Gout. Novel therapies for treatment of gout and hyperuricemia
© BioMed Central Ltd 2009
Published: 23 July 2009
In the past few decades, gout has increased not only in prevalence, but also in clinical complexity, the latter accentuated in part by a dearth of novel advances in treatments for hyperuricemia and gouty arthritis. Fortunately, recent research reviewed here, much of it founded on elegant translational studies of the past decade, highlights how gout can be better managed with cost-effective, well-established therapies. In addition, the advent of both new urate-lowering and anti-inflammatory drugs, also reviewed here, promises for improved management of refractory gout, including in subjects with co-morbidities such as chronic kidney disease. Effectively delivering improved management of hyperuricemia and gout will require a frame shift in practice patterns, including increased recognition of the implications of refractory disease and frequent noncompliance of patients with gout, and understanding the evidence basis for therapeutic targets in serum urate-lowering and gouty inflammation.
Common features of 'treatment-refractory' gout that complicate management
Polyarticular gout, uncontrolled flare activity, and/or chronic synovitis
Co-morbidities (for example, chronic kidney disease, cardiovascular disease, obesity, metabolic syndrome or diabetes, alcohol abuse)
Polypharmacy and drug interactions (for example, statins, macrolide antibiotics, oral anticoagulants)
Contra-indications or refractoriness to NSAIDs, colchicines, and/or glucocorticosteroids
Allopurinol intolerance or hypersensitivity and inability to employ uricosurics
Failure to adequately lower serum urate on appropriate doses of urate-lowering drugs
Gout therapy: how the current armamentarium is actually employed in the 'real world'
Overview of recent treatment patterns of gout in the USA
Total ambulatory visits, and visits to primary care versus specialists
Total number of ambulatory care visits
Number of visits for gout
3.9 million (0.4% of total)
Percentage of total visits for gout to:
'Other specialists or unknown'
Number of gout patient-specific anti-inflammatory prescriptions (absolute number of prescriptions/year)
Number of gout patient-specific urate-lowering prescriptions (absolute number of prescriptions/year)
Demographics of allopurinol prescribing: percentage of gout patients that are:
Advances in treatment of gouty arthritis by better use of the current drug armamentarium
Acute gouty arthritis is mediated by the capacity of monosodium urate crystals to activate multiple pro-inflammatory pathways in the joint, culminating in early activation of resident macrophages, and neutrophil adhesion, migration into the joint, and activation in the synovium and joint space that drive gouty inflammation [8, 9]. Current primary options for anti-inflammatory management of acute gout (nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and colchicine) bluntly dampen these inflammatory mechanisms in a cost-effective manner, though are limited by broad drug toxicities, particularly in subjects with significant co-morbidities [8–13]. Moreover, the evidence basis for some of these treatments has been limited by inadequate assessment in randomized, controlled, double-blind clinical trials, an issue due to the intrinsic self-limitation of the acute gout flare.
The recent definition of etoricoxib as an effective COX-2-selective inhibitor in acute gout  has opened up a new therapeutic approach, but the cardiovascular safety of COX2 inhibitors remains under review. The establishment, in the past 2 years, of the evidence basis for oral glucocorticosteroid treatment of acute gout is also particularly significant, for example, for subjects with CKD. Specifically, prednisolone 35 mg daily for 5 days and naproxen 500 mg twice daily for 5 days have been demonstrated to be comparable in efficacy and tolerance in a recent trial of acute gout treatment . Prednisolone (6 doses of 30 mg over 5 days) was also comparable in efficacy to indomethacin and better tolerated in an acute gout trial .
