by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Gout is a common metabolic disorder characterized by the excess accumulation of uric acid in the blood. Uric acid crystals deposit in joints over time.
From the Savient Pharmaceutical website...
This leads to acute attacks of inflammatory arthritis with crippling deformity if not treated. Also, gout can adversely affect kidney function leading to kidney failure.
People with gout may have other metabolic problems as well such as obesity, hypertension, elevated blood lipids, and diabetes.
The most recent drug approved for use in gout is Krystexxa.
The chemical name for Krystexxa is pegloticase. It is a drug that should be used only after other therapies have failed. Kyrstexxa is an enzyme that converts urate into allantoin. By doing this, Krystexxa converts the ingredient that accumulates in gout and causes organ damage into an inert ingredient that is removed by the kidneys fairly easily.
Krystexxa is given intravenously at a dose of 8 mg every two weeks and rapidly reduces blood uric acid levels.
In clinical trials, pegloticase was given to patients with severe gout who had not responded to other conventional therapies. 71 per cent of patients had tophi (large deposits of uric acid crystals under the skin.)
The average blood urate level was 10 mg/dL. The participants were mostly men (82%), with longstanding gout, who also had other medical conditions such as high blood pressure, heart disease, elevated lipids, and diabetes.
Several precaustions regarding the use of this drug were apparent from the clinical trials.
First, patients with glucose-6-phosphate dehydrogenase deficiency (G6PD) should not receive this drug.
Second, patients treated with this drug can expect an increased incidence of gout flares just as is seen with other anti-gout therapies.
Third, infusion reactions (reactions due to receiving an intravenous drug) were seen in a high percentage of patients. Forty-one per cent of patients receiving the drug every four weeks had an infusion reaction. A lower percentage was seen in patients getting the drug every two weeks.
Five per cent of patient had severe allergic reactions.
Worsening of congestive heart failure was also noted in a number of treated patients.
Antibodies to pegloticase were seen in about 92% of patients receiving the drug. This was significant since patients with high levels of antibody to the drug had less of a response to the drug and were also the ones who developed allergic reactions more readily.
The drug is given over a two hour period and patients need to be pre-treated with steroids and antihistamines. Patients need to be observed for at least an hour after infusion. Pegloticase is given every two weeks. The duration of treatment has not been determined yet.
Pegloticase should be reserved for patients with severe, refractory gout who are unable to get to a normal serum uric acid level with conventional therapy such as allopurinol or febuxostat (Uloric).
Measurement of a routine serum uric acid a few days before each infusion may be helpful in identifying patients who have lost a therapeutic response to pegloticase and may be at increased risk of infusion reactions and allergic reactions.
Personally, I’m not sure if I would use this drug unless I had a patient with extremely bad gout because of the high incidence of potential side effects. Fortunately, nowadays, we identify gout patients earlier and most of the times, conventional therapies are effective.
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