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Hammam N, Tharwat S, M Elsaman A, Bakhiet A, Mahmoud MB, Ismail F, El Saadany H, R ElShereef R, F Mohamed E, I Abd Elazeem M, Eid A, Ali F, Hamdy M, El Mallah R, Ha Mohammed R, M Gamal R, Fawzy S, Senara S, Hammam O, M Fathi H, Aboul Fotouh A, A Gheita T. Unsupervised cluster analysis of clinical and ultrasound features reveals unique gout subtypes: Results from the Egyptian College of Rheumatology (ECR). Diabetes Metab Syndr 2023; 17:102897. [PMID: 37979221 DOI: 10.1016/j.dsx.2023.102897] [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: 04/13/2023] [Revised: 09/25/2023] [Accepted: 10/20/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND Gout comprises a heterogeneous group of disorders; however, comorbidities have been the focus of most efforts to classify disease subgroups. OBJECTIVES We applied cluster analysis using musculoskeletal ultrasound (MSUS) combined with clinical and laboratory findings in patients with gout to identify disease phenotypes, and differences across clusters were investigated. PATIENTS AND METHODS Patients with gout who complied with the ACR/EULAR classification criteria were enrolled in the Egyptian College of Rheumatology (ECR)-MSUS Study Group, a multicenter study. Selected variables included demographic, clinical, and laboratory findings. MSUS scans assessed the bilateral knee and first metatarsophalangeal joints. We performed a K-mean cluster analysis and compared the features of each cluster. RESULTS 425 patients, 267 (62.8 %) males, mean age 54.2 ± 10.3 years were included. Three distinct clusters were identified. Cluster 1 (n = 138, 32.5 %) has the lowest burden of the disease and a lower frequency of MSUS characteristics than the other clusters. Cluster 2 (n = 140, 32.9 %) was mostly women, with a low rate of urate-lowering treatment (ULT). Cluster 3 (n = 147, 34.6 %) has the highest disease burden and the greatest proportion of comorbidities. Significant MSUS variations were found between clusters 2 and 3: joint effusion (p < 0.0001; highest: cluster 3), power Doppler signal (p < 0.0001; highest: clusters 2), and aggregates of crystal deposition (p < 0.0001; highest: cluster 3). CONCLUSION Cluster analysis using MSUS findings identified three gout subgroups. People with more MSUS features were more likely to receive ULT. Treatment should be tailored according to the cluster and MSUS features.
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Affiliation(s)
- Nevin Hammam
- Rheumatology Department, Faculty of Medicine, Assiut University, Egypt.
| | - Samar Tharwat
- Internal Medicine, Rheumatology Unit, Mansoura University, Egypt
| | - Ahmed M Elsaman
- Rheumatology Department, Faculty of Medicine, Sohag University, Egypt
| | - Ali Bakhiet
- Computer Science Department, Higher Institute of Computer Science and Information Systems, Culture & Science City, Giza, Egypt
| | - Mohamed Bakrey Mahmoud
- Computer Science Department, Higher Institute of Computer Science and Information Systems, Culture & Science City, Giza, Egypt
| | - Faten Ismail
- Rheumatology Department, Faculty of Medicine, Minia University, Egypt
| | | | | | - Eman F Mohamed
- Internal Medicine Department, Rheumatology Unit, Faculty of Medicine (Girls), Al-Azhar University, Egypt
| | | | - Ayman Eid
- Rheumatology Department, Faculty of Medicine, Beni-Suef University, Egypt
| | - Fatma Ali
- Rheumatology Department, Faculty of Medicine, Minia University, Egypt
| | - Mona Hamdy
- Rheumatology Department, Faculty of Medicine, Minia University, Egypt
| | - Reem El Mallah
- Rheumatology Department, Faculty of Medicine, Ain Shams University, Egypt
| | - Reem Ha Mohammed
- Rheumatology Department, Faculty of Medicine, Cairo University, Egypt
| | - Rania M Gamal
- Rheumatology Department, Faculty of Medicine, Assiut University, Egypt
| | - Samar Fawzy
- Rheumatology Department, Faculty of Medicine, Cairo University, Egypt
| | - Soha Senara
- Rheumatology Department, Faculty of Medicine, Fayoum University, Egypt
| | - Osman Hammam
- Department of Rheumatology and Rehabilitation, Faculty of Medicine, New Valley University, New Valley, Egypt
| | - Hanan M Fathi
- Rheumatology Department, Faculty of Medicine, Fayoum University, Egypt
| | - Adham Aboul Fotouh
- Egyptian School for Musculoskeletal Ultrasonography (EgySMUS), Egyptian Society of Musculoskeletal and Neuromuscular Sonography (ESMNS), Egypt
| | - Tamer A Gheita
- Rheumatology Department, Faculty of Medicine, Cairo University, Egypt