Dosing guidelines and the evidence basis for colchicine in acute gout treatment have also advanced in the past few years. In older oral colchicine regimens where the drug was given every 1 to 2 hours repeatedly for multiple doses, gastrointestinal toxicity, including severe diarrhea, was limiting, and occurred before a 50% reduction in pain was achieved in most subjects . Intense colchicine regimens have justifiably fallen out of favor. As an example, European League Against Rheumatism (EULAR) expert consensus guidelines for oral colchicine in acute gout are for a maximum of three colchicine 0.5 mg tablets per 24 hour period . Furthermore, in a large, randomized, controlled multicenter trial comparing low dose and extended dose colchicine regimens, results strongly supported the lower dose colchicine regimen for acute gout . In this study, within 12 hours of onset of acute gout symptoms patients self-administered 'high dose' colchicine (1.2 mg followed by 0.6 mg every hour for 6 hours (4.8 mg total)) or 'low dose' colchicine (1.2 mg followed by 0.6 mg in 1 hour (1.8 mg total)), or placebo. The 'low dose' colchicine was comparable to 'high dose' colchicine in efficacy, but did not differ from placebo with respect to diarrhea or other gastrointestinal side effects.
Advanced anti-inflammatory therapies for gout
Though anecdotal reports have suggested tumor necrosis factor-α antagonism to be beneficial in some cases of refractory human gouty inflammation , IL-1β appears to be far more central than tumor necrosis factor-α in experimental urate crystal-induced inflammation in mice . Concordantly, the most investigated biologic drug strategy in humans for gouty inflammation has been neutralization of IL-1, with promising results [9, 17]. A pilot study of ten patients with chronic refractory gouty inflammation given the soluble IL-1 receptor antagonist anakinra (100 mg daily subcutaneously for 3 days) suggested good overall responses , though results of larger, randomized, controlled studies of IL-1 inhibition for gouty arthritis are awaited.
Options in the treatment of hyperuricemia: recent establishment of the evidence basis for <6 mg/dL as the serum urate target level in gout
Pharmacologic urate-lowering approaches can employ primary, potent uricosurics (probenecid or benzbromarone), xanthine oxidase inhibitors to inhibit uric acid generation (allopurinol and the recently approved drug febuxostat), or experimental uricase treatment (with Rasburicase™ or pegloticase) to degrade urate [1, 10]. Since the solubility of urate in physiologic solutions is exceeded at approximately 6.7 to 7.0 mg/dL, current guidelines for inhibiting ongoing urate crystal deposition, reduction of total body urate stores, and resolution of macroscopic tophi are for continuing (lifelong) reduction of serum urate concentration to <6 mg/dL (approximately 360 mmol/l), and ideally in the 5 to 6 mg/dL range . As summarized in a detailed, recent review , achieving this target level in gout patients ultimately is associated with fewer gout flares, and it also may have direct and indirect beneficial effects on renal function [19, 20]. A more aggressive serum urate-lowering target such as 3 to 5 mg/dL appears appropriate for more rapid tophus de-bulking in those tophaceous gout patients with a body burden of urate assessed to be particularly large .
Advances in understanding renal urate handling and uricosuric therapy
A major advance that also could point to new and potentially genomics-customized uricosuric strategies is the identification of ATP-binding cassette sub-family G member 2 (ABCG2) as one of the functional urate anion secretory transporters at the apical membrane of the renal proximal tubule epithelial cell (Figure 2) . Moreover, genome-wide association studies have linked common URAT1, GLUT9, and now ABCG2 haplotypes or single nucleotide polymorphisms with altered susceptibility to gout [23–28, 30]. For example, the common ABCG2 rs2231142 single nucleotide polymorphism encoding the Q141K mutation in the nucleotide-binding domain of ABCG2 suppresses ABCG2 urate transport rates by approximately 50% in vitro, and in a large, population-based study, rs2231142 was strongly associated with serum urate levels in whites, who have a minor allele frequency of 0.11 . The adjusted odds ratio for gout of 1.68 per risk allele in whites and blacks argues that approximately 10% of all gout cases in whites may be attributable to ABCG2 rs2231142, and the risk allele also is highly prevalent in Asians, who have a higher gout prevalence than whites .
