A Case Report of Successful Management of Refractory Polyarticular Gout With Pegloticase

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Abstract

Gout is inflammatory arthritis and is easily recognizable by healthcare providers by its typical clinical presentation of acute gout flare or by the presence of chronic tophaceous deposits. However, chronic gouty arthropathy can be more challenging to diagnose in some cases, especially in the absence of a previous history of gout and other characteristic findings on exam. We present a case of chronic gouty arthropathy with features mimicking rheumatoid arthritis involving multiple small joints of hands and feet and other large joints. He had high serum uric acids and a dual-energy CT (DECT) scan of the feet and ankles was obtained which showed polyarticular gout. He was started on pegloticase in view of joint erosions, and severe limitations in activity which resulted in a lowering of monosodium urate crystals and symptomatic improvement.

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Gout: An old disease in new perspective – A review

Gaafar Ragab, Mohsen Elshahaly, Thomas Bardin (2017)

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The Rising Incidence of Gout and the Increasing Burden of Comorbidities: A Population-based Study over 20 Years

Mohanad M. Elfishawi, Nour Zleik, Zoran Kvrgic … (2018)

To examine the incidence of gout over the last 20 years and to evaluate possible changes in associated comorbid conditions. The medical records were reviewed of all adults with a diagnosis of incident gout in Olmsted County, Minnesota, USA, during 2 time periods (January 1, 1989–December 31, 1992, and January 1, 2009–December 31, 2010). Incident cases had to fulfill at least 1 of 3 criteria: the American Rheumatism Association 1977 preliminary criteria for gout, the Rome criteria, or the New York criteria. A total of 158 patients with new-onset gout were identified during 1989–1992 and 271 patients during 2009–2010, yielding age- and sex-adjusted incidence rates of 66.6/100,000 (95% CI 55.9–77.4) in 1989–1992 and 136.7/100,000 (95% CI 120.4–153.1) in 2009–2010. The incidence rate ratio was 2.62 (95% CI 1.80–3.83). At the time of their first gout flare, patients diagnosed with gout in 2009–2010 had higher prevalence of comorbid conditions compared with 1989–1992, including hypertension (69% vs 54%), diabetes mellitus (25% vs 6%), renal disease (28% vs 11%), hyperlipidemia (61% vs 21%), and morbid obesity (body mass index ≥ 35 kg/m 2 ; 29% vs 10%). The incidence of gout has more than doubled over the recent 20 years. This increase together with the more frequent occurrence of comorbid conditions and cardiovascular risk factors represents a significant public health challenge.

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Increased Efficacy and Tolerability of Pegloticase in Patients With Uncontrolled Gout Co-Treated With Methotrexate: A Retrospective Study

John A. Albert, Tony Hosey, Brian LaMoreaux (2020)

Introduction Gout is a painful inflammatory condition caused by chronically elevated serum uric acid levels (sUA). When standard urate-lowering therapies fail/are not tolerated, uncontrolled gout (elevated sUA, subcutaneous tophi, chronic gouty arthritis, frequent flares) can occur. Pegloticase, a recombinant uricase, converts uric acid to allantoin, a readily excreted molecule. Responder rate in trials was 42%, limited by anti-drug antibody (ADA) development. Immunomodulators attenuate ADA formation and case reports suggest immunomodulation increases pegloticase responder rates. The current study retrospectively examined responder rate in patients undergoing methotrexate/pegloticase co-therapy. Methods Patients who underwent methotrexate/pegloticase co-treatment at a single rheumatology practice were included. Demographics, clinical, treatment, and safety parameters were collected. The primary outcome was the proportion of responders (≥ 12 biweekly pegloticase infusions, sUA < 6 mg/dl just prior to infusion 12). Results Ten patients (nine men, 52.3 ± 13.5 years) with uncontrolled tophaceous gout (erosive damage, ulcerative tophi, frequent flares, gout-related hospitalizations) were included. Patients had failed allopurinol (100–300 mg) or febuxostat (40 mg) therapy (doses not increased because of intolerance, kidney concerns, noncompliance, or rapid tophi resolution requirement). Baseline sUA was 9.42 ± 2.05 mg/dl. Along with standard pre-infusion prophylaxis, nine patients received subcutaneous methotrexate (25 mg/week) initiated 14–35 days before pegloticase and one patient received oral methotrexate (12.5 mg/week) initiated 14 days after pegloticase. Eight patients (80%) were responders, receiving 15.5 ± 3.8 infusions (range, 12–21) over 31.8 ± 9.5 weeks. One patient had efficacy loss with mild infusion reaction during infusion 4 and one patient was lost to follow-up after infusion 5. One patient reported one gout flare. No new safety concerns emerged. Conclusions Methotrexate/pegloticase co-therapy resulted in a higher responder rate than the established 42% with pegloticase alone. