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Qi H, Sun M, Terkeltaub R, Merriman TR, Chen H, Li Z, Ji A, Xue X, Sun W, Wang C, Li X, He Y, Cui L, Dalbeth N, Li C. Hyperuricemia Subtypes Classified According to Renal Uric Acid Handling Manifesting Distinct Phenotypic and Genetic Profiles in People With Gout. Arthritis Rheumatol 2024; 76:1130-1140. [PMID: 38412854 DOI: 10.1002/art.42838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 02/19/2024] [Accepted: 02/26/2024] [Indexed: 02/29/2024]
Abstract
OBJECTIVE Hyperuricemia can be stratified into four subtypes according to renal uric acid handling. The aim of this study was to comprehensively describe the biologic characteristics (including genetic background) of clinically defined hyperuricemia subtypes in two large geographically independent gout cohorts. METHODS Hyperuricemia subtype was defined as renal uric acid overload (ROL), renal uric acid underexcretion (RUE), combined, or renal normal. Twenty single nucleotide polymorphisms (SNPs) previously identified as gout risk loci or associated with serum urate (SU) concentration in the East Asian population were genotyped. Weighted polygenic risk scores were calculated to assess the cumulative effect of genetic risks on the subtypes. RESULTS Of the 4,873 participants, 8.8% had an ROL subtype, 60.9% RUE subtype, 23.1% combined subtype, and 7.2% normal subtype. The ROL subtype was independently associated with older age at onset, lower SU, tophi, and diabetes mellitus; RUE was associated with lower body mass index (BMI) and non-diabetes mellitus; the combined subtype was associated with younger age at onset, higher BMI, SU, estimated glomerular filtration rate (eGFR), and smoking; and the normal subtype was independently associated with older age at onset, lower SU, and eGFR. Thirteen SNPs were associated with gout with 6 shared loci and subtype-dependent risk loci patterns. High polygenic risk scores were associated with ROL subtype (odds ratio [OR] = 9.63, 95% confidence interval [95% CI] 4.53-15.12), RUE subtype (OR = 2.18, 95% CI 1.57-3.03), and combined subtype (OR = 6.32, 95% CI 4.22-9.48) compared with low polygenic risk scores. CONCLUSION Hyperuricemia subtypes classified according to renal uric acid handling have subtype-specific clinical and genetic features, suggesting subtype-unique pathophysiologic mechanisms.
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Affiliation(s)
- Han Qi
- The Affiliated Hospital of Qingdao University, Qingdao University, and Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Mingshu Sun
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | | | - Tony R Merriman
- Qingdao University, Qingdao, China, and University of Alabama Birmingham
| | | | - Zhiqiang Li
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Aichang Ji
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaomei Xue
- The Affiliated Hospital of Qingdao University, Qingdao University, and Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Wenyan Sun
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Can Wang
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xinde Li
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuwei He
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lingling Cui
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | | | - Changgui Li
- The Affiliated Hospital of Qingdao University, Qingdao University, and Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
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Xue X, Sun M, Yan F, Dalbeth N, He Y, Li X, Qi H, Chen Y, Yuan X, Li M, Ji A, Terkeltaub R, Li C. Superiority of Low-Dose Benzbromarone Add-On to Low-Dose Febuxostat Compared With Febuxostat Monotherapy in Gout With Combined-Type Hyperuricemia. Arthritis Care Res (Hoboken) 2024; 76:703-711. [PMID: 38130040 PMCID: PMC11039362 DOI: 10.1002/acr.25283] [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] [Received: 06/23/2023] [Revised: 10/17/2023] [Accepted: 12/19/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE There is an unmet need for simpler urate-lowering therapy (ULT) regimens that achieve the serum urate target and improve the overall quality of gout care. We report a comparative effectiveness trial of febuxostat monotherapy versus benzbromarone add-on to low-dose febuxostat in gout specifically with combined renal urate underexcretion and overload. METHODS A prospective randomized trial was conducted on patients with combined-type hyperuricemia and estimated glomerular filtration rate >60 mL/min/1.73 m2 1:1 randomly assigned to febuxostat and benzbromarone combination therapy (initially febuxostat at 20 mg/day, with benzbromarone at 25 mg/day added onto 20 mg/day of febuxostat if not at target) or febuxostat monotherapy (initially 20 mg/day, escalating to 40 mg/day if not at target). The primary end point at 12 weeks was the proportion achieving a serum urate (SU) level <360 μmol/L. Other outcomes included altered liver and kidney function, new-onset urolithiasis, and gout flares. RESULTS There were 250 participants randomized; 219 completed 12-week treatment. More patients in the febuxostat and benzbromarone combination group achieved the SU target compared to patients in the febuxostat monotherapy group (75.5% vs 47.7%; odds ratio 3.37 [95% confidence interval 1.90-5.98]). Safety profiles were comparable between the two groups. CONCLUSION Simply adding on low-dose benzbromarone (25 mg/day) to low-dose (20 mg/day) febuxostat showed superior urate lowering compared to febuxostat monotherapy in gout with a combined-type hyperuricemia. For selected patients, expedited achievement of the SU target in more than 75% of patients using one titration step and low xanthine oxidase inhibitor and uricosuric doses is a potential alternative to standard ULT regimens.