Significantly, in current clinical practice, the most available primary uricosuric, probenecid, requires more than once daily dosing and increases the risk of urolithiasis, particularly in acid urine . More selective and potent uricosurics ideally would have a once daily dosing profile and could be designed such that urolithiasis risk is not unduly elevated. All uricosurics also become less effective and ultimately ineffective with progressively lower glomerular filtration rate [10, 31]. This may limit the role of combining uricosurics with xanthine oxidase inhibition in the treatment of refractory hyperuricemia in gout patients since xanthine oxidase inhibition lowers urinary uric acid clearance by excretion. Such a combination approach can normalize serum urate in a substantial fraction of patients on submaximal allopurinol . An approach of this nature, using certain drugs with wider availability than benzbromarone (for example, losartan, and fenofibrate) [33, 34] but with less potent uricosuric action than primary uricosurics such as probenecid, has to date been, at best, only moderately successful, when studied in only small numbers of subjects, as a potential strategy to further lower serum urate where there is suboptimal control with allopurinol. It appears likely that such combination strategies will be particularly constrained in effectiveness in those with stage 3 CKD or worse (creatinine clearance <60 calculated by Cockroft-Gault equation and adjusted for ideal body weight).
Advances in understanding allopurinol treatment failure
Given the limitations of uricosuric therapy highlighted above, the first line of pharmacologic therapy to lower serum urate for most gout patients is suppression of xanthine oxidase using allopurinol, which, when effective and well-tolerated, is a cost-effective option [6, 10]. Allopurinol is US Food and Drug Administration (FDA) approved for doses up to 800 mg daily . Recent expert consensus EULAR guidelines have reinforced FDA dosing guidelines for allopurinol in patients with preserved renal function [6, 35], specifically to initiate allopurinol at 100 mg daily, and then to increase the dose by 100 mg every 1 to 4 weeks until a target serum urate level (<6 mg/dL) is achieved or the maximum appropriate allopurinol dose is reached. FDA dosing guidelines have also advocated 200 to 300 mg allopurinol daily as adequate for most patients with mild gout, and an average dose of 400 to 600 mg allopurinol daily as the expected amount to control hyperuricemia in patients with moderately severe tophaceous gout . In small studies of gout patients, the mean daily dose of allopurinol needed to normalize serum urate was 372 mg , and allopurinol dose increases from 300 mg to 600 mg daily markedly increased serum urate-lowering efficiency in patients without stage 3 or worse CKD . Data from recent, large, randomized, controlled clinical trials indicated that allopurinol 300 mg daily lowered serum urate by approximately 33% in a population of gout patients where approximately 25 to 30% had detectable tophi, serum urate was approximately 9.5 to 10 mg/dL, and renal function was largely intact [38, 39].
In clinical practice, noncompliance with allopurinol has recently been elucidated to be a problem in approximately 50% of subjects in the first year of therapy . Moreover, it appears that allopurinol is widely under-dosed overall in clinical practice, since the vast majority of allopurinol prescriptions are for 300 mg daily or less . This circumstance reflects influential maintenance dosing guidelines for allopurinol in CKD dating from the 1980s and calibrated for serum levels (in relationship to estimated glomerular filtration rate) of oxypurinol, which is the major, long-lived active allopurinol metabolite and is primarily excreted by the kidney . The intent of the older guidelines was to lessen the incidence of allopurinol hypersensitivity syndrome, particularly with CKD . These guidelines are now recognized not to be based on evidence, to fail to adequately treat hyperuricemia, and also to fail to prevent allopurinol hypersensitivity syndrome in all patients, including those with CKD [35, 42]. Though HLA-B58 is a newly identified risk factor for severe cutaneous adverse reactions to allopurinol (that is, Stevens-Johnson syndrome or toxic epidermal necrolysis) [43–45], there remains no reliable way to identify whether an individual patient will develop such toxicity on allopurinol [35, 42].
FDA and more recent EULAR dosing guidelines for allopurinol have suggested the use of reduced doses in renal failure in order to lessen the risk of drug toxicity [6, 35]. For example, the FDA-recommended maximum allopurinol dose is 200 mg daily with a creatinine clearance of 10 to 20 ml/min, and 100 mg daily with a creatinine clearance of <10 ml/min. More recently, dose reduction of allopurinol in moderate CKD was supported via retrospective analysis of renal function-adjusted dosing of allopurinol in relation to drug toxicities . The lack of a definition of safety and tolerability of allopurinol maintenance doses above those previously calibrated for serum oxypurinol levels related to creatinine clearance  needs to be considered when weighing the decision to employ more advanced serum urate lowering therapeutic options.
