1
|
Wright DFB, Hishe HZ, Stocker SL, Dalbeth N, Horne A, Drake J, Haslett J, Phipps-Green AJ, Merriman TR, Stamp LK. The development and evaluation of dose-prediction tools for allopurinol therapy (Easy-Allo tools). Br J Clin Pharmacol 2024; 90:1268-1279. [PMID: 38359899 DOI: 10.1111/bcp.16005] [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: 11/29/2023] [Revised: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 02/17/2024] Open
Abstract
AIMS Dose escalation at the initiation of allopurinol therapy can be protracted and resource intensive. Tools to predict the allopurinol doses required to achieve target serum urate concentrations would facilitate the implementation of more efficient dose-escalation strategies. The aim of this research was to develop and externally evaluate allopurinol dosing tools, one for use when the pre-urate-lowering therapy serum urate is known (Easy-Allo1) and one for when it is not known (Easy-Allo2). METHODS A revised population pharmacokinetic-pharmacodynamic model was developed using data from 653 people with gout. Maintenance doses to achieve the serum urate target of <0.36 mmol L-1 in >80% of individuals were simulated and evaluated against external data. The predicted and observed allopurinol doses were compared using the mean prediction error (MPE) and root mean square error (RMSE). The proportion of Easy-Allo predicted doses within 100 mg of the observed was quantified. RESULTS Allopurinol doses were predicted by total body weight, baseline urate, ethnicity and creatinine clearance. Easy-Allo1 produced unbiased and suitably precise dose predictions (MPE 2 mg day-1 95% confidence interval [CI] -13-17, RMSE 91%, 90% within 100 mg of the observed dose). Easy-Allo2 was positively biased by about 70 mg day-1 and slightly less precise (MPE 70 mg day-1 95% CI 52-88, RMSE 131%, 71% within 100 mg of the observed dose). CONCLUSIONS The Easy-Allo tools provide a guide to the allopurinol maintenance dose requirement to achieve the serum urate target of <0.36 mmol L-1 and will aid in the development of novel dose-escalation strategies for allopurinol therapy.
Collapse
Affiliation(s)
- Daniel F B Wright
- School of Pharmacy, University of Otago, Dunedin, New Zealand
- Sydney Pharmacy School, University of Sydney, Sydney, Australia
| | - Hailemichael Z Hishe
- School of Pharmacy, University of Otago, Dunedin, New Zealand
- School of Pharmacy, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Sophie L Stocker
- Sydney Pharmacy School, University of Sydney, Sydney, Australia
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Darlinghurst, Australia
- Musculoskeletal Health, University of Sydney, Sydney, Australia
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Anne Horne
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Jill Drake
- Department of Rheumatology, Immunology and Allergy, Te Whatu Ora Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
| | - Janine Haslett
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | | | - Tony R Merriman
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
- School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Lisa K Stamp
- Department of Rheumatology, Immunology and Allergy, Te Whatu Ora Health New Zealand Waitaha Canterbury, Christchurch, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
| |
Collapse
|
2
|
Stamp LK, Dalbeth N. Moving urate-lowering therapy in gout beyond guideline recommendations. Semin Arthritis Rheum 2024; 65:152358. [PMID: 38219395 DOI: 10.1016/j.semarthrit.2023.152358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/05/2023] [Accepted: 12/18/2023] [Indexed: 01/16/2024]
Abstract
The 'treat-to target serum urate strategy' when using urate-lowering therapy has been recommended by most specialist rheumatology societies for many years. An alternative "treat-to-avoid-symptoms" in gout has been suggested, albeit without a clear definition of what this means and how it might be implemented in clinical trials or clinical practice. This has hampered efforts to design clinical trials that compare the "treat-to-target [urate]" and "treat-to-avoid-symptoms" strategies in the long-term management of gout. In this review we consider the rationale for the treat-to-target urate strategy when using urate-lowering therapy, potential definitions of a "treat-to-avoid-symptoms" strategy, or perhaps what is not "treat-to-avoid-symptoms", and approaches that might address this uncertainty.
