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Nayak RR, Orellana DA. The impact of the human gut microbiome on the treatment of autoimmune disease. Immunol Rev 2024. [PMID: 38864582 DOI: 10.1111/imr.13358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
Autoimmune (or rheumatic) diseases are increasing in prevalence but selecting the best therapy for each patient proceeds in trial-and-error fashion. This strategy can lead to ineffective therapy resulting in irreversible damage and suffering; thus, there is a need to bring the promise of precision medicine to patients with autoimmune disease. While host factors partially determine the therapeutic response to immunosuppressive drugs, these are not routinely used to tailor therapy. Thus, non-host factors likely contribute. Here, we consider the impact of the human gut microbiome in the treatment of autoimmunity. We propose that the gut microbiome can be manipulated to improve therapy and to derive greater benefit from existing therapies. We focus on the mechanisms by which the human gut microbiome impacts treatment response, provide a framework to interrogate these mechanisms, review a case study of a widely-used anti-rheumatic drug, and discuss challenges with studying multiple complex systems: the microbiome, the human immune system, and autoimmune disease. We consider open questions that remain in the field and speculate on the future of drug-microbiome-autoimmune disease interactions. Finally, we present a blue-sky vision for how the microbiome can be used to bring the promise of precision medicine to patients with rheumatic disease.
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Affiliation(s)
- Renuka R Nayak
- Rheumatology Division, Department of Medicine, University of California, San Francisco, California, USA
- Veterans Affairs Medical Center, San Francisco, California, USA
| | - Diego A Orellana
- Rheumatology Division, Department of Medicine, University of California, San Francisco, California, USA
- Veterans Affairs Medical Center, San Francisco, California, USA
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Card-Gowers J, Retat L, Kumar A, Marder BA, Padnick-Silver L, LaMoreaux B, Webber L. Projected Health and Economic Burden of Comorbid Gout and Chronic Kidney Disease in a Virtual US Population: A Microsimulation Study. Rheumatol Ther 2024:10.1007/s40744-024-00681-2. [PMID: 38836994 DOI: 10.1007/s40744-024-00681-2] [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: 04/02/2024] [Accepted: 05/13/2024] [Indexed: 06/06/2024] Open
Abstract
INTRODUCTION Gout, a common comorbidity of chronic kidney disease (CKD), is associated with high morbidity and healthcare utilization. However, a large proportion of gout remains undermanaged or untreated which may lead to worse patient outcomes and greater healthcare costs. This study estimates the present and future health and economic burden of controlled and uncontrolled gout in a virtual United States (US) CKD population. METHODS A validated microsimulation model was used to project the burden of gout in patients with CKD in the USA through 2035. Databases were utilized to build a virtual CKD population of "individuals" with controlled or uncontrolled gout. Modelling assumptions were made on the basis of the literature, which was sparse in some cases. Health and economic outcomes with the current care (baseline) scenario were evaluated, along with potential benefits of urate-lowering intervention scenarios. RESULTS The prevalence of comorbid gout and CKD in the USA was projected to increase by 29%, from 7.9 million in 2023 to 9.6 million in 2035 in the baseline scenario. Gout flares, tophi, and comorbidity development were also projected to increase markedly through 2035, with the economic burden of gout in the CKD population subsequently increasing from $38.9 billion in 2023 to $47.3 billion in 2035. An increased use of oral urate-lowering therapies in undermanaged patients, and pegloticase use in patients refractory to oral urate-lowering therapies were also project to result in 744,000 and 353,000 fewer uncontrolled gout cases, respectively, by 2035. Marked reductions in complications and costs ensued. CONCLUSIONS This study projected a substantial increase in comorbid gout and CKD. However, improved use of urate-lowering interventions could mitigate this growth and reduce the health and economic burdens of gout.
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Affiliation(s)
| | - Lise Retat
- HealthLumen Limited, 35 Ballards Lane, London, N3 1XW, UK
| | | | | | | | | | - Laura Webber
- HealthLumen Limited, 35 Ballards Lane, London, N3 1XW, UK.
