Injected Drug May Be New Weapon Against Gout

Injected Drug May Be New Weapon Against Gout

A new approach to preventing gout attacks looks promising for people not already helped by existing treatments.

Researchers are looking at an anti-inflammatory drug called canakinumab (Ilaris) to treat this painful form of arthritis.

Instead of targeting excessively high uric acid levels as existing gout drugs do, the new strategy aims to reduce overall inflammation. The drug goes after a specific inflammatory molecule called interleukin-1.

The result was a 50 percent drop in gout attack risk, the researchers found.

“This was a very large effect,” said study lead author Dr. Daniel Solomon, a rheumatologist with Brigham and Women’s Hospital in Boston.

He acknowledged it was “very surprising” that the drug packed an equally protective punch whether patients had normal uric acid levels or very high levels.

But Ilaris is unlikely to be the preventive drug of choice any time soon, said Solomon.

For one, it has not yet received approval for gout treatment in the United States. And most patients already achieve risk reduction with standard uric acid-lowering treatments, such as allopurinol (brand names Zyloprim, Aloprim).

What’s more, decades-old allopurinol is a cheap daily pill.

“Canakinumab is very expensive,” said Solomon. Its main role to date is as a last-ditch treatment for rare, so-called “orphan” diseases. At its current price, he said, “it is not a viable option for most patients with gout.”

Also, it must be injected every three months by a caregiver.

Still, Solomon said Ilaris may have a clinical role for patients who don’t respond to or tolerate standard medications.

Prior research had shown that interleukin-1B inhibitors can shorten gout attacks, but it wasn’t known if they could prevent them, the study authors said.

The new research was funded by Novartis, the maker of Ilaris. The results were published online Sept. 17 in Annals of Internal Medicine.

Gout is the most common form of inflammatory arthritis. When a chemical called uric acid builds up in the body, it triggers the formation of tiny jagged crystals that cause severe joint paint, most often in the foot, particularly the big toe. Gout’s prevalence has increased considerably in recent decades.

Heart disease and gout often overlap, the researchers noted. To explore whether Ilaris has potential as a preventive measure, investigators conducted a secondary analysis of the so-called Canakinumab Anti-Inflammatory Thrombosis Outcomes Study (CANTOS). This enlisted more than 10,000 heart attack patients to see if Ilaris might help reduce future cardiovascular complications among high-risk individuals.

The researchers found that patients treated with four injections of Ilaris a year faced half the risk for a gout attack, compared with those given a dummy (placebo) treatment, regardless of uric acid levels.

“We have no strong reason to believe that [Ilaris] would be less effective in patients without known heart disease,” said Solomon.

Howard Feinberg, a professor of rheumatology at Touro University in Vallejo, Calif., agreed.

Based on the current and prior research, “we can assume that this drug will work for most patients,” including those without a history of heart disease, he said.

Feinberg said he “would not recommend its use for someone who did well on older medications” because of its high cost and the need to give it as in injection.

“The type of patient who would benefit the most is someone who was allergic or could not take standard therapy,” Feinberg said, mentioning patients with kidney disease. “This treatment is also ideal for someone whose gout could not be controlled on allopurinol or other older therapies.”

More information

Learn more about gout treatment at the Arthritis Foundation.

SOURCES: Daniel H. Solomon, M.D., MPH, chief, clinical sciences, division of rheumatology, Brigham and Women’s Hospital, Boston, and professor, medicine, Harvard Medical School; Howard L. Feinberg, D.O., F.A.C.O.I., F.A.C.R., professor, rheumatology, and regional director, medical education and clerkship performance, clinical education department, Touro University, Vallejo, Calif.; Sept. 17, 2018, Annals of Internal Medicine, online

Gout

What is gout?

Gout is a health problem that causes inflamed, painful joints. The symptoms are caused by deposits of urate crystals at the joints. Gout used to be associated with kings who overindulged in rich food and wine. In truth, anyone can get gout. Gout affects more men than women. It is often linked with obesity, high blood pressure, high levels of lipids in the blood (hyperlipidemia), and diabetes.

What causes gout?

