soluble immune effector molecules [II]: agents targeting interleukins, immunoglobulins and complement factors). Clin Microbiol Infect 2018; 24 Suppl 2:S21-S40. [PMID: 29447987 DOI: 10.1016/j.cmi.2018.02.002] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/31/2018] [Accepted: 02/03/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND The present review is part of the ESCMID Study Group for Infections in Compromised Hosts (ESGICH) Consensus Document on the safety of targeted and biological therapies. AIMS To review, from an Infectious Diseases perspective, the safety profile of agents targeting interleukins, immunoglobulins and complement factors and to suggest preventive recommendations. SOURCES Computer-based MEDLINE searches with MeSH terms pertaining to each agent or therapeutic family. CONTENT Patients receiving interleukin-1 (IL-1) -targeted (anakinra, canakinumab or rilonacept) or IL-5-targeted (mepolizumab) agents have a moderate risk of infection and no specific prevention strategies are recommended. The use of IL-6/IL-6 receptor-targeted agents (tocilizumab and siltuximab) is associated with a risk increase similar to that observed with anti-tumour necrosis factor-α agents. IL-12/23-targeted agents (ustekinumab) do not seem to pose a meaningful risk of infection, although screening for latent tuberculosis infection may be considered and antiviral prophylaxis should be given to hepatitis B surface antigen-positive patients. Therapy with IL-17-targeted agents (secukinumab, brodalumab and ixekizumab) may result in the development of mild-to-moderate mucocutaneous candidiasis. Pre-treatment screening for Strongyloides stercoralis and other geohelminths should be considered in patients who come from areas where these are endemic who are receiving IgE-targeted agents (omalizumab). C5-targeted agents (eculizumab) are associated with a markedly increased risk of infection due to encapsulated bacteria, particularly Neisseria spp. Meningococcal vaccination and chemoprophylaxis must be administered 2-4 weeks before initiating eculizumab. Patients with high-risk behaviours and their partners should also be screened for gonococcal infection. IMPLICATIONS Preventive strategies are particularly encouraged to minimize the occurrence of neisserial infection associated with eculizumab.
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Affiliation(s)
- K L Winthrop
- Division of Infectious Diseases, Oregon Health and Science University, Portland, OR, USA.
| | - X Mariette
- Department of Rheumatology, Hôpitaux Universitaire Paris-Sud, Université Paris-Sud, INSERM U1184, Paris, France
| | - J T Silva
- Department of Infectious Diseases, University Hospital of Badajoz, Fundación para La Formación e Investigación de Los Profesionales de La Salud (FundeSalud), Badajoz, Spain
| | - E Benamu
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - L H Calabrese
- Department of Rheumatic and Immunological Diseases, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, Case Western University, Cleveland, OH, USA
| | - A Dumusc
- Department of Rheumatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - J S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - J M Aguado
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
| | - M Fernández-Ruiz
- Unit of Infectious Diseases, Hospital Universitario "12 de Octubre", Instituto de Investigación Hospital "12 de Octubre" (i+12), School of Medicine, Universidad Complutense, Madrid, Spain; Spanish Network for Research in Infectious Diseases (REIPI RD16/0016), Instituto de Salud Carlos III, Madrid, Spain
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Balasubramaniam G, Parker T, Turner D, Parker M, Scales J, Harnett P, Harrison M, Ahmed K, Bhagat S, Marianayagam T, Pitzalis C, Mallen C, Roddy E, Almond M, Dasgupta B. Feasibility randomised multicentre, double-blind, double-dummy controlled trial of anakinra, an interleukin-1 receptor antagonist versus intramuscular methylprednisolone for acute gout attacks in patients with chronic kidney disease (ASGARD): protocol study. BMJ Open 2017; 7:e017121. [PMID: 28877949 PMCID: PMC5588981 DOI: 10.1136/bmjopen-2017-017121] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Acute gout occurs in people with chronic kidney disease, who are commonly older people with comorbidities such as hypertension, heart disease and diabetes. Potentially harmful treatments are administered to these vulnerable patients due to a lack of clear evidence. Newly available treatment that targets a key inflammatory pathway in acute gout attacks provides an opportunity to undertake