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Holladay EE, Mudano AS, Xie F, Zhang J, Mikuls TR, Saag K, Yun H, LaMoreaux B, Francis-Sedlak M, Curtis JR. Real-World Effectiveness of Pegloticase Associated With Use of Concomitant Immunomodulatory Therapy. Arthritis Care Res (Hoboken) 2024. [PMID: 38719773 DOI: 10.1002/acr.25361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 04/09/2024] [Accepted: 04/18/2024] [Indexed: 06/27/2024]
Abstract
OBJECTIVE The objective of this study was to ascertain pegloticase persistence and adverse events associated with concomitant immunomodulatory drug treatment in patients with gout. METHODS We conducted a retrospective analysis of patients with gout using the American College of Rheumatology's Rheumatology Informatics System for Effectiveness registry from January 2016 through June 2020. The first pegloticase infusion defined the index date. Based on concomitant immunomodulatory drug treatment, we identified three exposure groups: (1) immunomodulatory drug initiators (patients initiating an immunomodulatory prescription ±60 days from the index date), (2) prevalent immunomodulatory drug recipients (patients receiving their first immunomodulatory drug prescription >60 days before the index date with at least one prescription within ±60 days of the index date), and (3) immunomodulatory nonrecipients (patients receiving pegloticase without concomitant immunomodulatory drugs). We calculated the proportion of patients who achieved serum urate levels ≤6 mg/dL and who had laboratory abnormalities (white blood cell count <3.4 x 109/L, platelet count <135,000, hematocrit level <30%, alanine aminotransferase or aspartate aminotransferase level ≥1.5 times the upper limit normal value) within 180 days after the index date. Cox regression analyzed time to pegloticase discontinuation, controlling for potential confounders. RESULTS We identified 700 pegloticase recipients (91 immunomodulatory drug initiators, 33 prevalent immunomodulatory drug recipients, and 576 nonrecipients), with a median follow-up of 14 months. Immunomodulatory drug recipients were less likely to discontinue pegloticase. The adjusted hazard ratios of pegloticase discontinuation associated with concomitant immunomodulatory drug initiation and prevalent treatment were 0.52 (95% confidence interval [CI] 0.37-0.75) and 0.69 (95% CI 0.42-1.16), respectively. Laboratory abnormalities were uncommon (<5%) and were not higher in concomitant immunomodulatory drug treatment. CONCLUSION Consistent with clinical trials, results from this large observational registry suggest that concomitant immunomodulatory drug treatment improves pegloticase persistence.
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Affiliation(s)
| | | | | | | | - Ted R Mikuls
- University of Nebraska Medical Center and the VA Nebraska-Western Iowa Health Care System, Omaha
| | - Ken Saag
- University of Alabama at Birmingham
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Holladay EE, Mudano AS, Xie F, Zhang J, Mikuls TR, LaMoreaux B, Padnick-Silver L, Curtis JR. Urate-lowering therapy, serum urate, inflammatory biomarkers, and renal function in patients with gout following pegloticase discontinuation. Arthritis Res Ther 2024; 26:86. [PMID: 38609967 PMCID: PMC11010378 DOI: 10.1186/s13075-024-03318-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND/PURPOSE Little is known about long-term clinical outcomes or urate-lowering (ULT) therapy use following pegloticase discontinuation. We examined ULT use, serum urate (SU), inflammatory biomarkers, and renal function following pegloticase discontinuation. METHODS We conducted a retrospective analysis of gout patients who discontinued pegloticase using the Rheumatology Informatics System for Effectiveness (RISE) registry from 1/2016 to 6/2022. We defined discontinuation as a gap ≥ 12 weeks after last infusion. We examined outcomes beginning two weeks after last dose and identified ULT therapy following pegloticase discontinuation. We evaluated changes in lab values (SU, eGFR, CRP and ESR), comparing on- treatment (≤ 15 days of the second pegloticase dose) to post-treatment. RESULTS Of the 375 gout patients discontinuing pegloticase, median (IQR) laboratory changes following discontinuation were: SU: +2.4 mg/dL (0.0,6.3); eGFR: -1.9 mL/min (- 8.7,3.7); CRP: -0.8 mg/L (-12.8,0.0); and ESR: -4.0 mm/hr (-13.0,0.0). Therapy post-discontinuation included oral ULTs (86.0%), restarting pegloticase (4.5%), and no documentation of ULT (9.5%), excluding patients with multiple same-day prescriptions (n = 17). Oral ULTs following pegloticase were: 62.7% allopurinol, 34.1% febuxostat. The median (IQR) time to starting/restarting ULT was 92.0 days (55.0,173.0). Following ULT prescribing (≥ 30 days), only 51.0% of patients had SU < 6 mg/dL. Patients restarting pegloticase achieved a median SU of 0.9 mg/dL (IQR:0.2,9.7) and 58.3% had an SU < 6 mg/dL. CONCLUSION Pegloticase treats uncontrolled gout in patients with failed response to xanthine oxidase inhibitors, but among patients who discontinue, optimal treatment is unclear. Based on this analysis, only half of those starting another ULT achieved target SU. Close follow-up is needed to optimize outcomes after pegloticase discontinuation.