Advanced options for treatment-refractory hyperuricemia in gout: febuxostat
The xanthine oxidase inhibitor febuxostat, now approved in Europe and the USA, is an appropriate choice in circumstances of allopurinol hypersensitivity or intolerance, or failure of allopurinol (at a maximal dose appropriate for the individual patient) to normalize serum urate and, ultimately, improve physical function and quality of life parameters. Febuxostat is a particularly appropriate second line option to allopurinol where uricosuric therapy is contra-indicated, as in stage 3 or worse CKD, and in patients with a history of urolithiasis, an inability to adequately increase hydration, or with identified uric acid overproduction .
Febuxostat 40 to 120 mg daily (and a safety dose trial of 240 mg daily) has now been analyzed in large, randomized, clinical trials in which tophi were seen in approximately 25 to 30% of subjects, with a maximum dose of 300 mg allopurinol employed in comparison groups [38, 39, 48, 49]. Results of all of these trials unequivocally established the failure of 300 mg allopurinol daily to achieve a serum urate target level of <6 mg/dL in a substantial majority of the patient population studied. In a 52-week trial, febuxostat 80 and 120 mg both achieved the target level of serum urate <6 mg/dL in the majority of subjects, though gout flare rates at 52 weeks were comparable to those in subjects randomized to allopurinol 300 mg daily . In a second, large phase 3 trial, febuxostat 40 mg daily demonstrated serum urate-lowering to target of <6 mg/dL roughly equivalent to allopurinol 300 mg daily in those with intact renal function, and 80 mg febuxostat daily was superior to allopurinol 300 mg or febuxostat 40 mg daily in achieving a serum urate target level of <6 mg/dL, with comparable drug tolerance . In a subset of patients with stage 2 to 3 CKD, febuxostat 40 and 80 mg daily were also superior in achieving the serum urate target level in comparison to renally dose-adjusted allopurinol (200 to 300 mg daily) .
Comparison of early gouty arthritis flares, triggered by serum urate-lowering and putative remodeling, was instructive in these studies. The early flares occurred in association with the most intense serum urate-lowering effect in both febuxostat and allopurinol recipients, and early flares were a greater problem when prophylactic colchicine was stopped at 8 weeks as opposed to 6 months into urate-lowering treatment, but gout flares tapered off later in this study [38, 48]. For these reasons, the European Medicines Agency (EMEA) astutely recommended gout flare prophylaxis for a 6 month period when febuxostat is initiated.
Tophus size is reduced by 50 to 80% after 1 year of either febuxostat or allopurinol treatment, with the greatest tophus and gout flare reduction linked to the greatest degree of serum urate-lowering irrespective of drug. A small, open-label extension study in which patients failing initial therapy on allopurinol were switched to febuxostat to achieve serum urate <6 mg/dL suggested that approximately half of febuxostat-treated patients with tophi can achieve elimination of tophi by 2 years, and approximately 70% by 5 years . Quality of life parameters have been favorably impacted by extended febuxostat treatment in uncontrolled studies .
Febuxostat is approved for use in European countries at 80 and 120 mg daily. The FDA approved febuxostat for use in the USA in February, 2009. The USA label is for a dose of 40 mg daily, followed by dose increase to 80 mg daily if serum urate is not normalized after at least 2 weeks. Side effects of febuxostat include rash in <2% of subjects, and elevation of hepatic enzymes, diarrhea, and arthralgia may also occur. As is the case for allopurinol, xanthine oxidase inhibition by febuxostat carries the potential for major drug interactions with azathioprine, 6-mercaptopurine and theophylline .
Uricase therapy: an experimental 'biologic' option for serum urate lowering
Various uricase therapies for hyperuricemia have been attempted experimentally for several decades . For example, recent, limited reports or pilot studies have evaluated the off-label use in severe, chronic gout of the non-PEGylated recombinant fungal enzyme rasburicase [52, 53], which is FDA-approved for single course therapy in pediatric tumor lysis syndrome. Unfortunately, rasburicase is both highly antigenic and has a plasma half-life of 18 to 24 hours . Efficacy, tolerability, and sustainability of rasburicase treatment beyond 6 to 12 months appear to be poor for treatment of refractory hyperuricemia in gout [52, 53].