the first-ever trial specifically looking treating people with kidney disease. This paper describes the protocol for a feasibility randomised controlled trial (RCT) comparing anakinra, a novel interleukin-1 antagonist versus steroids in people with chronic kidney disease (ASGARD). METHODS AND ANALYSIS ASGARD is a two-parallel group double-blind, double-dummy multicentre RCT comparing anakinra 100 mg, an interleukin-1 antagonist, subcutaneous for 5 days against intramuscular methylprednisolone 120 mg. The primary objective is to assess the feasibility of the trial design and procedures for a definitive RCT. The specific aims are: (1) test recruitment and retention rates and willingness to be randomised; (2) test eligibility criteria; (3) collect and analyse outcome data to inform sample and power calculations for a trial of efficacy; (4) collect economic data to inform a future economic evaluation estimating costs of treatment and (5) assess capacity of the project to scale up to a national multicentre trial. We will also gather qualitative insights from participants. It aims to recruit 32 patients with a 1:1 randomisation. Information from this feasibility study will help design a definitive trial and provide general information in designing acute gout studies. ETHICS AND DISSEMINATION The London-Central Ethics Committee approved the protocol. The results will be disseminated in peer-reviewed journals and at scientific conferences. TRIAL REGISTRATION NUMBER EudraCT No. 2015-001787-19, NCT/Clinicalstrials.gov No. NCT02578394, pre-results, WHO Universal Trials Reference No. U1111-1175-1977. NIHR Grant PB-PG-0614-34090.
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Affiliation(s)
- Gowrie Balasubramaniam
- Department of Renal Medicine, Southend University Hospital NHS Foundation Trust, Prittlewell Chase, Southend, Essex, UK
| | - Trisha Parker
- Clinical Trials Unit, Anglia Ruskin University, Bishops Hall Lane, Chelmsford, UK
| | - David Turner
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Mike Parker
- Clinical Trials Unit, Anglia Ruskin University, Bishops Hall Lane, Chelmsford, UK
| | - Jonathan Scales
- School of Health and Human Sciences, University of Essex, Wivenhoe Park, Colchester, UK
| | - Patrick Harnett
- Department of Renal Medicine, Southend University Hospital NHS Foundation Trust, Prittlewell Chase, Southend, Essex, UK
| | - Michael Harrison
- Clinical Trials Unit, Anglia Ruskin University, Bishops Hall Lane, Chelmsford, UK
| | - Khalid Ahmed
- The Princess Alexandria Hospital NHS Trust, Harlow, Essex, UK
| | - Sweta Bhagat
- West Suffolk Hospital NHS Foundation Trust, Bury Saint Edmunds, Suffolk
| | - Thiraupathy Marianayagam
- Lister Hospital, East and North Herfordshire NHS Trust, Corey Mills Lane, Stevenage, Hertfordshire, UK
| | - Costantino Pitzalis
- Centre for Experimental Medicine and Rheumatology, William Harvey Research Institute, Barts and the London, London, UK
| | - Christian Mallen
- Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Edward Roddy
- Primary Care and Health Sciences, Keele University, Keele, Staffordshire, UK
| | - Mike Almond
- Department of Renal Medicine, Southend University Hospital NHS Foundation Trust, Prittlewell Chase, Southend, Essex, UK
| | - Bhaskar Dasgupta
- Department of Renal Medicine, Southend University Hospital NHS Foundation Trust, Prittlewell Chase, Southend, Essex, UK
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Abstract
INTRODUCTION Gout is a common disease responsible for recurrent flares triggered by the deposition of monosodium urate crystals secondary to longstanding hyperuricaemia. The management of gout implies both the treatment of flares and the treatment of hyperuricaemia itself. Recent improvement in the understanding of the disease led to the development of new drugs. Areas covered: This review covers data related to 'old' treatments of flares and hyperuricaemia, evidence on the recently approved drugs and emerging therapies in development. Expert opinion: Recent data provide a good grasp of the optimal use of colchicine, corticosteroids and NSAIDs for the treatment of flares. Interleukin-1 blocking therapies have an increasing role in the management of difficult-to-treat gout. Sub-optimal use of allopurinol is common and its potency to reduce serum uric acid (SUA) levels is underestimated. Febuxostat effectively reduces SUA levels. New uricosurics, notably lesinurad and arhalofenate, in combination with xanthine oxidase inhibitors, offer promising perspectives to help a greater number of patients achieve sufficient SUA reduction.