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Affiliation(s)
- Emily E Holladay
- University of Alabama at Birmingham, 1825 University Blvd, Birmingham, AL, 35233, USA
| | - Amy S Mudano
- Foundation for Advancing Science, Technology, Education, and Research, Birmingham, AL, USA
| | - Fenglong Xie
- University of Alabama at Birmingham, 1825 University Blvd, Birmingham, AL, 35233, USA
| | - Jingyi Zhang
- University of Alabama at Birmingham, 1825 University Blvd, Birmingham, AL, 35233, USA
| | - Ted R Mikuls
- University of Nebraska Medical Center and the VA Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| | - Brian LaMoreaux
- Horizon Therapeutics Plc (Now Amgen Inc.), Deerfield, IL, USA
| | | | - Jeffrey R Curtis
- University of Alabama at Birmingham, 1825 University Blvd, Birmingham, AL, 35233, USA.
- Foundation for Advancing Science, Technology, Education, and Research, Birmingham, AL, USA.
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Baraf HSB, Khanna PP, Kivitz AJ, Strand V, Choi HK, Terkeltaub R, Dalbeth N, DeHaan W, Azeem R, Traber PG, Keenan RT. The COMPARE head-to-head, randomized controlled trial of SEL-212 (pegadricase plus rapamycin-containing nanoparticle, ImmTOR™) versus pegloticase for refractory gout. Rheumatology (Oxford) 2024; 63:1058-1067. [PMID: 37449908 PMCID: PMC10986798 DOI: 10.1093/rheumatology/kead333] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 06/01/2023] [Accepted: 06/17/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVES Serum urate (SU) lowering with PEGylated uricases in gout can reduce flares and tophi. However, treatment-emergent anti-drug antibodies adversely affect safety and efficacy and the currently approved PEGylated uricase pegloticase requires twice-monthly infusions. Investigational SEL-212 therapy aims to promote uricase-specific tolerance via monthly sequential infusions of a proprietary rapamycin-containing nanoparticle (ImmTOR) and pegadricase. METHODS COMPARE was a randomized, phase 2, open-label trial of SEL-212 vs pegloticase in adults with refractory gout. SEL-212 [ImmTOR (0.15 mg/kg) and pegadricase (0.2 mg/kg)] was infused monthly or pegloticase (8 mg) twice monthly for 6 months. The primary endpoint was the proportion of participants with SU <6 mg/dl for ≥80% of the time during 3 and 6 months. Secondary outcomes were mean SU, gout flares, number of tender and/or swollen joints and safety. RESULTS During months 3 and 6 combined, numerically more participants achieved and maintained a SU <6 mg/dl for ≥80% of the time with SEL-212 vs pegloticase (53.0% vs 46.0%, P = 0.181). The percentage reductions in SU levels were statistically greater during months 3 and 6 with SEL-212 vs pegloticase (-73.79% and -47.96%, P = 0.0161). Reductions in gout flare incidence and number of tender and/or swollen joints were comparable between treatments. There were numerical differences between the most common treatment-related adverse events of interest with SEL-212 and pegloticase: gout flares (60.2% vs 50.6%), infections (25.3% vs 18.4%) and infusion-related reactions (15.7% vs 11.5%), respectively. Stomatitis (and related terms) was experienced by eight participants (9.6%) with SEL-212 and none with pegloticase. Stomatitis, a known event for rapamycin, was associated with ImmTOR only. CONCLUSIONS SEL-212 efficacy and tolerability were comparable to pegloticase in refractory gout. This was associated with a substantial reduction in treatment burden with SEL-212 due to decreased infusion frequency vs pegloticase. CLINICAL TRIAL REGISTRATION NCT03905512.