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Abdellatif A, Zhao L, Chamberlain J, Cherny K, Xin Y, Marder BA, Scandling JD, Saag K. Pegloticase efficacy and safety in kidney transplant recipients; results of the phase IV, open-label PROTECT clinical trial. Clin Transplant 2023; 37:e14993. [PMID: 37138473 DOI: 10.1111/ctr.14993] [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: 12/27/2022] [Revised: 03/07/2023] [Accepted: 03/13/2023] [Indexed: 05/05/2023]
Abstract
INTRODUCTION Kidney transplant (KT) recipients have a high prevalence and severity of gout. Pegloticase (pegylated recombinant uricase) rapidly metabolizes serum uric acid (sUA), and its efficacy is not impacted by kidney function. METHODS This open-label, Phase 4 trial (PROTECT NCT04087720) examined safety and efficacy of pegloticase in 20 participants with KT > 1 year prior to enrollment and with uncontrolled gout (sUA ≥7 mg/dL, intolerance/inefficacy to urate lowering therapy, and ≥1 of the following: tophi, chronic gouty arthritis, ≥2 flares in past year) and functioning KT (estimated glomerular filtration rate [eGFR] ≥15 mL/min/1.73 m2 ) on stable immunosuppression therapy. RESULTS The primary endpoint was sUA response during month 6 (sUA < 6 mg/dL for ≥80% of time). The study enrolled 20 participants (mean ± SD); age: 53.9 ± 10.9 years, time since KT: 14.7 ± 6.9 years, sUA: 9.4 ± 1.5 mg/dL, gout duration: 8.4 ± 11.6 years; all on ≥2 stable doses of immunosuppression agents. Pegloticase (8 mg intravenous every 2 weeks) in KT recipients with uncontrolled gout showed a high response rate of 89% (16/18 responders). Two participants discontinued treatment solely due to COVID-19 concerns prior to month 6 were not included in the primary analysis. Pegloticase exposures were higher than those historically observed with pegloticase monotherapy, and no anaphylaxis or infusion reaction events occurred during the study. CONCLUSIONS This improved response rate to pegloticase in the KT population reflects observations from other trials and reports on immunomodulation with pegloticase. As the KT population has a high prevalence of gout and limitations with oral urate lowering medication options, these findings suggest a potential option for uncontrolled gout therapy in KT participants.
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Affiliation(s)
- Abdul Abdellatif
- Nephrology Division, Baylor College of Medicine and CLS Health, Houston, Texas, USA
| | - Lin Zhao
- Horizon Therapeutics plc, Deerfield, Illinois, USA
| | | | - Katya Cherny
- Horizon Therapeutics plc, Deerfield, Illinois, USA
| | - Yan Xin
- Horizon Therapeutics plc, Deerfield, Illinois, USA
| | | | - John D Scandling
- Division of Nephrology, Stanford School of Medicine, Stanford, California, USA
| | - Kenneth Saag
- Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, Birmingham, Alabama, USA
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Kivitz A, DeHaan W, Azeem R, Park J, Rhodes S, Inshaw J, Leung SS, Nicolaou S, Johnston L, Kishimoto TK, Traber PG, Sands E, Choi H. Phase 2 Dose-Finding Study in Patients with Gout Using SEL-212, a Novel PEGylated Uricase (SEL-037) Combined with Tolerogenic Nanoparticles (SEL-110). Rheumatol Ther 2023; 10:825-847. [PMID: 37069364 PMCID: PMC10326180 DOI: 10.1007/s40744-023-00546-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/03/2023] [Indexed: 04/19/2023] Open
Abstract
INTRODUCTION SEL-212 is a developmental treatment for uncontrolled gout characterized by serum uric acid (sUA) levels ≥ 6 mg/dl despite treatment. It comprises a novel PEGylated uricase (SEL-037; also called pegadricase) co-administered with tolerogenic nanoparticles containing sirolimus (rapamycin) (SEL-110; also called ImmTOR®), which mitigates the formation of anti-drug antibodies (ADAs) against uricase and SEL-037 (PEGylated uricase), thereby enabling sustained sUA control (sUA < 6 mg/dl). The aim of this study was to identify appropriate dosing for SEL-037 and SEL-110 for use in phase 3 clinical trials. METHODS This open-label phase 2 study was conducted in adults with symptomatic gout and sUA ≥ 6 mg/dl. Participants received five monthly infusions of SEL-037 (0.2 or 0.4 mg/kg) alone or in combination with three or five monthly infusions of SEL-110 (0.05-0.15 mg/kg). Safety, tolerability, sUA, ADAs, and tophi were monitored for 6 months. RESULTS A total of 152 adults completed the study. SEL-037 alone resulted in rapid sUA reductions that were not sustained beyond 30 days in most