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Affiliation(s)
- Xiaomei Xue
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Mingshu Sun
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
- Department of Rheumatology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Fei Yan
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Yuwei He
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xinde Li
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Han Qi
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ying Chen
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Xuan Yuan
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China
| | - Maichao Li
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Aichang Ji
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Robert Terkeltaub
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Changgui Li
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China
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Qi H, Sun M, Terkeltaub R, Xue X, Li X, Cui L, He Y, Yan F, Sun R, Chen Y, Jia Z, Cheng X, Ma L, Liu T, Dalbeth N, Li C. Response to febuxostat according to clinical subtypes of hyperuricemia: a prospective cohort study in primary gout. Arthritis Res Ther 2023; 25:241. [PMID: 38082308 PMCID: PMC10712161 DOI: 10.1186/s13075-023-03228-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 12/02/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND While xanthine oxidase inhibitors target uric acid production, renal urate underexcretion is the predominant subtypes in gout. This study was to compare treatment response to the XOI febuxostat in a gout cohort according to clinical subtypes of hyperuricemia. METHODS A prospective cohort study was conducted to compare the efficacy and safety of febuxostat (initially 20 mg daily, escalating to 40 mg daily if not at target) in 644 gout patients with the three major clinical subtypes for 12 weeks. Hyperuricemia was defined as the renal overload subtype, the renal underexcretion subtype, or the combined subtype based on UUE > or ≤ 600 mg/d/1.73 m2 and FEUA < or ≥ 5.5%. The primary endpoint was the rate of achieving serum urate (SU) < 6 mg/dL at week 12. RESULTS Fewer participants with combined subtype achieved the SU target, 45.5% compared with 64.8% with overload subtype (P = 0.007), and 56.6% with underexcretion subtype (P = 0.022). More participants with combined subtype (82%) had febuxostat escalated to 40 mg than those with overload (62%, P = 0.001) or underexcretion subtype (68%, P = 0.001). In all participants, combined subtype hyperuricemia (OR = 0.64, 95%CI 0.41-0.99, P = 0.048) and baseline SU (OR = 0.74, 95%CI 0.62-0.89, P = 0.001) were independently associated with lower rates of achieving SU target. CONCLUSIONS People with combined subtype have a lower response to febuxostat, compared to those with either overload or underexcretion subtype. Assessment of hyperuricemia subtype may provide useful clinical data in predicting febuxostat response.
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Affiliation(s)
- Han Qi
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
| | - Mingshu Sun
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
- Department of Rheumatology, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Robert Terkeltaub
- VA San Diego VA Healthcare Center, University of California San Diego, La Jolla, CA, USA
| | - Xiaomei Xue
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xinde Li
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lingling Cui
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuwei He
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Fei Yan
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ruixia Sun
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Ying Chen
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhaotong Jia
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xiaoyu Cheng
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lidan Ma
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Tian Liu
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Nicola Dalbeth
- Department of Medicine, University of Auckland, Auckland, New Zealand.
| | - Changgui Li
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China.
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China.
- Institute of Metabolic Diseases, Qingdao University, Qingdao, China.
- Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China.
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Kawada T. Superiority of low-dose benzbromarone to low-dose febuxostat in gout patients with renal uric acid underexcretion: comment on the article by Yan et al. Arthritis Rheumatol 2023; 75:1680-1681. [PMID: 36908047 DOI: 10.1002/art.42499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 03/06/2023] [Indexed: 03/14/2023]
Affiliation(s)
- Tomoyuki Kawada
- Department of Hygiene and Public Health, Nippon Medical School, Tokyo, Japan
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Xue X, Yan F, Guo K, He Y, Li C. Reply. Arthritis Rheumatol 2023; 75:1681-1683. [PMID: 36908087 DOI: 10.1002/art.42494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/06/2023] [Indexed: 03/14/2023]
Affiliation(s)
- Xiaomei Xue
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Fei Yan
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Kai Guo
- Department of Endocrinology and Metabolism, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuwei He
- Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout, the Affiliated Hospital of Qingdao University, Qingdao, China
| | - Changgui Li
- Department of Endocrinology and Metabolism, Shandong Provincial Key Laboratory of Metabolic Diseases and Qingdao Key Laboratory of Gout Affiliated Hospital of Qingdao University, Institute of Metabolic Diseases, Qingdao University and Shandong Provincial Clinical Research Center for Immune Diseases and Gout, Qingdao, China
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