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Affiliation(s)
- Herbert S B Baraf
- Rheumatology, Center for Rheumatology and Bone Research, Wheaton, MD, USA
- Rheumatology, George Washington University, Washington DC, USA
| | - Puja P Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Alan J Kivitz
- Department of Rheumatology, Altoona Center for Clinical Research, Duncansville, PA, USA
| | - Vibeke Strand
- Division of Immunology/Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Hyon K Choi
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
| | - Robert Terkeltaub
- Rheumatology, Allergy and Immunology Division, San Diego VA Healthcare Service and UCSD, San Diego, CA, USA
| | - Nicola Dalbeth
- Bone and Joint Research Group, Department of Medicine, University of Auckland, Auckland, New Zealand
| | | | | | | | - Robert T Keenan
- Duke University School of Medicine, Durham, NC, USA
- Arthrosi Therapeutics, San Diego, CA, USA
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Albert J, Broadwell A, Padnick-Silver L, Marder B, LaMoreaux B. Intensive urate-lowering with pegloticase plus methotrexate co-therapy in uncontrolled gout patients with and without chronic kidney disease: A retrospective case series. Medicine (Baltimore) 2024; 103:e37424. [PMID: 38457582 PMCID: PMC10919538 DOI: 10.1097/md.0000000000037424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 03/10/2024] Open
Abstract
Chronic kidney disease (CKD) and gout commonly co-occur. Pegloticase lowers serum urate (SU) in uncontrolled gout patients but antidrug antibodies limit urate-lowering response and increase infusion reaction (IR) risk. Methotrexate (MTX) co-administration increases pegloticase response rate and mitigates IR risk but CKD limits MTX use. This pooled case series examined pegloticase + MTX co-therapy in uncontrolled gout patients with and without CKD. Cases of pegloticase + MTX co-therapy in existing datasets were retrospectively examined. Baseline eGFR classified patients as CKD (eGFR < 60 mL/min/1.73 m2) or non-CKD (eGFR ≥ 60 mL/min/1.73 m2). Patient characteristics, treatment parameters, laboratory values, urate-lowering response rate (≥12 pegloticase infusions received and SU < 6 mg/dL just before infusion 12), and AEs were examined. Fifteen CKD (eGFR: 43.2 ± 11.3 mL/min/1.73 m2; SU: 8.6 ± 2.2 mg/dL), 27 non-CKD (eGFR: 82.9 ± 19.0 mL/min/1.73 m2; SU: 9.5 ± 1.7 mg/dL) patients were included. Comorbidity profiles were similar, but CKD patients were older (72.0 ± 9.9 vs 52.3 ± 14.3 years) and more often female (33.3% vs 7.4%). Treatment parameters were similar with 4-week MTX Run-in followed by mean of 14.7 ± 8.1 [CKD] vs 14.1 ± 7.1 [non-CKD] pegloticase infusions. However, CKD patients had lower MTX dose (14.8 ± 5.8 vs 19.3 ± 4.9 mg/week). Urate-lowering response was similar (92% vs 86%). eGFR increased during treatment in 60% of CKD (+11.5 ± 20.9 mL/min/1.73 m2, 87% stable/improved CKD-stage) and 44% of non-CKD (+4.2 ± 15.0 mL/min/1.73 m2) patients. AEs were similar (≥1 AE CKD: 53%, non-CKD: 67%; gout flare most-reported). One case each of pancytopenia and IR (mild) occurred in non-CKD patients. These real-world data show similar pegloticase + MTX efficacy in CKD and non-CKD patients. No new safety signals were identified, with most CKD patients showing renal function stability or improvement during therapy.
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Affiliation(s)
| | | | | | - Brad Marder
- Horizon Therapeutics plc (now Amgen, Inc.), Deerfield, IL
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Dalbeth N, Botson J, Saag K, Kumar A, Padnick-Silver L, LaMoreaux B, Becce F. Monosodium urate crystal depletion and bone erosion remodeling during pegloticase treatment in patients with uncontrolled gout: Exploratory dual-energy computed tomography findings from MIRROR RCT. Joint Bone Spine 2024; 91:105715. [PMID: 38447697 DOI: 10.1016/j.jbspin.2024.105715] [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: 12/01/2023] [Revised: 01/19/2024] [Accepted: 02/21/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE Monosodium-urate (MSU) crystal deposits can be visualized and quantified with dual-energy CT (DECT). Pegloticase lowers serum urate (SU) in uncontrolled gout patients, with methotrexate (MTX) co-therapy recommended to increase SU-lowering response rate and decrease infusion reaction risk. The literature on serial DECT-imaging during pegloticase+MTX co-therapy is sparse, with only 2 prior cases of rapid MSU deposition depletion with subsequent bone-erosion remodeling reported from a small open-label trial. Here, we report DECT findings during pegloticase treatment in a larger number of patients from a randomized controlled trial to confirm bone-erosion remodeling that follows MSU depletion with pegloticase. The influence of length-of-therapy is also explored. METHODS Patients received pegloticase (8mg every 2weeks)+MTX (15mg/week orally) or pegloticase+placebo (PBO) during the MIRROR RCT trial. A subset underwent DECT-imaging on Day1 (first pegloticase infusion) and at Weeks 14, 24, and 52. Patients with paired baseline-Week 52 images were included. Imaged regions with baseline MSU-crystal volume (VMSU)<0.5cm3 were excluded to minimize artifact contributions. VMSU and bone-erosion remodeling were assessed. RESULTS Eight patients (6 MTX, 2 PBO) were included. Included patients had received 52weeks (5 MTX), 42weeks (1 PBO), and 6weeks (1 MTX, 1 PBO) of pegloticase therapy. Patients who prematurely discontinued pegloticase maintained SU<6mg/dL on allopurinol (n=2)/febuxostat (n=1). At Week 52, VMSU had markedly decreased in both the pegloticase+MTX and pegloticase+PBO treatment groups, with faster depletion during pegloticase therapy. Bone-erosion remodeling was observed in 29/42 (69%) evaluated erosions: 29 (69%) size decrease, 4 (9.5%) recortication, 3 (7.1%) new bone formation. CONCLUSION Rapid VMSU depletion during pegloticase therapy was observed with concomitant bone remodeling within 1year. Following pegloticase discontinuation, VMSU reduction slowed or stopped even when SU was maintained<6mg/dL with oral ULT. CLINICAL TRIAL REGISTRATION NCT03994731.