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Affiliation(s)
- Tristan Pascart
- a Department of Rheumatology, Lille Catholic Hospitals , University of Lille , Lomme , France.,b EA 4490, PMOI, Physiopathologie des Maladies Osseuses Inflammatoires , University of Lille , Lille , France
| | - Pascal Richette
- c Department of Rheumatology, Assistance Publique-Hôpitaux de Paris , Hôpital Lariboisiere , Paris , France.,d INSERM U1132 and University Paris-Diderot , Paris , France
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Desai J, Steiger S, Anders HJ. Molecular Pathophysiology of Gout. Trends Mol Med 2017; 23:756-768. [PMID: 28732688 DOI: 10.1016/j.molmed.2017.06.005] [Citation(s) in RCA: 145] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 06/18/2017] [Accepted: 06/18/2017] [Indexed: 02/07/2023]
Abstract
Three contradictory clinical presentations of gout have puzzled clinicians and basic scientists for some time: first, the crescendo of sterile inflammation in acute gouty arthritis; second, its spontaneous resolution, despite monosodium urate (MSU) crystal persistence in the synovium; and third, immune anergy to MSU crystal masses observed in tophaceous or visceral gout. Here, we provide an update on the molecular pathophysiology of these gout manifestations, namely, how MSU crystals can trigger the auto-amplification loop of necroinflammation underlying the crescendo of acute gouty arthritis. We also discuss new findings, such as how aggregating neutrophil extracellular traps (NETs) might drive the resolution of arthritis and how these structures, together with granuloma formation, might support immune anergy, but yet promote tissue damage and remodeling during tophaceous gout.
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Affiliation(s)
- Jyaysi Desai
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Stefanie Steiger
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Hans-Joachim Anders
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany.
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Soskind R, Abazia DT, Bridgeman MB. Updates on the treatment of gout, including a review of updated treatment guidelines and use of small molecule therapies for difficult-to-treat gout and gout flares. Expert Opin Pharmacother 2017; 18:1115-1125. [DOI: 10.1080/14656566.2017.1349099] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Rose Soskind
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
| | - Daniel T. Abazia
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
- Department of Pharmacy, Capital Health Regional Medical Center, Trenton, NJ, USA
| | - Mary Barna Bridgeman
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
- Department of Pharmacy, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
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Hui M, Carr A, Cameron S, Davenport G, Doherty M, Forrester H, Jenkins W, Jordan KM, Mallen CD, McDonald TM, Nuki G, Pywell A, Zhang W, Roddy E. The British Society for Rheumatology Guideline for the Management of Gout. Rheumatology (Oxford) 2017; 56:e1-e20. [DOI: 10.1093/rheumatology/kex156] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Indexed: 12/13/2022] Open
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Abstract
PURPOSE OF REVIEW Blockade of interleukin (IL)-1 signaling is one of the oldest biologic therapies, yet the use of these agents is on the rise as the role of IL-1 activation is being recognized in a wide spectrum of inflammatory disorders. This review will cover established and emerging uses of IL-1 antagonism in rheumatic diseases. RECENT FINDINGS Expanding off-label indications for IL-1 blockade include neutrophil-dominant skin diseases, including pyoderma gangrenosum, hidradenitis supperativa, and pustular psoriasis. There is also increasing evidence for the use of IL-1 blockade in heart failure associated with rheumatic diseases. Somatic mosaicism in NLRP3 may explain the onset of later-in-life presentations of periodic fevers which are responsive to IL-1 blockade. Of importance, clinical response to anti-IL-1 therapy does not always denote protection from autoinflammatory disease complications such as macrophage activation syndrome or amyloidosis. SUMMARY Indications for IL-1 blocking therapies will likely continue to broaden, but given the rarity of many rheumatic diseases which respond to such treatment, rigorous, large clinical trials for each indication are unlikely to occur. Thus, recommended use of these medications will often fall to the discretion of the astute physician. However, medication cost and hurdles of insurance approval, rather than drug efficacy, may be the primary limitation for more widespread use.