participants due to ADA formation and loss of uricase activity. Levels of ADAs decreased with increasing doses of SEL-110 up to 0.1 mg/kg, with anti-uricase titers < 1080 correlating with sustained sUA control and reductions in tophi. Overall, 66% of evaluable participants achieved sUA control at week 20 following five monthly doses of SEL-037 0.2 mg/kg + SEL-110 0.1-0.15 mg/kg, whereas only 26% achieved sUA control at week 20 when SEL-110 was withdrawn after week 12. Compared to other dose combinations, SEL-037 0.2 mg/kg + SEL-110 0.15 mg/kg achieved the greatest sUA control at week 12 and was well-tolerated with no safety concerns. CONCLUSION Results provide continued support for the use of multiple monthly administrations of SEL-037 0.2 mg/kg + SEL-110 0.1-0.15 mg/kg in clinical trials for SEL-212. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT02959918.
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Affiliation(s)
- Alan Kivitz
- Altoona Center for Clinical Research, Duncansville, PA, USA
| | | | - Rehan Azeem
- Selecta Biosciences, Inc., Watertown, MA, USA
| | - Justin Park
- Selecta Biosciences, Inc., Watertown, MA, USA
| | | | | | | | - Savvas Nicolaou
- University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada
| | | | | | | | - Earl Sands
- Selecta Biosciences, Inc., Watertown, MA, USA
| | - Hyon Choi
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Boston, MA, USA
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Botson JK, Saag K, Peterson J, Parikh N, Ong S, La D, LoCicero K, Obermeyer K, Xin Y, Chamberlain J, LaMoreaux B, Verma S, Sainati S, Grewal S, Majjhoo A, Tesser JRP, Weinblatt ME. A Randomized, Placebo-Controlled Study of Methotrexate to Increase Response Rates in Patients with Uncontrolled Gout Receiving Pegloticase: Primary Efficacy and Safety Findings. Arthritis Rheumatol 2023; 75:293-304. [PMID: 36099211 PMCID: PMC10107774 DOI: 10.1002/art.42335] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/09/2022] [Accepted: 08/19/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess efficacy, safety, pharmacokinetics, and immunogenicity of pegloticase plus methotrexate (MTX) versus pegloticase plus placebo cotreatment for uncontrolled gout in a randomized, placebo-controlled, double-blind trial. METHODS This study included adults with uncontrolled gout, defined as serum urate ≥7 mg/dl, oral urate-lowering therapy failure or intolerance, and presence of ongoing gout symptoms including ≥1 tophus, ≥2 flares in the past 12 months, or gouty arthritis. Key exclusion criteria included MTX contraindication, current immunosuppressant use, G6PDH deficiency, and estimated glomerular filtration rate <40 ml/minute/1.73 m2 . Patients were randomized 2:1 to 52 weeks of pegloticase (8 mg biweekly) with either oral MTX (15 mg/week) or placebo. The primary end point was the proportion of treatment responders during month 6 (defined as serum urate <6 mg/dl for ≥80% of visits during weeks 20-24). Efficacy was evaluated in all randomized patients (intent-to-treat population), and safety was evaluated in all patients receiving ≥1 blinded MTX or placebo dose. RESULTS A total of 152 patients were randomized, 100 to receive pegloticase plus MTX, 52 to receive pegloticase plus placebo. Significantly higher treatment response occurred during month 6 in the MTX group versus the placebo group (71.0% [71 of 100 patients] versus 38.5% [20 of 52 patients], respectively; between-group difference 32.3% [95% confidence interval 16.3%, 48.3%]) (P < 0.0001 for between-group difference). During the first 6 months of pegloticase plus MTX or pegloticase plus placebo treatment, 78 (81.3%) of 96 MTX patients versus 47 (95.9%) of 49 placebo patients experienced ≥1 adverse event (AE), most commonly gout flare (64 [66.7%] of 96 MTX patients and 34 [69.4%] of 49 placebo patients). Reports of AEs and serious AEs were comparable between groups, but the infusion reaction rate was considerably lower with MTX cotherapy (4.2% [4 of 96 MTX patients, including 1 patient who had anaphylaxis]) than with placebo cotherapy (30.6% [15 of 49 placebo patients, 0 who had anaphylaxis]) (P < 0.001). Antidrug antibody positivity was also lower in the MTX group. CONCLUSION MTX cotherapy markedly increased pegloticase response rate over placebo (71.0% versus 38.5%) during month 6 with no new safety signals. These findings verify higher treatment response rate, lower infusion reaction incidence, and lower immunogenicity when pegloticase is coadministered with MTX.