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Affiliation(s)
- Nicola Dalbeth
- Department of Medicine, University of Auckland, M&HS Building 507, 28 Park Ave. Grafton, 1023 Auckland, New Zealand
| | - John Botson
- Orthopedic Physicians Alaska, 3801 Lake Otis Parkway, 99508 Anchorage, AK, United States
| | - Kenneth Saag
- University of Alabama at Birmingham, 2000 6th Ave. South, Floor 3, 35233 Birmingham, AL, United States
| | - Ada Kumar
- Horizon Therapeutics plc (now Amgen, Inc.), 1 Horizon Way, 60015 Deerfield, IL, United States
| | - Lissa Padnick-Silver
- Horizon Therapeutics plc (now Amgen, Inc.), 1 Horizon Way, 60015 Deerfield, IL, United States.
| | - Brian LaMoreaux
- Horizon Therapeutics plc (now Amgen, Inc.), 1 Horizon Way, 60015 Deerfield, IL, United States
| | - Fabio Becce
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, University of Lausanne, rue du Bugnon 46, 1011 Lausanne, Switzerland
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Huang X, Zhang W. Macrophage membrane-camouflaged biomimetic nanovesicles for targeted treatment of arthritis. Ageing Res Rev 2024; 95:102241. [PMID: 38387516 DOI: 10.1016/j.arr.2024.102241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/03/2024] [Accepted: 02/19/2024] [Indexed: 02/24/2024]
Abstract
Arthritis has become the most common joint disease globally. Current attention has shifted towards preventing the disease and exploring pharmaceutical and surgical treatments for early-stage arthritis. M2 macrophages are known for their anti-inflammatory properties and their ability to support cartilage repair, offering relief from arthritis. Whereas, it remains a great challenge to promote the beneficial secretion of M2 macrophages to prevent the progression of arthritis. Therefore, it is warranted to investigate new strategies that could use the functions of M2 macrophages and enhance its therapeutic effects. This review aims to explore the macrophage cell membrane-coated biomimetic nanovesicles for targeted treatment of arthritis such as osteoarthritis (OA), rheumatoid arthritis (RA), and gouty arthritis (GA). Cell membrane-camouflaged biomimetic nanovesicle has attracted increasing attention, which successfully combine the advantages and properties of both cell membrane and delivered drug. We discuss the roles of macrophages in the pathophysiology and therapeutic targets of arthritis. Then, the common preparation strategies of macrophage membrane-coated nanovesicles are concluded. Moreover, we investigate the applications of macrophage cell membrane-camouflaged nanovesicles for arthritis, such as OA, RA, and GA. Taken together, macrophage cell membrane-camouflaged nanovesicles hold the tremendous prospect for biomedical applications in the targeted treatment of arthritis.
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Affiliation(s)
- Xin Huang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Weiyue Zhang
- Department of Endocrinology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
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Jatuworapruk K, Louthrenoo W. Emerging therapeutic options for refractory gout. Nat Rev Rheumatol 2024; 20:73-74. [PMID: 38102493 DOI: 10.1038/s41584-023-01066-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Affiliation(s)
- Kanon Jatuworapruk
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Worawit Louthrenoo
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
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Wang X, Lu H, Rong J, Sun Z, Zheng Y, Fan B, Jia Z. PEGylated porcine-human recombinant uricase: A novel fusion protein with improved efficacy and safety for the treatment of hyperuricemia and renal complications. Open Life Sci 2024; 19:20220799. [PMID: 38283118 PMCID: PMC10811527 DOI: 10.1515/biol-2022-0799] [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: 06/16/2023] [Revised: 10/08/2023] [Accepted: 11/06/2023] [Indexed: 01/30/2024] Open
Abstract
The growing prevalence of hyperuricemia necessitates the urgent development of more potent treatments. This study aimed to develop, optimize, and evaluate the safety and efficacy of porcine-human recombinant uricase (PHRU) both in vitro and in vivo. The study employed gene editing of PHRU through site-directed mutagenesis, with recombinant proteins expressed in vitro utilizing Escherichia coli. The polyethylene glycol (PEG) approach was employed to augment uricase stability and diminish immunogenicity. The pharmacokinetics and pharmacodynamics of PHRU were tested in vitro and in Sprague Dawley rats. Successful expression of the fusion protein in E. coli and the development of the PEGylated drug were achieved. In vitro experiments confirmed the efficacy of PEG-PHRU in degrading uric acid, with PEGylation not markedly affecting the biological activity of PHRU. Animal studies revealed that PEG-PHRU significantly lowered plasma uric acid levels and mitigated hyperuricemia-induced renal damage in rats. Both drug metabolism and pharmacokinetics exhibited favorable characteristics without observable adverse effects in experimental animals. This novel fusion protein shows the potential for ameliorating hyperuricemia and related renal complications, highlighting it as a promising drug candidate with substantial market applications.