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Lu WW, Zhang JM, Lv ZT, Chen AM. Update on the Clinical Effect of Acupuncture Therapy in Patients with Gouty Arthritis: Systematic Review and Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2016; 2016:9451670. [PMID: 27847529 PMCID: PMC5099464 DOI: 10.1155/2016/9451670] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 08/01/2016] [Accepted: 08/24/2016] [Indexed: 01/18/2023]
Abstract
Objective. The aim of this study is to evaluate the clinical efficacy and safety of acupuncture therapy in the treatment of acute gouty arthritis. Methods. A literature search of PubMed, EMBASE, ISI Web of Science, CENTRAL, and CNKI was conducted from the inception date of each database up to October 2015. Two investigators screened each article independently and were blinded to the findings of the other reviewer. Data was extracted according to the predetermined collection form. Meta-analysis was performed. Results. We analyzed data from 28 RCTs involving 2237 patients with gouty arthritis. Compared with conventional pharmacological treatments acupuncture was more effective in rendering patients free from symptoms after 24 hours, lowering serum urate, alleviating pain associated with gouty arthritis, and decreasing the ESR; regarding CRP, no statistically significant difference was found. In addition, the frequency of adverse events in acupuncture treatment was lower than that in control group. Conclusion. Based on the findings of our study, we cautiously suggest that acupuncture is an effective and safe therapy for patients with gouty arthritis. However, the potential beneficial effect of acupuncture might be overstated due to the methodological deficiency of included studies. High quality RCTs with larger scale are encouraged.
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Affiliation(s)
- Wei-wei Lu
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Jin-ming Zhang
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Zheng-tao Lv
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - An-min Chen
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
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Abstract
A subgroup of patients with gouty arthritis have a chronic recurring form that is particularly difficult to treat. Such patients experience repeated flares and often have abundant tophi. Many also have underlying comorbidities, such as renal impairment, cardiovascular disease, gastrointestinal disorders, obesity, and hypertension, which contraindicate the use of standard anti-inflammatory medications. Five patients with difficult to treat gouty arthritis who were either candidates and/or treated with anti-IL therapy are described.
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Abstract
There is still debate on whether high uric acid increases bone mineral density (BMD) against osteoporotic fracture or bone resorption caused by gout inflammation. This study aimed to evaluate whether gout offers a protective effect on bone health or not. We conducted a nationwide population-based retrospective cohort study to evaluate the association between gout history and risk factors of fracture.A retrospective cohort study was designed using the claim data from Longitudinal Health Insurance Database (LHID). A total of 43,647 subjects with gout and a cohort of 87,294 comparison subjects without gout were matched in terms of age and sex between 2001 and 2009, and the data were followed until December 31, 2011. The primary outcome of the study was the fracture incidence, and the impacts of gout on fracture risks were analyzed using the Cox proportional hazards model.After an 11-year follow-up period, 6992 and 11,412 incidents of fracture were reported in gout and comparison cohorts, respectively. The overall incidence rate of fracture in individuals with gout was nearly 23%, which was higher than that in individuals without gout (252 vs 205 per 10,000 person-years) at an adjusted hazard ratio of 1.17 (95% confidence interval = 1.14-1.21). Age, sex, and fracture-associated comorbidities were adjusted accordingly. As for fracture locations, patients with gout were found at significant higher fracture risks for upper/lower limbs and spine fractures. In gout patient, the user of allopurinol or benzbromarone has significantly lower risk of facture than nonusers.Gout history is considered as a risk factor for fractures, particularly in female individuals and fracture sites located at the spine or upper/lower limbs.