Collapse
Affiliation(s)
- Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, Christchurch, New Zealand.
| | - Nicola Dalbeth
- Faculty of Medicine, University of Auckland, Auckland, New Zealand
| |
Collapse
|
3
|
Wen YF, Brundage RC, Roman YM, Culhane-Pera KA, Straka RJ. Population pharmacokinetics, pharmacodynamics and pharmacogenetics modelling of oxypurinol in Hmong adults with gout and/or hyperuricemia. Br J Clin Pharmacol 2023; 89:2964-2976. [PMID: 37202871 PMCID: PMC10527451 DOI: 10.1111/bcp.15792] [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: 09/29/2022] [Revised: 05/04/2023] [Accepted: 05/10/2023] [Indexed: 05/20/2023] Open
Abstract
AIMS The aim of this study was to quantify identifiable sources of variability, including key pharmacogenetic variants in oxypurinol pharmacokinetics and their pharmacodynamic effect on serum urate (SU). METHODS Hmong participants (n = 34) received 100 mg allopurinol twice daily for 7 days followed by 150 mg allopurinol twice daily for 7 days. A sequential population pharmacokinetic pharmacodynamics (PKPD) analysis with non-linear mixed effects modelling was performed. Allopurinol maintenance dose to achieve target SU was simulated based on the final PKPD model. RESULTS A one-compartment model with first-order absorption and elimination best described the oxypurinol concentration-time data. Inhibition of SU by oxypurinol was described with a direct inhibitory Emax model using steady-state oxypurinol concentrations. Fat-free body mass, estimated creatinine clearance and SLC22A12 rs505802 genotype (0.32 per T allele, 95% CI 0.13, 0.55) were found to predict differences in oxypurinol clearance. Oxypurinol concentration required to inhibit 50% of xanthine dehydrogenase activity was affected by PDZK1 rs12129861 genotype (-0.27 per A allele, 95% CI -0.38, -0.13). Most individuals with both PDZK1 rs12129861 AA and SLC22A12 rs505802 CC genotypes achieve target SU (with at least 75% success rate) with allopurinol below the maximum dose, regardless of renal function and body mass. In contrast, individuals with both PDZK1 rs12129861 GG and SLC22A12 rs505802 TT genotypes would require more than the maximum dose, thus requiring selection of alternative medications. CONCLUSIONS The proposed allopurinol dosing guide uses individuals' fat-free mass, renal function and SLC22A12 rs505802 and PDZK1 rs12129861 genotypes to achieve target SU.
Collapse
Affiliation(s)
- Ya-Feng Wen
- Department of Experimental and Clinical Pharmacology,
College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA
| | - Richard C. Brundage
- Department of Experimental and Clinical Pharmacology,
College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA
| | - Youssef M. Roman
- Department of Pharmacotherapy & Outcomes Science,
School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, USA
| | | | - Robert J. Straka
- Department of Experimental and Clinical Pharmacology,
College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA
| |
Collapse
|
4
|
Dewi C, Puspita F, Puspitasari IM, Zakiyah N. Hepatic Safety of Febuxostat and Allopurinol for Gout Patients: A Systematic Review of Randomized Controlled Trial. Ther Clin Risk Manag 2023; 19:731-743. [PMID: 37744559 PMCID: PMC10516211 DOI: 10.2147/tcrm.s424598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
Purpose This study aims to systematically review the hepatic safety of febuxostat and allopurinol in adult gout patients. Methods We searched for information using the following databases: PubMed, Cochrane Library, and Scopus. The inclusion criteria were to review all randomized controlled trials (RCT) that compared allopurinol and febuxostat for adult gout patients that had an assessment of liver function outcomes. Non-English studies on case reports, case series, reviews, and abstracts only were excluded. We extracted information from the studies to answer the research question, ie, study design, publication year, population, sample size, patient characterization, duration, Jadad score, and liver function outcomes. Results We screened 512 publications from the databases and identified 11 studies that met the inclusion criteria. Ten out of 11 included studies were double-blind RCTs. In the majority of the included studies, no statistically significant differences were observed in terms of hepatic safety data between febuxostat and allopurinol. However, in studies where allopurinol titration was used, it posed a challenge to maintain blinding. Notably, consistent adverse events related to liver function findings were observed across all reviewed RCTs. These abnormal liver function test results sometimes led to study withdrawal based on the investigators' assessment. Nevertheless, the investigators classified most liver function test elevations as mild to moderate in severity. Conclusion Our analysis concluded that adult gout patients enrolled in the included RCTs exhibited similar hepatic safety profiles for both febuxostat and allopurinol treatment. Liver function abnormalities were identified in all RCTs included in this systematic review. Consequently, it is important for the product labeling information of both allopurinol and febuxostat to present and describe the current safety data to guide healthcare practitioners when prescribing these medications to patients. Pharmacovigilance and post-marketing pharmacoepidemiology data are essential in establishing the comprehensive safety profile.