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Affiliation(s)
- Xiangyan Wang
- Hubei Provincial Key Laboratory for Applied Toxicology, Hubei Provincial Center for Disease Control and Prevention, Wuhan430079, China
| | - Hao Lu
- Hubei Provincial Key Laboratory for Applied Toxicology, Hubei Provincial Center for Disease Control and Prevention, Wuhan430079, China
| | - Jun Rong
- College of Life Science, Yangtze University, Jingzhou434000, PR China
| | - Zhongjie Sun
- Jing Zhou Chang Xin Biotechnology Co., Ltd, Jingzhou434000, PR China
| | - Yanhua Zheng
- Hubei Provincial Key Laboratory for Applied Toxicology, Hubei Provincial Center for Disease Control and Prevention, Wuhan430079, China
| | - Bolin Fan
- Hubei Provincial Key Laboratory for Applied Toxicology, Hubei Provincial Center for Disease Control and Prevention, Wuhan430079, China
| | - Ziming Jia
- Hubei Provincial Key Laboratory for Applied Toxicology, Hubei Provincial Center for Disease Control and Prevention, Wuhan430079, China
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Schlesinger N, Pérez-Ruiz F, Lioté F. Mechanisms and rationale for uricase use in patients with gout. Nat Rev Rheumatol 2023; 19:640-649. [PMID: 37684360 DOI: 10.1038/s41584-023-01006-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 09/10/2023]
Abstract
Xanthine oxidase inhibitors such as allopurinol and febuxostat have been the mainstay urate-lowering therapy (ULT) for treating hyperuricaemia in patients with gout. However, not all patients receiving oral ULT achieve the target serum urate level, in part because some patients cannot tolerate, or have actual or misconceived contraindications to, their use, mainly due to comorbidities. ULT dosage is also limited by formularies and clinical inertia. This failure to sufficiently lower serum urate levels can lead to difficult-to-treat or uncontrolled gout, usually due to poorly managed and/or under-treated gout. In species other than humans, uricase (urate oxidase) converts urate to allantoin, which is more soluble in urine than uric acid. Exogenic uricases are an exciting therapeutic option for patients with gout. They can be viewed as enzyme replacement therapy. Uricases are being used to treat uncontrolled gout, and can achieve rapid reduction of hyperuricaemia, dramatic resolution of tophi, decreased chronic joint pain and improved quality of life. Availability, cost and uricase immunogenicity have limited their use. Uricases could become a leading choice in severe and difficult-to-treat gout as induction and/or debulking therapy (that is, for lowering of the urate pool) to be followed by chronic oral ULT. This Review summarizes the evidence regarding available uricases and those in the pipeline, their debulking effect and their outcomes related to gout and beyond.
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Affiliation(s)
- Naomi Schlesinger
- Division of Rheumatology, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA.