Frequent early acute gout flares (up to approximately 80%) in the first few months of pegloticase therapy  tapered off with more prolonged therapy in responders. Infusion reactions were moderate to severe in approximately 8 to 11% of subjects, and included flushing, urticaria, and hypotension, and, by undefined mechanisms, noncardiac chest pain or muscle cramping [55, 57]. Anaphylaxis was uncommon (approximately 2%) in the phase 3 pegloticase study . However, high titer antibodies to pegloticase emerged in many patients as treatment evolved over a few months, including IgM and IgG antibodies that did not directly neutralize the enzyme but appeared to adversely alter both its pharmacokinetics and pharmacodynamics . High titer anti-pegloticase antibodies were also strongly linked with infusion reactions and were rare in serum urate responders (as assessed at the 6-month time-point) . Hence, the dense polyethylene glycol (PEG) multimers linked to pegloticase  (Figure 5) do not prevent antigenicity, and also have been suggested to independently modulate the immune response to pegloticase in some subjects .
All uricase therapies have the potential to induce oxidative stress, since degradation of the high micromolar plasma concentrations of urate in gout patients by uricases has the capacity to generate substantial amounts of hydrogen peroxide [1, 59, 60]. Whether increased nitric oxide bioavailability [61, 62] and the profound, rapid decrement in the serum antioxidant activity normally exerted by serum urate  contribute to oxidative challenge by uricase therapy is not yet clear. Circulating oxidative stress triggered by hydrogen peroxide generation alone is subject to marked dampening by the normal abundance of catalase on erythrocytes [51, 59, 60] and potentially by other plasma antioxidant defenses. Yet methemoglobinemia and/or hemolysis have been unequivocal indicators of uricase-induced oxidative stress [1, 59, 60]. Importantly, with Rasburicase™ therapy, methemoglobinemia and hemolysis (fortunately <1% in incidence) were linked to glucose-6-phosphate dehydrogenase deficiency in some but not all affected subjects [59, 60]; subsequently, this deficiency has become an exclusion criterion for any uricase therapy. It has been suggested that assessment for erythrocyte catalase activity should be done prior to uricase therapy [59, 60]. In my opinion, monitoring for treatment-induced subclinical methemoglobinemia also could ultimately be informative.
Uricases, by oxidizing urate (Figure 4), generate the intermediate form 5-hydroxyisourate, and subsequent hydrolysis of this produces 2-oxo-4-hydroxy-4-carboxy-5-ureidoimidazoline, which is decarboxylated to S-(+)-allantoin . The enzymes carrying out rapid degradation of these urate oxidation intermediates were lost in human evolution along with uricase . It has been suggested that addition of these enzymes to uricase therapy would be useful if the aforementioned uric acid oxidation intermediates are found to have noxious biologic properties .
Overall, it is not yet known if there is significant subclinical oxidative stress at the tissue level, rather than simply at the erythrocyte level [59, 60], with uricase treatment in gout patients. Because of this issue, close monitoring of uricase-treated gout patients appears in order. Whether potential concomitant oxidative stress due to selected co-medications, congestive heart failure, anemia, hyperlipidemia, and CKD influences uricase safety remains to be defined.
At the time of writing this review, uricase therapy for tophaceous gout for which treatment has failed remains an unapproved, experimental approach that will be substantially more expensive than oral therapies, and consensus, evidence-based therapeutic guidelines are needed, whereas only draft guidelines have been proposed for uricase . Tophus debulking is impressively rapid (months) in responders, but uricase therapies tested to date have all been substantially limited by drug immunogenicity. The safety of this particular 'biologic' approach, especially beyond a term of 6 to 12 months, will require further investigation.
In my opinion, any form of uricase therapy (over a finite term) is appropriate only for carefully selected patients that would benefit from accelerated, tophus de-bulking to address incapacitating tophi linked with active synovitis, and where other serum urate lowering therapies have failed or cannot achieve this objective . As an 'induction therapy', uricase could ultimately be replaced by less intensive maintenance oral urate-lowering therapy with other agents, once evidence of normalization of body urate stores, including resolution of clinically detectable tophi and gross synovitis, is achieved.