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Affiliation(s)
| | | | - Jeff Peterson
- Western Washington Arthritis Clinic, Bothell, Washington
| | | | | | - Dan La
- Keck USC Medical Center, Los Angeles, California
| | | | | | - Yan Xin
- Horizon Therapeutics plc, Deerfield, Illinois
| | | | | | - Supra Verma
- Horizon Therapeutics plc, Deerfield, Illinois
| | | | - Suneet Grewal
- East Bay Rheumatology Medical Group Inc., San Leandro, California
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Ul-Haq A, Lee KA, Seo H, Kim S, Jo S, Ko KM, Moon SJ, Kim YS, Choi JR, Song HY, Kim HS. Characteristic alterations of gut microbiota in uncontrolled gout. J Microbiol 2022; 60:1178-1190. [PMID: 36422845 DOI: 10.1007/s12275-022-2416-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/09/2022] [Accepted: 11/15/2022] [Indexed: 06/16/2023]
Abstract
Microbiome research has been on the rise recently for a more in-depth understanding of gout. Meanwhile, there is a need to understand the gut microbiome related to uric acid-lowering drug resistance. In this study, 16S rRNA gene-based microbiota analysis was performed for a total of 65 stool samples from 17 healthy controls and 48 febuxostat-treated gout patients (including 28 controlled subjects with decreased uric acid levels and 20 uncontrolled subjects with non-reduced uric acid levels). Alpha diversity of bacterial community decreased in the healthy control, controlled, and uncontrolled groups. In the case of beta diversity, the bacterial community was significantly different among groups (healthy control, controlled, and uncontrolled groups). Taxonomic biomarker analysis revealed the increased population of g-Bifidobacterium in healthy controls and g-Prevotella in uncontrolled patients. PCR further confirmed this result at the species level. Additionally, functional metagenomics predictions led to the exploration of various functional biomarkers, including purine metabolism. The results of this study can serve as a basis for developing potential new strategies for diagnosing and treating gout from microbiome prospects.
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Affiliation(s)
- Asad Ul-Haq
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, 04401, Republic of Korea
- Probiotics Microbiome Convergence Center, Soonchunhyang University, Asan, 31538, Republic of Korea
| | - Kyung-Ann Lee
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, 04401, Republic of Korea
| | - Hoonhee Seo
- Probiotics Microbiome Convergence Center, Soonchunhyang University, Asan, 31538, Republic of Korea
- Department of Microbiology and Immunology, School of Medicine, Soonchunhyang University, Cheonan, 33151, Republic of Korea
| | - Sukyung Kim
- Department of Microbiology and Immunology, School of Medicine, Soonchunhyang University, Cheonan, 33151, Republic of Korea
| | - Sujin Jo
- Probiotics Microbiome Convergence Center, Soonchunhyang University, Asan, 31538, Republic of Korea
| | - Kyung Min Ko
- Division of Rheumatology, Department of Internal Medicine, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, Incheon, 22711, Republic of Korea
| | - Su-Jin Moon
- Division of Rheumatology, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 07345, Republic of Korea
| | - Yun Sung Kim
- Division of Rheumatology, Department of Internal Medicine, Chosun University College of Medicine, Gwangju, 61452, Republic of Korea
| | - Jung Ran Choi
- Divison of Rheumatology, Department of Internal Medicine, Pohang St. Mary's Hospital, Pohang, 37661, Republic of Korea
| | - Ho-Yeon Song
- Probiotics Microbiome Convergence Center, Soonchunhyang University, Asan, 31538, Republic of Korea.
- Department of Microbiology and Immunology, School of Medicine, Soonchunhyang University, Cheonan, 33151, Republic of Korea.
| | - Hyun-Sook Kim
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, 04401, Republic of Korea.