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Affiliation(s)
- Huey-En Tzeng
- Graduate Institute of Clinical Medicine
- School of Medicine, China Medical University
- Division of Hematology/Oncology
| | - Che-Chen Lin
- Healthcare Service Research Center (HSRC), Taichung Veterans General Hospital
| | - I-Kuan Wang
- Graduate Institute of Clinical Medicine
- School of Medicine, China Medical University
- Division of Nephrology
| | - Po-Hao Huang
- School of Medicine, China Medical University
- Division of Rheumatology
| | - Chun-Hao Tsai
- Graduate Institute of Clinical Medicine
- School of Medicine, China Medical University
- Department of Orthopedic Surgery, China Medical University Hospital, Taichung, Taiwan
- Correspondence: Chun-Hao Tsai, Department of Orthopedic Surgery, China Medical University Hospital, China Medical University, #91 Hsueh-Shih Road, Taichung 404, Taiwan (e-mail: )
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Richette P, Doherty M, Pascual E, Barskova V, Becce F, Castañeda-Sanabria J, Coyfish M, Guillo S, Jansen TL, Janssens H, Lioté F, Mallen C, Nuki G, Perez-Ruiz F, Pimentao J, Punzi L, Pywell T, So A, Tausche AK, Uhlig T, Zavada J, Zhang W, Tubach F, Bardin T. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis 2016; 76:29-42. [DOI: 10.1136/annrheumdis-2016-209707] [Citation(s) in RCA: 817] [Impact Index Per Article: 102.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/14/2016] [Accepted: 06/29/2016] [Indexed: 12/22/2022]
Abstract
BackgroundNew drugs and new evidence concerning the use of established treatments have become available since the publication of the first European League Against Rheumatism (EULAR) recommendations for the management of gout, in 2006. This situation has prompted a systematic review and update of the 2006 recommendations.MethodsThe EULAR task force consisted of 15 rheumatologists, 1 radiologist, 2 general practitioners, 1 research fellow, 2 patients and 3 experts in epidemiology/methodology from 12 European countries. A systematic review of the literature concerning all aspects of gout treatments was performed. Subsequently, recommendations were formulated by use of a Delphi consensus approach.ResultsThree overarching principles and 11 key recommendations were generated. For the treatment of flare, colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), oral or intra-articular steroids or a combination are recommended. In patients with frequent flare and contraindications to colchicine, NSAIDs and corticosteroids, an interleukin-1 blocker should be considered. In addition to education and a non-pharmacological management approach, urate-lowering therapy (ULT) should be considered from the first presentation of the disease, and serum uric acid (SUA) levels should be maintained at<6 mg/dL (360 µmol/L) and <5 mg/dL (300 µmol/L) in those with severe gout. Allopurinol is recommended as first-line ULT and its dosage should be adjusted according to renal function. If the SUA target cannot be achieved with allopurinol, then febuxostat, a uricosuric or combining a xanthine oxidase inhibitor with a uricosuric should be considered. For patients with refractory gout, pegloticase is recommended.ConclusionsThese recommendations aim to inform physicians and patients about the non-pharmacological and pharmacological treatments for gout and to provide the best strategies to achieve the predefined urate target to cure the disease.
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Targeting the inflammasome in rheumatic diseases. Transl Res 2016; 167:125-37. [PMID: 26118952 PMCID: PMC4487391 DOI: 10.1016/j.trsl.2015.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 06/02/2015] [Accepted: 06/04/2015] [Indexed: 12/13/2022]
Abstract
Activation of the inflammasome, a protein complex responsible for many cellular functions, including the activation of the proinflammatory cytokines interleukin (IL)-1β and IL-18, has been identified as a key participant in many rheumatic diseases including autoimmune, inflammatory, and autoinflammatory syndromes. This review will discuss the recent advances in understanding the role of this complex in various rheumatic diseases. Furthermore, it will focus on available therapies, which directly and indirectly target the inflammasome and its downstream cytokines to quiet inflammation and possibly dampen autoimmune processes.