Do cardiovascular safety signals in urate-lowering trials in gout reflect the influence of inflammation?
There have been death signals in both congestive heart failure patients on experimental oxypurinol therapy  and febuxostat-treated gout patients . Moreover, there is higher cardiovascular mortality in hyperuricemia gout patients, related in part to co-morbidities in gout, and also possibly to independent effects of hyperuricemia on the vasculature [65, 66].
Clinical trials to date in which death signals have arisen with serum urate-lowering strategies all have limitations in interpretability due to small numbers of events and subjects and relatively short durations of treatment. Hence, statistical significance may not be in lockstep with clinical and biological significance in such studies to this point. One constant associated with the more intense serum urate lowering achievable in recent trials of emerging antihyperuricemics is increased risk for acute gout flares in the first few months of therapy [38, 55]. In my opinion, the known association of atrial and ventricular arrythmias and quantifiable altered heart rate variability with systemic inflammation (putatively mediated by specific cytokines markedly up-regulated in acute gouty inflammation, such as IL-6 and CXCL8) [67–69] deserves direct investigation as a potential factor in cardiovascular morbidity and mortality in gout patients undergoing serum-urate lowering therapy.
Challenges in translating novel gout and hyperuricemia therapies to better clinical practice
Compliance of gout patients with therapy appears lower than that for therapy of a variety of other common medical conditions, including hypertension, diabetes, osteoporosis, and hyperlipidemia . Younger gout patients with fewer co-morbidities and fewer office visits are the least compliant gout patients, and we need to address systematic failures in both physician and patient education in gout treatment. Physicians appear to underestimate the impact of gout on quality of life and physical function [71–74]. Gout patients have more co-morbidities, poorer quality of life and physical function, increased health care costs, and increased adverse cardiovascular outcomes than controls [65, 71–75].
Not only patient education, but also quality of care in gout treatment have significant room for improvement [76–78]. The identification of certain improved outcomes with sustained serum urate lowering below 6 mg/dL has ushered in a new era of gout therapy, where practitioners 'treat to target' in lowering serum urate . Now the true definition of 'treatment-refractory' gout and gout-specific quality of life and disability will need careful assessment and direct attention in clinical practice. Such efforts would be timely, since 'treatment-refractory' gout, associated with an overall decrease in quality of life , has been proposed as a specific indication for aggressive urate-lowering strategies and possibly for initially lower serum urate targets than the widely used metric of <6 mg/dL .
The future of gout treatment is intriguing. For example, promising genomics and imaging technologies have the potential to improve prevention, diagnosis, and therapy by identifying disease earlier and tailoring treatment strategies. Examples include single nucleotide polymorphism and haplotype identification for renal urate transporters in patients with hyperuricemia . Dual energy computed tomography, which is highly sensitive and specific in visualizing tissue stores of monosodium urate crystals as well as renal uric acid urolithiasis [81, 82], has the potential, for example, to assist in diagnosis of gout in patients with hyperuricemia or joint pain, and to better quantify tophus dissolution in therapy.
Whether using well-established or newer and emerging approaches and agents for gout and hyperuricemia management, the bottom line will remain that gout and hyperuricemia treatments need to be better translated into a collective of favorable outcomes for both control of gouty inflammation and management of hyperuricemia, as well as improved outcomes of gout-related quality of life and co-morbidities. This will require careful attention to both drug safety and cost-effectiveness of established versus emerging therapies, relative to quantifiable patient-centered outcomes, in a financially challenging era.
This review is part of a series on Gout edited by Alex So.
Other articles in this series can be found at http://arthritis-research.com/series/gout
ATP-binding cassette sub-family G member 2
chronic kidney disease
European League Against Rheumatism
Food and Drug Administration
nonsteroidal anti-inflammatory drug
Dr John Scavulli (Kaiser Permanente, San Diego, CA, USA) provided the author with a helpful review of gout care in the USA. Supported by the Research Service of the Department of Veterans Affairs.
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