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Broadwell A, Albert JA, Padnick-Silver L, LaMoreaux B. Community Practice Experiences with a Variety of Immunomodulatory Agents Co-Administered with Pegloticase for the Treatment of Uncontrolled Gout. Rheumatol Ther 2022; 9:1549-1558. [PMID: 36136270 PMCID: PMC9561461 DOI: 10.1007/s40744-022-00492-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 08/30/2022] [Indexed: 11/28/2022] Open
Abstract
Objective Patients with uncontrolled/refractory gout have heavy disease burden, but few treatment options. Pegloticase lowers serum urate (SU), but anti-drug antibodies can limit treatment efficacy. Evidence supports immunomodulator-pegloticase co-administration to increase sustained urate-lowering rates, but published cases are limited. This study investigated experience with pegloticase-immunomodulation co-therapy at two community rheumatology practices. Methods Patients initiating pegloticase with immunomodulation in 2017 or later were included. Patient/treatment characteristics and proportion of responders (≥ 12 pegloticase infusions, SU < 6 mg/dl at infusion-12) were examined. Patients on therapy at data collection with < 12 infusions were excluded from response analyses. eGFR before and after therapy was examined. Results Thirty-four patients (79% male, 62.4 ± 16.3 years) with uncontrolled gout (SU = 9.1 ± 2.0 mg/dl, 91% tophaceous) were included. Most-reported comorbidities were hypertension (76%), obesity (71%), osteoarthritis (68%), and CKD (47%). Pre-therapy eGFR was 65.4 ± 25.2 ml/min/1.73 m2 (41% eGFR < 60 ml/min/1.73 m2). All patients initiated immunomodulation before (5.3 ± 3.0 weeks, n = 32) or at (n = 2) first pegloticase infusion. Subcutaneous methotrexate (15.4 ± 4.9 mg/week, n = 20), oral methotrexate (15.3 ± 3.6 mg/week, n = 9), mycophenolate mofetil (1000 mg/day, n = 3), and azathioprine (100 mg/day, n = 2) were administered. Patients received 14.6 ± 7.1 infusions over 28.5 ± 14.9 weeks. Overall response rate was 89%, ranging among immunomodulators (subcutaneous methotrexate: 93%, oral methotrexate: 89%, mycophenolate mofetil: 100%, azathioprine: 50%). On average, eGFR increased during therapy (+ 10.3 ± 16.9 ml/min/1.73 m2), with CKD stability/improvement in 85%. Nineteen patients (56%) experienced gout flares. No infusion reactions or infections were noted. No new safety concerns were identified. Conclusions These real-world findings provide further support for increased pegloticase response rates when co-treatment with immunomodulating therapy is used. Patients with gout that does not respond to oral urate-lowering therapies have heavy disease burden and few treatment options. Pegloticase lowers serum urate levels (SU) and resolves tophi, but anti-drug antibodies can limit urate-lowering efficacy duration. Evidence increasingly supports co-administering an immunomodulator with pegloticase to increase the proportion of patients with sustained urate-lowering response. However, there are few published cases from real-world clinical practice. This study examined treatment with pegloticase + immunomodulation at two community rheumatology practices. Patients who began treatment with pegloticase and an immunomodulator in 2017 or later were included. The proportion of patients with sustained urate-lowering response (≥ 12 infusions received, SU < 6 mg/dl at infusion 12) was investigated. Renal function before and after therapy was also examined. Thirty-four patients were included. Before treatment, SU averaged 9.1 mg/dl and most-reported comorbidities were hypertension (76%), obesity (71%), osteoarthritis (68%), and chronic kidney disease (47%). All patients began using an immunomodulator before or at first pegloticase infusion (subcutaneous methotrexate [20 patients], oral methotrexate [9 patients], mycophenolate mofetil [3 patients], and azathioprine [2 patients]). On average, 14.6 infusions were administered over 28.5 weeks and overall response rate was 89%. Response rate varied among different immunomodulators: subcutaneous methotrexate: 93%, oral methotrexate: 89%, mycophenolate mofetil: 100%, azathioprine: 50%. On average, kidney function improved, with chronic kidney disease stage stability/improvement in 85% of patients. Nineteen patients (56%) experienced gout flares. No infusion reactions or infections were noted and no new safety concerns were identified. These real-world findings provide further support for administering immunomodulation as co-therapy to pegloticase.