Gout is caused by monosodium urate crystal deposits in the joints. This is due to an excess of uric acid in the body. Too much uric acid may be caused by several things. It may be caused by the body making too much uric acid. Or the kidneys may not get rid of enough uric acid. It may also be caused by eating a lot of foods that are high in purines. Purines turn into uric acid in the body.

Foods high in purines include:

  • Alcoholic drinks and sugary drinks high in fructose
  • Certain meats, such as game meats, kidney, brains, and liver
  • Dried beans and dried peas
  • Seafood, such as anchovies, herring, scallops, sardines, and mackerel

Gout attacks may be triggered by any of the following:

  • Drinking alcohol
  • Eating a lot of protein-rich foods
  • Emotional stress
  • Fatigue
  • Illness
  • Minor surgery

Who is at risk for gout?

You are at higher risk for gout if you:

  • Are a man
  • Are a postmenopausal woman
  • Have kidney disease
  • Have high blood pressure, high cholesterol, or diabetes
  • Have family members with gout

What are the symptoms of gout?

Gout causes sudden, recurrent attacks of symptoms that often occur without warning. Severe, chronic gout may lead to deformity. Symptoms can occur a bit differently in each person. Common symptoms include:

  • Chills
  • Fever
  • General feeling of illness
  • Hard lumps of urate crystal deposits under the skin (tophi)
  • Severe, sudden pain in one or more joints, most often the joint in the big toe
  • Skin that is red or purple, tight, and shiny over the joint
  • Swollen joint(s)
  • Warmth in the joint area

Some symptoms of gout can be like other health conditions. Make sure to see your healthcare provider for a diagnosis.

How is gout diagnosed?

The process starts with a medical history and a physical exam. A fluid sample may be taken from the joint and checked for urate crystals.

How is gout treated?

Treatment will depend on your symptoms, your age, and your general health. It will also depend on how severe the condition is. Treatment may include:

  • Avoiding alcoholic drinks
  • Colchicine, an oral or IV medicine to relieve pain and inflammation
  • Corticosteroids to reduce inflammation
  • Drinking more nonalcoholic fluids
  • Eating less protein-rich foods
  • Medicine to block production of uric acid in the body
  • Medicine to lower the uric acid level in the blood
  • Nonsteroidal anti-inflammatory medicines to relieve pain and inflammation
  • Surgery to remove extremely large tophi
  • Weight loss, if obesity is an issue

Talk with your healthcare provider about the risks, benefits, and possible side effects of all medicines.

What are the complications of gout?

People with gout have a higher risk for kidney stones, due to crystal deposits in the kidneys. They can also have kidney damage. Crystal deposits in the joints can cause some disability due to stiffness and pain.

Living with gout

You can reduce the risk of future flare-ups of gout and decrease their severity by taking medicine as prescribed. If you are given medicine to take when a flare-up occurs, it is best to start taking it at the first sign of symptoms. Or get medical attention at the first sign of symptoms. To help prevent episodes of gout:

  • Talk with your healthcare provider before taking any new medicine, including over-the-counter medicines
  • Drink plenty of water
  • Don’t drink alcohol
  • Exercise regularly
  • Lose weight if needed
  • Don’t eat foods that are high in purines

When should I call my health care provider?

If your symptoms get worse or you have new symptoms, let your healthcare provider know.

Key points about gout

  • Gout causes inflamed, painful joints due to urate crystal deposits at the joints.
  • Gout can also cause urate crystal deposits that cause lumps under the skin.
  • Gout can be triggered by eating foods high in purines and drinking alcohol.
  • Treatment of gout is aimed at reducing pain and the risk of future flare-ups.
  • Gout can be managed with medicines and lifestyle changes.

Next steps

Before you agree to the test or the procedure make sure you know:

  • The name of the test or procedure
  • The reason you are having the test or procedure
  • What results to expect and what they mean
  • The risks and benefits of the test or procedure
  • What the possible side effects or complications are
  • When and where you are to have the test or procedure
  • Who will do the test or procedure and what that person’s qualifications are
  • What would happen if you did not have the test or procedure
  • Any alternative tests or procedures to think about
  • When and how will you get the results
  • Who to call after the test or procedure if you have questions or problems
  • How much will you have to pay for the test or procedure