Collapse
Affiliation(s)
- Christiyanti Dewi
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
| | - Falerina Puspita
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
| | - Irma Melyani Puspitasari
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
| | - Neily Zakiyah
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
| |
Collapse
|
5
|
Honorary Professor Garry Graham. Inflammopharmacology 2021; 29:1255-1259. [PMID: 34533655 DOI: 10.1007/s10787-021-00872-1] [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: 08/19/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
An appreciation of the contribution of Professor Gary Graham to anti-inflammatory and antirheumatic pharmacology and clinical pharmacology.
Collapse
|
6
|
Vora B, Brackman DJ, Zou L, Garcia-Cremades M, Sirota M, Savic RM, Giacomini KM. Oxypurinol pharmacokinetics and pharmacodynamics in healthy volunteers: Influence of BCRP Q141K polymorphism and patient characteristics. Clin Transl Sci 2021; 14:1431-1443. [PMID: 33931953 PMCID: PMC8301548 DOI: 10.1111/cts.12992] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/23/2020] [Accepted: 01/14/2021] [Indexed: 12/30/2022] Open
Abstract
The missense variant, breast cancer resistance protein (BCRP) p.Q141K, which encodes a reduced function BCRP, has been linked to poor response to allopurinol. Using a multifaceted approach, we aimed to characterize the relationship(s) between BCRP p.Q141K, the pharmacokinetics (PK) and pharmacodynamics (PD) of oxypurinol (the active metabolite of allopurinol), and serum uric acid (SUA) levels. A prospective clinical study (NCT02956278) was conducted in which healthy volunteers were given a single oral dose of 300 mg allopurinol followed by intensive blood sampling. Data were analyzed using noncompartmental analysis and population PK/PD modeling. Additionally, electronic health records were analyzed to investigate whether clinical inhibitors of BCRP phenocopied the effects of the p.Q141K variant with respect to SUA. Subjects homozygous for p.Q141K had a longer half‐life (34.2 ± 12.2 h vs. 19.1 ± 1.42 h) of oxypurinol. The PK/PD model showed that women had a 24.8% lower volume of distribution. Baseline SUA was affected by p.Q141K genotype and renal function; that is, it changed by 48.8% for every 1 mg/dl difference in serum creatinine. Real‐world data analyses showed that patients prescribed clinical inhibitors of BCRP have higher SUA levels than those that have not been prescribed inhibitors of BCRP, consistent with the idea that BCRP inhibitors phenocopy the effects of p.Q141K on uric acid levels. This study identified important covariates of oxypurinol PK/PD that could affect its efficacy for the treatment of gout as well as a potential side effect of BCRP inhibitors on increasing uric acid levels, which has not been described previously.
Collapse
Affiliation(s)
- Bianca Vora
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Deanna J Brackman
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Ling Zou
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Maria Garcia-Cremades
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Marina Sirota
- Bakar Computational Health Sciences Institute, University of California San Francisco, San Francisco, CA, USA
| | - Radojka M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Kathleen M Giacomini
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, CA, USA.,Institute for Human Genetics, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
7
|
Braga TT, Foresto-Neto O, Camara NOS. The role of uric acid in inflammasome-mediated kidney injury. Curr Opin Nephrol Hypertens 2021; 29:423-431. [PMID: 32452918 DOI: 10.1097/mnh.0000000000000619] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Uric acid is produced after purine nucleotide degradation, upon xanthine oxidase catalytic action. In the evolutionary process, humans lost uricase, an enzyme that converts uric acid into allantoin, resulting in increased serum uric acid levels that may vary according to dietary ingestion, pathological conditions, and other factors. Despite the controversy over the inflammatory role of uric acid in its soluble form, crystals of uric acid are able to activate the NLRP3 inflammasome in different tissues. Uric acid, therefore, triggers hyperuricemic-related disease such as gout, metabolic syndrome, and kidney injuries. The present review provides an overview on the role of uric acid in the inflammasome-mediated kidney damage. RECENT FINDINGS Hyperuricemia is present in 20-35% of patients with chronic kidney disease. However, whether this increased circulating uric acid is a risk factor or just a biomarker of renal and cardiovascular injuries has become a topic of intense discussion. Despite these conflicting views, several studies support the idea that hyperuricemia is indeed a cause of progression of kidney disease, with a putative role for soluble uric acid in activating renal NLRP3 inflammasome, in reprograming renal and immune cell metabolism and, therefore, in promoting kidney inflammation/injury. SUMMARY Therapies aiming to decrease uric acid levels prevent renal NLRP3 inflammasome activation and exert renoprotective effects in experimental kidney diseases. However, further clinical studies are needed to investigate whether reduced circulating uric acid can also inhibit the inflammasome and be beneficial in human conditions.