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Schett G, Dayer JM, Manger B. Interleukin-1 function and role in rheumatic disease. Nat Rev Rheumatol 2015; 12:14-24. [DOI: 10.1038/nrrheum.2016.166] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Sullivan PM, William A, Tichy EM. Hyperuricemia and gout in solid-organ transplant: update in pharmacological management. Prog Transplant 2015; 25:263-70. [PMID: 26308787 DOI: 10.7182/pit2015322] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Hyperuricemia is a common comorbid condition experienced by up to 28% of kidney transplant recipients. These patients are at elevated risk of acute flare-ups of gout because of transplant-specific risk factors such as impaired renal function, chronic contributing pharmacotherapy (eg, calcineurin inhibitors, diuretics), and associated comorbid conditions. After transplant, treatment is often complicated by drug-drug interactions, renal impairment, and toxic effects of drugs with the use of first-line recommended agents. A number of therapeutic options remain available for transplant recipients, including dose modifications of historic agents and newer pharmacotherapeutic options. Notably, the Kidney Disease Improving Global Outcomes guidelines address the management of hyperuricemia and gout, but these guidelines were last published in 2009, and new data and treatment options have emerged since then. The management of hyperuricemia and acute and chronic gout is described, including the use of novel agents including urate oxidases, interleukin 1 inhibitors, and human urate transporter 1 inhibitors and alternative immunosuppressive therapy strategies.
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Affiliation(s)
- Peter M Sullivan
- Memorial Sloan-Kettering Cancer Center, New York, New York (PMS), Yale University School of Medicine (AW), Yale-New Haven Hospital (EMT), New Haven, Connecticut
| | - Asch William
- Memorial Sloan-Kettering Cancer Center, New York, New York (PMS), Yale University School of Medicine (AW), Yale-New Haven Hospital (EMT), New Haven, Connecticut
| | - Eric M Tichy
- Memorial Sloan-Kettering Cancer Center, New York, New York (PMS), Yale University School of Medicine (AW), Yale-New Haven Hospital (EMT), New Haven, Connecticut
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Thueringer JT, Doll NK, Gertner E. Anakinra for the treatment of acute severe gout in critically ill patients. Semin Arthritis Rheum 2015; 45:81-5. [DOI: 10.1016/j.semarthrit.2015.02.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 02/16/2015] [Accepted: 02/16/2015] [Indexed: 12/29/2022]
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Balasubramaniam G, Almond M, Dasgupta B. Improved renal function in diabetic patients with acute gout treated with anakinra. Kidney Int 2015; 88:195-6. [DOI: 10.1038/ki.2015.125] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Efficacy of anakinra for various types of crystal-induced arthritis in complex hospitalized patients: a case series and review of the literature. Mediators Inflamm 2015; 2015:792173. [PMID: 25922564 PMCID: PMC4398911 DOI: 10.1155/2015/792173] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 03/12/2015] [Accepted: 03/12/2015] [Indexed: 12/15/2022] Open
Abstract
Background. There are few data on anakinra use after failure of conventional medications for crystal-induced peripheral arthritis and/or crowned dens syndrome among complex hospitalized patients. Methods. We retrospectively analyzed the outcome of six patients affected with subacute crystal-induced arthritis who had received anakinra in second or third line therapy, including three patients with crowned dens syndrome and three others with gouty arthritis. Patients' comorbidities, reasons for anakinra use and associated drugs, and outcomes were recorded. Results. All patients presented with elevated inflammatory syndrome, systemic symptoms with poly/oligoarthritis. Except for absolute contraindications, all patients were previously treated with full or decreased dose of NSAID, colchicine, and/or glucocorticoids, with unsatisfactory response. All three gouty patients exhibited complete responses in all acute involvements under anakinra within 3 to 5 days, including one of them who needed the reintroduction of colchicine treatment that was previously unsuccessful. Crowned dens syndrome patients, including two with pseudogout and one with subacute hydroxyapatite deposition disease, needed 9 to 11 days to achieve complete response. Tolerance to anakinra was good. Conclusion. In case series of complex hospitalized patients, anakinra showed good activity in crowned dens syndrome and associated crystal-induced peripheral arthritis, with longer treatment duration than in gouty arthritis.
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Pai S, Raslan A, Schlesinger N. Gout: Update on Current Therapeutics. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2015. [DOI: 10.1007/s40674-015-0013-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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