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Affiliation(s)
- Aaron Broadwell
- Rheumatology and Osteoporosis Specialists, Shreveport, LA, USA
| | | | | | - Brian LaMoreaux
- Horizon Therapeutics plc, 1 Horizon Way, Deerfield, IL, USA.
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Doehner W, Anker SD, Butler J, Zannad F, Filippatos G, Ferreira JP, Salsali A, Kaempfer C, Brueckmann M, Pocock SJ, Januzzi JL, Packer M. Uric acid and sodium-glucose cotransporter-2 inhibition with empagliflozin in heart failure with reduced ejection fraction: the EMPEROR-reduced trial. Eur Heart J 2022; 43:3435-3446. [PMID: 35788657 PMCID: PMC9492270 DOI: 10.1093/eurheartj/ehac320] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 05/10/2022] [Accepted: 06/03/2022] [Indexed: 12/13/2022] Open
Abstract
Background The sodium-glucose cotransporter-2 inhibitor empagliflozin decreases the risk of cardiovascular death or hospitalization for heart failure (HF) in patients with HF with reduced ejection fraction. Empagliflozin reduces serum uric acid (SUA), but the relevance of this effect in patients with HF is unclear. This study aimed to investigate the effect of empagliflozin on SUA levels and the therapeutic efficacy of empagliflozin in relation to SUA. Methods The association between SUA and the composite primary outcome of cardiovascular death or hospitalization for worsening HF, its components, and all-cause mortality was investigated in 3676 patients of the EMPEROR-Reduced trial (98.6% of the study cohort). The treatment effect of empagliflozin was studied in relation to SUA as continuous variable, to clinical hyperuricaemia (SUA >5.7 mg/dL for women, >7.0 mg/dL for men) and in subgroups of patients of tertiles of SUA. Results Hyperuricaemia was prevalent in 53% of patients with no sex differences. Elevated SUA (highest tertile, mean SUA 9.38 ± 1.49 mg/dL) was associated with advanced severity of HF and with worst outcome [composite outcome, hazard ratio (HR) 1.64 (95% confidence interval, CI 1.28–2.10); cardiovascular mortality, HR 1.98 (95% CI 1.35–2.91); all-cause mortality, HR 1.8 (95% CI 1.29–2.49), all P < 0.001] in multivariate adjusted analyses, as compared with the lowest tertile. SUA was reduced following treatment with empagliflozin at 4 weeks (vs. placebo: −1.12 ± 0.04 mg/dL, P < 0.0001) and remained lower throughout follow-up, with a similar reduction in all prespecified subgroups. Empagliflozin reduced events of clinically relevant hyperuricaemia (acute gout, gouty arthritis or initiation of anti-gout therapy) by 32% [HR 0.68 (95% CI 0.52–0.89), P = 0.004]. The beneficial effect of empagliflozin on the primary endpoint was independent of baseline SUA [HR 0.76 (95% CI 0.65–0.88), P < 0.001) and of the change in SUA at 4 weeks [HR 0.81 (95% CI 0.69–0.95), P = 0.012]. As a hypothesis-generating finding, an interaction between SUA and treatment effect suggested a benefit of empagliflozin on mortality (cardiovascular and all-cause mortality) in patients in elevated SUA (P for interaction = 0.005 and = 0.011, respectively). Conclusion Hyperuricaemia is common in HF and is an independent predictor of advanced disease severity and increased mortality. Empagliflozin induced a rapid and sustained reduction of SUA levels and of clinical events related to hyperuricaemia. The benefit of empagliflozin on the primary outcome was observed independently of SUA.