Collapse
Affiliation(s)
- Tarcio Teodoro Braga
- Department of Basic Pathology, Federal University of Parana, Curitiba, PR.,Carlos Chagas Institute - Fiocruz-Parana, Curitiba
| | - Orestes Foresto-Neto
- Nephrology Division, Federal University of São Paulo.,Department of Immunology, Institute of Biomedical Sciences IV, University of São Paulo, SP, Brazil
| | - Niels Olsen Saraiva Camara
- Nephrology Division, Federal University of São Paulo.,Department of Immunology, Institute of Biomedical Sciences IV, University of São Paulo, SP, Brazil
| |
Collapse
|
8
|
Better outcomes for patients with gout. Inflammopharmacology 2020; 28:1395-1400. [PMID: 32095979 DOI: 10.1007/s10787-020-00694-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 02/11/2020] [Indexed: 12/27/2022]
Abstract
Gout is increasing in prevalence despite effective pharmacotherapies. Barriers to effective management are largely educational deficiencies. Sufferers, usually men, need to understand more about gout, especially that maintaining serum urate below 0.36 mmol/L will eliminate recurrent attacks. Also, of great importance is appreciating that sub-optimal adherence to urate-lowering therapy (ULT) will result in a return of attacks. Prescribers also need to understand that acute attacks are likely to occur in the first few months of urate-lowering therapy (ULT), but these can be mitigated by commencing with a dose of ULT reflective of renal function and escalating the dose slowly, every 2-5 weeks until target serum urate is achieved. Prophylaxis against acute attacks over the initial 6 months period of ULT can be enhanced further with concomitant colchicine or nonsteroidal anti-inflammatory drugs (NSAIDs).Gout is largely managed in primary care. Rates of adherence to ULT are 50% or less, worse than most other chronic illnesses. Efforts at educating primary care physicians to, firstly, manage gout effectively and, secondly, to educate their gout patients sufficiently have not been successful. Allied health practitioners, such as nurses, working with prescribers in primary care settings and given the mandate to educate and manage patients with gout, have been spectacularly effective. However, this approach is resource intensive. 'Personalised' eHealth interventions show promise as an alternative strategy, notably in improving adherence to ULT.Numerous applications for smart phones (apps) are now available to assist people with chronic health conditions. Their design needs to accommodate the barriers and enablers perceived by patients to maintaining adherence to prescribed therapies. Personalised feedback of serum urate may represent an important enabler of adherence to ULT in the case of gout.Harnessing mobile apps to support patients managing their chronic illnesses represents an important opportunity to enhance health outcomes. Rigorous, patient-centred and driven development is critical. These tools also require careful evaluation for effectiveness.