| | - Fernando Pérez-Ruiz
- Rheumatology Division, Cruces University Hospital, Vizcaya, Spain
- Arthritis Investigation Group, Biocruces-Bizkaia Health Research Institute, Vizcaya, Spain
- Medicine Department, Medicine and Nursing School, University of the Basque Country, Biskay, Spain
| | - Frédéric Lioté
- Université Paris Cité, UFR de Médecine, Paris, France
- Department of Rheumatology, DMU Locomotion, AP-HP Nord & Inserm UMR 1132, Bioscar (Centre Viggo Petersen), Hôpital Lariboisière, Paris, France
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Chen R, Yang J, Wu M, Zhao D, Yuan Z, Zeng L, Hu J, Zhang X, Wang T, Xu J, Zhang J. M2 Macrophage Hybrid Membrane-Camouflaged Targeted Biomimetic Nanosomes to Reprogram Inflammatory Microenvironment for Enhanced Enzyme-Thermo-Immunotherapy. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2023; 35:e2304123. [PMID: 37339776 DOI: 10.1002/adma.202304123] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/16/2023] [Indexed: 06/22/2023]
Abstract
Excessive inflammatory reactions caused by uric acid deposition are the key factor leading to gout. However, clinical medications cannot simultaneously remove uric acid and eliminate inflammation. An M2 macrophage-erythrocyte hybrid membrane-camouflaged biomimetic nanosized liposome (USM[H]L) is engineered to deliver targeted self-cascading bienzymes and immunomodulators to reprogram the inflammatory microenvironment in gouty rats. The cell-membrane-coating endow nanosomes with good immune escape and lysosomal escape to achieve long circulation time and intracellular retention times. After being uptaken by inflammatory cells, synergistic enzyme-thermo-immunotherapies are achieved: uricase and nanozyme degraded uric acid and hydrogen peroxide, respectively; bienzymes improved the catalytic abilities of each other; nanozyme produced photothermal effects; and methotrexate has immunomodulatory and anti-inflammatory effects. The uric acid levels markedly decrease, and ankle swelling and claw curling are effectively alleviated. The levels of inflammatory cytokines and ROS decrease, while the anti-inflammatory cytokine levels increase. Proinflammatory M1 macrophages are reprogrammed to the anti-inflammatory M2 phenotype. Notably, the IgG and IgM levels in USM[H]L-treated rats decrease substantially, while uricase-treated rats show high immunogenicity. Proteomic analysis show that there are 898 downregulated and 725 upregulated differentially expressed proteins in USM[H]L-treated rats. The protein-protein interaction network indicates that the signaling pathways include the spliceosome, ribosome, purine metabolism, etc.
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Affiliation(s)
- Ran Chen
- College of Pharmacy, Chongqing Medical University, Chongqing, 400016, China
| | - Jie Yang
- College of Pharmacy, Chongqing Medical University, Chongqing, 400016, China
| | - Mingjun Wu
- Institute of Life Sciences, Chongqing Medical University, Chongqing, 400016, China
| | - Dezhang Zhao
- College of Pharmacy, Chongqing Medical University, Chongqing, 400016, China
| | - Ziyi Yuan
- College of Pharmacy, Chongqing Medical University, Chongqing, 400016, China
| | - Linggao Zeng
- NMPA Key Laboratory for Quality Monitoring of Narcotic Drugs and Psychotropic Substances, Chongqing Institute for Food and Drug Control, Chongqing, 401121, China
| | - Juan Hu
- College of Pharmacy, Chongqing Medical University, Chongqing, 400016, China
| | - Xinping Zhang
- College of Pharmacy, Chongqing Medical University, Chongqing, 400016, China
| | - Tingting Wang
- Biochemistry and Molecular Biology Laboratory, Experimental Teaching and Management Center, Chongqing Medical University, Chongqing, 400016, China
| | - Jingxin Xu
- College of Pharmacy, Chongqing Medical University, Chongqing, 400016, China
| | - Jingqing Zhang
- College of Pharmacy, Chongqing Medical University, Chongqing, 400016, China
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Botson JK, Saag K, Peterson J, Obermeyer K, Xin Y, LaMoreaux B, Padnick‐Silver L, Verma S, Grewal S, Majjhoo A, Tesser JRP, Weinblatt ME. A Randomized, Double-Blind, Placebo-Controlled Multicenter Efficacy and Safety Study of Methotrexate to Increase Response Rates in Patients With Uncontrolled Gout Receiving Pegloticase: 12-Month Findings. ACR Open Rheumatol 2023; 5:407-418. [PMID: 37385296 PMCID: PMC10425585 DOI: 10.1002/acr2.11578] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/08/2023] [Accepted: 05/22/2023] [Indexed: 07/01/2023] Open
Abstract