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Affiliation(s)
- Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies, and Department of Cardiology (CVK), and German Centre for Cardiovascular Research Partner Site Berlin, and Center for Stroke Research Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Stefan D Anker
- Berlin Institute of Health Center for Regenerative Therapies, and Department of Cardiology (CVK), and German Centre for Cardiovascular Research Partner Site Berlin, and Center for Stroke Research Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Javed Butler
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX 75226 USA.,Department of Medicine, University of Mississippi School of Medicine, Jackson, MS 39216, USA
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy 54500, France
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, 12461, Haidari Athens, Greece
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy 54500, France.,UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
| | - Afshin Salsali
- Heart Failure and Diabetes Global Development, Boehringer Ingelheim Pharmaceuticals, Inc, 900 Ridgebury Rd, Ridgefield, CT 06877, USA.,Faculty of Medicine, Rutgers University, New Brunswick, NJ 07103, USA
| | - Carolyn Kaempfer
- Faculty of Medicine, Rutgers University, New Brunswick, NJ 07103, USA.,mainanalytics GmbH, Sulzbach, Otto-Volger-Str. 3c, 65843 Sulzbach/Taunus, Germany
| | - Martina Brueckmann
- Boehringer Ingelheim International, Binger Str. 173, 55218 Ingelheim, Germany.,First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Milton Packer
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.,Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas ,TX 75226 USA.,Imperial College, London SW7 2BX, UK
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Masri KR, Padnick-Silver L, Winterling K, LaMoreaux B. Effect of Leflunomide on Pegloticase Response Rate in Patients with Uncontrolled Gout: A Retrospective Study. Rheumatol Ther 2022; 9:555-563. [PMID: 34997911 PMCID: PMC8964845 DOI: 10.1007/s40744-021-00421-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/20/2021] [Indexed: 12/27/2022] Open
Abstract
Background Pegloticase,
a PEGylated uricase for uncontrolled gout, rapidly lowers serum urate (SU). Not all patients complete a full-therapy course because anti-pegloticase antibodies can develop, causing efficacy loss and infusion reactions. The literature and clinical trial data indicate that methotrexate co-administration markedly improves pegloticase response rates from the established monotherapy response rate of 42%. Unfortunately, methotrexate use is restricted by kidney disease, which is often present in uncontrolled gout patients. Leflunomide is less restricted in patients with renal dysfunction. This study examined the treatment response rate of pegloticase co-administered with leflunomide. Methods Patients co-treated with pegloticase (8 mg biweekly infusion) and oral leflunomide (20 mg/day) were included. Patient/treatment characteristics and safety parameters (adverse events [AEs], laboratory parameters) were examined. Pre-infusion prophylaxis was administered (day of infusion: IV solumedrol, night before and morning of infusion: oral fexofenadine or diphenhydramine). Patients were considered treatment responders if ≥ 12 pegloticase infusions were administered and pre-infusion SU < 6 mg/dl at infusion-12. Results Ten patients (five male, 72.7 ± 12.5 years) were included. The most common comorbidities were chronic kidney disease (90%), hypertension (70%), diabetes mellitus (60%), obesity (60%), and congestive heart failure (50%). Baseline SU was 7.1 ± 2.4 mg/dl and nine patients (90%) had subcutaneous tophi noted. Seven patients (70%) met responder criteria, receiving 26.6 ± 14.0 infusions (range 13–55) with a pre-infusion-12 SU of 0.9 ± 1.5 mg/dl. The three non-responders received < 12 infusions because of unrelated AEs or loss of follow-up. Three patients (30%) experienced AEs. One had unrelated cardiac disease worsening and three gout flares, one had a pre-infusion solumedrol reaction (wooziness/loss of consciousness), and one had two mild, transient increases in liver enzymes. Conclusions This study supports leflunomide as co-therapy to pegloticase in uncontrolled gout patients. Heterogeneity and high comorbidity burden in uncontrolled gout patients makes having a variety of immunomodulators options important.
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Affiliation(s)
| | | | | | - Brian LaMoreaux
- Horizon Therapeutics, Lake Forest, IL, USA.
- , 1 Horizon Way, Deerfield, IL, 600615, USA.