Collapse
|
9
|
Day RO, Lau W, Stocker SL, Aung E, Coleshill MJ, Schulz M, Bechara J, Carland JE, Graham GG, Williams KM, McLachlan AJ. Management of gout in older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2019. [DOI: 10.1002/jppr.1511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Richard O. Day
- St Vincent's Hospital Clinical School; UNSW Medicine; Sydney Australia
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
| | - Wendy Lau
- Westmead Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | - Sophie L. Stocker
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | - Eindra Aung
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
| | - Mathew J. Coleshill
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | - Marcel Schulz
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | - Jacob Bechara
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | - Jane E. Carland
- Department of Clinical Pharmacology and Toxicology; St Vincent's Hospital; Sydney Australia
- UNSW Medicine; Sydney Australia
| | | | | | - Andrew J. McLachlan
- Sydney Pharmacy School; University of Sydney; Sydney Australia
- Department of Clinical Pharmacology; St Vincent's Hospital; Sydney Darlinghurst Australia
| |
Collapse
|
10
|
|
11
|
Graham GG, Stocker SL, Kannangara DRW, Day RO. Predicting Response or Non-response to Urate-Lowering Therapy in Patients with Gout. Curr Rheumatol Rep 2018; 20:47. [PMID: 29931553 DOI: 10.1007/s11926-018-0760-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW To review the extent of treatment success or failure with the xanthine oxidoreductase inhibitors allopurinol and febuxostat and indicate how the dosage of urate-lowering therapy (ULT) may be modified to increase the response in the majority of patients with gout. RECENT FINDINGS Gout flares are associated with serum concentrations of urate above 0.42 mmol/L (7 mg/dL). Achieving and maintaining serum urate below 0.36 mmol/L is considered an effective response to ULT. On an intention to treat basis, clinical trials indicate that allopurinol at daily doses of 100 to 300 mg decreases serum urate adequately in only about 40% of gout patients while febuxostat 80 mg daily reduces serum urate adequately in approximately 70% of gout patients. Higher doses of ULT may be required in patients receiving concomitant diuretics. The addition of a uricosuric agent to allopurinol and febuxostat therapy significantly increases the proportion of patients achieving adequate lowering of serum urate. Finally, carriers of a genetic variant of the transporter, ABCG2 (BCRP), have a decreased response to allopurinol. Careful examination of medication adherence, titration of doses, and the addition of uricosuric agents increase the percentage of patients responding to allopurinol and febuxostat.
Collapse
Affiliation(s)
- Garry G Graham
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, Australia
| | - Sophie L Stocker
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia. .,St Vincent's Clinical School, St Vincent's Hospital, University of New South Wales, Kensington, Sydney, Australia.
| | - Diluk R W Kannangara
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, Australia.,St Vincent's Clinical School, St Vincent's Hospital, University of New South Wales, Kensington, Sydney, Australia.,School of Medicine, University of Notre Dame, Sydney, Australia
| | - Richard O Day
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.,School of Medical Sciences, University of New South Wales, Kensington, NSW, Australia.,St Vincent's Clinical School, St Vincent's Hospital, University of New South Wales, Kensington, Sydney, Australia
| |
Collapse
|
12
|
Drivelegka P, Sigurdardottir V, Svärd A, Jacobsson LTH, Dehlin M. Comorbidity in gout at the time of first diagnosis: sex differences that may have implications for dosing of urate lowering therapy. Arthritis Res Ther 2018; 20:108. [PMID: 29855389 PMCID: PMC5984404 DOI: 10.1186/s13075-018-1596-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/18/2018] [Indexed: 12/22/2022] Open
Abstract
Background The aim of this study is to examine the occurrence of comorbidities at the time of first diagnosis of gout compared with matched population controls, overall and by sex, as well as to examine the crude and age-standardized prevalence of these comorbidities in men and women with gout at first diagnosis. Methods A population-based study used data from Swedish national and regional registers, including 14,113 gout patients aged ≥ 20 years, with a first recorded diagnosis of gout between 1 January 2006 and 31 December 2012, and 65,782 population controls, matched by age, sex and county. Prevalence ratios (95% confidence intervals) comparing gout cases and controls were calculated, overall and by sex. Crude and age-standardized prevalence (95% confidence interval) of all comorbidities in gout patients were calculated, to show differences between sexes, taking also the higher age at diagnosis in women into account. Results All examined comorbidities were 1.2–2.5-fold more common in gout patients at diagnosis than in population controls in both sexes. Women with gout were on average 6 years older than men at first gout diagnosis and most comorbidities, including obesity and diuretic use, were or tended to be more frequent in women than in men. When standardizing for age, women had a higher prevalence of thromboembolism (6.6% vs 5.2%) and chronic obstructive pulmonary disease (3.1% vs 2.4%). Men, on the other hand, had a higher prevalence of coronary heart disease (9.4% vs 6.4%), atrial fibrillation (9.0% vs 6.0%), congestive heart failure (7.7% vs 6.6%) and stroke (4.1% vs 3.3%). Conclusions The occurrence of most comorbidities was significantly increased at first diagnosis of gout in both sexes. Women were older at diagnosis and had higher occurrence of most comorbidities, including obesity and diuretic use, factors that increase serum urate, and this needs to be taken into account when starting and optimizing urate lowering therapy. These sex differences were attenuated when standardizing for age and the occurrence of cardiovascular diseases was actually higher in men. Electronic supplementary material The online version of this article (10.1186/s13075-018-1596-x) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Panagiota Drivelegka
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy, University of Gothenburg, Grona Straket 12, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.