OBJECTIVE To assess 12-month safety and efficacy of pegloticase + methotrexate (MTX) versus pegloticase + placebo (PBO) cotherapy in a PBO-controlled, double-blind trial (A randomized, double-blind, placebo-controlled, multicenter, efficacy and safety study of methotrexate to increase response rates in patients with uncontrolled gout receiving pegloticase [MIRROR RCT]). METHODS Patients with uncontrolled gout (serum urate level [SU] ≥7 mg/dl, oral urate-lowering therapy failure or intolerance, and presence of one or more gout symptoms [one or more tophi, two or more flares in 12 months, gouty arthropathy]) were randomized 2:1 to receive pegloticase (8-mg infusion every 2 weeks) with blinded MTX (oral 15 mg/week) or PBO for 52 weeks. Efficacy end points included proportion of responders (SU level <6 mg/dl for ≥80% of examined month) in the intent-to-treat population (ITT) (all randomized patients) during month 6 (primary end point), month 9, and month 12; proportion with resolution of one or more tophi (ITT); mean SU reduction (ITT); and time to SU-monitoring pegloticase discontinuation. Safety was evaluated via adverse event reporting and laboratory values. RESULTS Month 12 response rate was significantly higher in patients cotreated with MTX (60.0% [60 of 100] vs. 30.8% [16 of 52]; difference: 29.1% [95% confidence interval (CI): 13.2%-44.9%], P = 0.0003), with fewer SU discontinuations (22.9% [22 of 96] vs. 63.3% [31 of 49]). Complete resolution of one or more tophi occurred in 53.8% (28 of 52) versus 31.0% (9 of 29) of MTX versus PBO patients at week 52 (difference: 22.8% [95% CI: 1.2%-44.4%], P = 0.048), more than at week 24 (34.6% [18 of 52] vs. 13.8% [4 of 29]). Consistent with observations through month 6, pharmacokinetic and immunogenicity findings showed increased exposure and lower immunogenicity of pegloticase when administered with MTX, with an otherwise similar safety profile. No infusion reactions occurred after 24 weeks. CONCLUSION Twelve-month MIRROR RCT data further support MTX cotherapy with pegloticase. Tophi resolution continued to increase through week 52, suggesting continued therapeutic benefit beyond month 6 for a favorable treatment effect.
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Affiliation(s)
| | | | | | | | - Yan Xin
- Horizon Therapeutics plcDeerfieldIllinois
| | | | | | | | - Suneet Grewal
- East Bay Rheumatology Medical Group Inc.San LeandroCalifornia
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Tran L, Das S, Zhao L, Finn MG, Gaucher EA. Oral Delivery of Nanoparticles Carrying Ancestral Uricase Enzyme Protects against Hyperuricemia in Knockout Mice. Biomacromolecules 2023; 24:2003-2008. [PMID: 37126604 PMCID: PMC10170503 DOI: 10.1021/acs.biomac.2c01388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
The therapeutic value of delivering recombinant uricase to human patients has been appreciated for decades. The development of therapeutic uricases has been hampered by the fact that humans do not encode an endogenous uricase and therefore most recombinant forms of the protein are recognized as foreign by the immune system and are therefore highly immunogenic. In order to both shield and stabilize the active enzyme, we encapsulated a functional ancestral uricase in recombinant, noninfectious Qβ capsid nanoparticles and characterized its catalytic activity. Oral delivery of the nanoparticles moderated key symptoms of kidney dysfunction in uricase-knockout mice by lowering uric acid levels. Histological kidney samples of the treated mice suggest that delivery of recombinant uricase had a protective effect against the destructive effects of uric acid that lead to renal failure caused by hyperuricemia.
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Affiliation(s)
- Lily Tran
- Department of Biology, Center for Diagnostics and Therapeutics, Georgia State University, Atlanta, Georgia 30303, United States
| | - Soumen Das
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia 30306, United States
| | - Liangjun Zhao
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia 30306, United States
| | - M G Finn
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, Georgia 30306, United States
- School of Biological Sciences, Georgia Institute of Technology, Atlanta, Georgia 30306, United States
| | - Eric A Gaucher
- Department of Biology, Center for Diagnostics and Therapeutics, Georgia State University, Atlanta, Georgia 30303, United States
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Lee ZC, Santosa A, Khor AYK, Sriranganathan MK. The Singapore Experience With Uncontrolled Gout: Unmet Needs in the Management of Patients. Cureus 2023; 15:e36682. [PMID: 36987445 PMCID: PMC10039979 DOI: 10.7759/cureus.36682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Gout is the most common type of inflammatory arthritis, and its impact on cardiovascular health and quality of life is often underestimated. The prevalence and incidence of gout are increasing globally. Further, ischemic heart disease (IHD) and chronic kidney disease (CKD) are prevalent in gout patients. Some unmet needs for gout management include physicians' low initiation rate of urate-lowering therapy (ULT) and poor treatment adherence in patients with gout. There is also a lack of randomized controlled trials that establish safe doses of acute and long-term treatment for gout, particularly in patients with IHD and stage 4 CKD and above (including end-stage renal failure). Furthermore, there is also a lack of studies showing optimal serum uric acid (SUA) target and validated clinical outcome measures, including disease activity and remission criteria for gout tailored to treat-to-target approaches and the high cost of newer gout medications. The causal relationship between asymptomatic hyperuricemia or gout with comorbidities such as IHD and CKD has yet to be fully elucidated. There is a pressing need for collaborative international efforts to address the overall suboptimal management of gout.
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