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Botson JK, Obermeyer K, LaMoreaux B, Zhao L, Weinblatt ME, Peterson J. Improved joint and patient-reported health assessments with pegloticase plus methotrexate co-therapy in patients with uncontrolled gout: 12-month exploratory outcomes of the MIRROR open-label trial. Arthritis Res Ther 2022; 24:281. [PMID: 36575505 PMCID: PMC9793599 DOI: 10.1186/s13075-022-02979-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 12/13/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Uncontrolled/refractory gout patients are recalcitrant/intolerant to oral urate-lowering therapies (ULTs), experiencing frequent gout flares, functionally limiting tophi, and low quality of life. Pegloticase lowers urate, but anti-pegloticase antibodies limit urate-lowering efficacy and increase infusion reaction (IR) risk. Immunomodulator + pegloticase co-administration may improve treatment response rates, with 79% of MIRROR open-label trial (MIRROR-OL, pegloticase + oral methotrexate) participants meeting 6-month response criteria. Exploratory outcomes from MIRROR-OL are described here. METHODS Adults with uncontrolled gout (serum urate [SU] ≥ 6 mg/dL and ULT-intolerance/recalcitrance or functionally limiting tophi) were included. Oral methotrexate (15 mg/week) was administered 4 weeks before and during pegloticase treatment (biweekly 8 mg infusion, ≤ 52 weeks). Exploratory outcomes included change from baseline (CFB) in number of affected joints, Health Assessment Questionnaires (HAQs), and Gout Global Assessments. RESULTS Fourteen patients received ≥ 1 pegloticase infusion, with 13 included in 52-week analyses (1 enrolled before treatment-extension amendment, exited at 24 weeks). Three patients prematurely exited due to SU rise; 10 completed 52-week evaluations (8 completed 52 weeks of co-therapy, 2 completed 24 weeks [met treatment goals]). At 52 weeks, SU averaged 1.1 ± 2.5 mg/dL, with improvements in HAQ pain and health (CFB: - 33.6 and - 0.7, respectively), Patient and Physician Global Assessments (CFB: - 4.6 and - 5.7, respectively), and joint involvement (CFB: - 5.6, - 8.4, - 6.0 tender, swollen, tophi-affected joints, respectively). Two patients underwent dual-energy computed tomography, showing concomitant monosodium urate volume reductions. All patients had ≥ 1 AE, with 92.9% experiencing acute flare. One mild IR ("cough") occurred and no new safety signals were identified. CONCLUSION Pegloticase + methotrexate co-therapy resulted in sustained SU-lowering with meaningful improvements in clinical measures, urate burden, and patient-reported outcomes. TRIAL REGISTRATION ClinicalTrials.gov (NCT03635957).
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Affiliation(s)
- John K. Botson
- Orthopedic Physicians Alaska, 3801 Lake Otis Parkway, Anchorage, AK 99508 USA
| | - Katie Obermeyer
- grid.476366.60000 0004 4903 3495Horizon Therapeutics plc, Deerfield, IL USA
| | - Brian LaMoreaux
- grid.476366.60000 0004 4903 3495Horizon Therapeutics plc, Deerfield, IL USA
| | - Lin Zhao
- grid.476366.60000 0004 4903 3495Horizon Therapeutics plc, Deerfield, IL USA
| | - Michael E. Weinblatt
- grid.62560.370000 0004 0378 8294Division of Rheumatology, Immunology and Immunity, Brigham and Women’s Hospital, Boston, MA USA
| | - Jeff Peterson
- Western Washington Arthritis Clinic, Bothell, WA USA
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Cox P, Gupta S, Zhao SS, Hughes DM. The incidence and prevalence of cardiovascular diseases in gout: a systematic review and meta-analysis. Rheumatol Int 2021; 41:1209-1219. [PMID: 33987709 PMCID: PMC8164620 DOI: 10.1007/s00296-021-04876-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/21/2021] [Indexed: 02/07/2023]
Abstract
The aims of this systematic review and meta-analysis were to describe prevalence of cardiovascular disease in gout, compare these results with non-gout controls and consider whether there were differences according to geography. PubMed, Scopus and Web of Science were systematically searched for studies reporting prevalence of any cardiovascular disease in a gout population. Studies with non-representative sampling, where a cohort had been used in another study, small sample size (< 100) and where gout could not be distinguished from other rheumatic conditions were excluded, as were reviews, editorials and comments. Where possible meta-analysis was performed using random-effect models. Twenty-six studies comprising 949,773 gout patients were included in the review. Pooled prevalence estimates were calculated for five cardiovascular diseases: myocardial infarction (2.8%; 95% confidence interval (CI)s 1.6, 5.0), heart failure (8.7%; 95% CI 2.9, 23.8), venous thromboembolism (2.1%; 95% CI 1.2, 3.4), cerebrovascular accident (4.3%; 95% CI 1.8, 9.7) and hypertension (63.9%; 95% CI 24.5, 90.6). Sixteen studies reported comparisons with non-gout controls, illustrating an increased risk in the gout group across all cardiovascular diseases. There were no identifiable reliable patterns when analysing the results by country. Cardiovascular diseases are more prevalent in patients with gout and should prompt vigilance from clinicians to the need to assess and stratify cardiovascular risk. Future research is needed to investigate the link between gout, hyperuricaemia and increased cardiovascular risk and also to establish a more thorough picture of prevalence for less common cardiovascular diseases.
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Affiliation(s)
- Peter Cox
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Biosciences Building, Crown Street, Liverpool, L69 7BE, UK.
| | - Sonal Gupta
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Sizheng Steven Zhao
- Musculoskeletal Biology, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - David M Hughes
- Department of Health Data Science, University of Liverpool, Liverpool, UK
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