| | - Valgerdur Sigurdardottir
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy, University of Gothenburg, Grona Straket 12, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.,Centre of Clinical Research Dalarna, Falun, Sweden
| | - Anna Svärd
- Centre of Clinical Research Dalarna, Falun, Sweden
| | - Lennart T H Jacobsson
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy, University of Gothenburg, Grona Straket 12, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Mats Dehlin
- Department of Rheumatology and Inflammation Research, Sahlgrenska Academy, University of Gothenburg, Grona Straket 12, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| |
Collapse
|
13
|
Ranieri L, Contero C, Peral ML, Calabuig I, Zapater P, Andres M. Impact of diuretics on the urate lowering therapy in patients with gout: analysis of an inception cohort. Arthritis Res Ther 2018; 20:53. [PMID: 29566736 PMCID: PMC5863897 DOI: 10.1186/s13075-018-1559-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 03/06/2018] [Indexed: 11/26/2022] Open
Abstract
Background Diuretics have been associated with impaired response and refractoriness in gout, but whether this effect is still present with new urate-lowering drugs (ULD) and treat-to-target strategies is unknown. The aim of the present study was to assess the impact of the diuretics on the response to ULD in patients with gout. Methods This was a retrospective analysis of an inception cohort. Participants were classified according to the type of ULD prescribed. We analysed the maximal dose of ULD (primary outcome variable), serum urate (SU) reduction, and the achievement of different SU targets (6 mg/dL, 5 mg/dL, and 4 mg/dL), according to the type of ULD prescribed and use of diuretics (loop and/or thiazide). We adjusted for confounders using multiple linear regression analysis. Results We included 245 patients: 208 treated with allopurinol (66 on diuretics, 31.7%), 35 with febuxostat (19 on diuretics, 57.6%), and 2 with benzbromarone. Significantly fewer participants in the allopurinol plus diuretics subgroup achieved SU levels of less than 5 mg/dL, but we found no other significant differences in SU targets associated with diuretics. Regarding the maximum ULD dose, a simple linear regression suggested an inverse relationship with diuretics (beta = − 0.125, p = 0.073), but this did not hold in the multivariable analysis (beta = − 0.47, p = 0.833). There was no association with febuxostat (beta = − 0.116, p = 0.514). Conclusion Diuretics do not appear to have a significant impact on managing gout. Electronic supplementary material The online version of this article (10.1186/s13075-018-1559-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Laura Ranieri
- Rheumatology Deparment, Hospital General Universitario de Alicante-ISABIAL, Pintor Baeza 12, 03010, Alicante, Spain
| | | | - Maria-Luisa Peral
- Rheumatology Deparment, Hospital General Universitario de Alicante-ISABIAL, Pintor Baeza 12, 03010, Alicante, Spain
| | - Irene Calabuig
- Rheumatology Deparment, Hospital General Universitario de Alicante-ISABIAL, Pintor Baeza 12, 03010, Alicante, Spain
| | - Pedro Zapater
- Universidad Miguel Hernández, Elche, Alicante, Spain.,Clinical Pharmacology Deparment, Hospital General Universitario de Alicante-ISABIAL, Alicante, Spain
| | - Mariano Andres
- Rheumatology Deparment, Hospital General Universitario de Alicante-ISABIAL, Pintor Baeza 12, 03010, Alicante, Spain. .,Universidad Miguel Hernández, Elche, Alicante, Spain.
| |
Collapse
|
14
|
Wallace MC, Roberts RL, Nanavati P, Miner JN, Dalbeth N, Topless R, Merriman TR, Stamp LK. Association between ABCG2 rs2231142 and poor response to allopurinol: replication and meta-analysis. Rheumatology (Oxford) 2018; 57:656-660. [DOI: 10.1093/rheumatology/kex467] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Indexed: 12/15/2022] Open
Affiliation(s)
- Mary C Wallace
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Rebecca L Roberts
- Department of Surgical Sciences, University of Otago, Dunedin, New Zealand
| | - Payal Nanavati
- Biology Department, Ardea Biosciences, Inc., San Diego, CA, USA
| | - Jeffrey N Miner
- Biology Department, Ardea Biosciences, Inc., San Diego, CA, USA
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Ruth Topless
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Tony R Merriman
- Department of Biochemistry, University of Otago, Dunedin, New Zealand
| | - Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, New Zealand
| |
Collapse
|
15
|
Jones G, Panova E, Day R. Guideline development for the management of gout: role of combination therapy with a focus on lesinurad. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:3077-3081. [PMID: 29123379 PMCID: PMC5661481 DOI: 10.2147/dddt.s97959] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
The aim of this review was to summarize the evidence for combination therapy to achieve serum urate (SUA) target levels in gout. Within this overarching aim, a second aim was to evaluate the evidence for a new uricosuric agent lesinurad, which inhibits urate transport in the kidney. In summary, this review indicates that there are a number of ways to approach patients who do not achieve a target serum urate with allopurinol (APL) monotherapy. These include higher doses of APL up to 600–800 mg/d, switching to febuxostat, or adding in a uricosuric. For the latter option, controlled supporting evidence is available for benzbromarone, probenecid, and lesinurad. All options appear similar in terms of success rates, so the choice of option comes down to physician and patient choice, cost, experience, and strength of the evidence base. Increasing the dose of APL is the cheapest option, while febuxostat is consistently superior to standard doses of APL. The strongest evidence for the uricosuric option is available for lesinurad as trials of other agents are either nonexistent or based on small single-centre trials. It is suggested that guidelines should be expanded to consider all of these evidence-based options in the not-uncommon occurrence of APL inadequate response.
Collapse
Affiliation(s)
- Graeme Jones
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Elena Panova
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Richard Day
- University of New South Wales, Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| |
Collapse
|
16
|
Kannangara DRW, Graham GG, Wright DFB, Stocker SL, Portek I, Pile KD, Barclay ML, Williams KM, Stamp LK, Day RO. Individualising the dose of allopurinol in patients with gout. Br J Clin Pharmacol 2017; 83:2015-2026. [PMID: 28417592 DOI: 10.1111/bcp.13307] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 03/14/2017] [Accepted: 04/04/2017] [Indexed: 12/01/2022] Open
Abstract
AIMS The aims of the study were to: 1) determine if a plasma oxypurinol concentration-response relationship or an allopurinol dose-response relationship best predicts the dose requirements of allopurinol in the treatment of gout; and 2) to construct a nomogram for calculating the optimum maintenance dose of allopurinol to achieve target serum urate (SU) concentrations. METHODS A nonlinear regression analysis was used to examine the plasma oxypurinol concentration- and allopurinol dose-response relationships with serum urate. In 81 patients (205 samples), creatinine clearance (CLCR ), concomitant diuretic use and SU concentrations before (UP ) and during (UT ) treatment were monitored across a range of allopurinol doses (D, 50-700 mg daily). Plasma concentrations of oxypurinol (C) were measured in 47 patients (98 samples). Models (n = 47 patients) and predictions from each relationship were compared using F-tests, r2 values and paired t-tests. The best model was used to construct a nomogram. RESULTS The final plasma oxypurinol concentration-response relationship (UT = UP - C*(UP - UR )/(ID50 + C), r2 = 0.64) and allopurinol dose-response relationship (UT = UP - D* (UP - UR )/(ID50 + D), r2 = 0.60) did not include CLCR or diuretic use as covariates. There was no difference (P = 0.87) between the predicted SU concentrations derived from the oxypurinol concentration- and allopurinol dose-response relationships. The nomogram constructed using the allopurinol dose-response relationship for all recruited patients (n = 81 patients) required pretreatment SU as the predictor of allopurinol maintenance dose. CONCLUSIONS Plasma oxypurinol concentrations, CLCR and diuretic status are not required to predict the maintenance dose of allopurinol. Using the nomogram, the maintenance dose of allopurinol estimated to reach target concentrations can be predicted from UP .
Collapse
Affiliation(s)
- Diluk R W Kannangara
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia.,School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Garry G Graham
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia.,School of Medical Sciences, University of New South Wales, Sydney, Australia
| | | | - Sophie L Stocker
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia.,School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Ian Portek
- Department of Rheumatology, St George Hospital, Sydney, Australia
| | - Kevin D Pile
- Department of Medicine, Western Sydney University, Campbelltown, Australia
| | - Murray L Barclay
- Department of Medicine, University of Otago, Christchurch, New Zealand.,Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand
| | - Kenneth M Williams
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia.,School of Medical Sciences, University of New South Wales, Sydney, Australia
| | - Lisa K Stamp
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Richard O Day
- Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital, Sydney, Australia.,School of Medical Sciences, University of New South Wales, Sydney, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, Australia
| |
Collapse
|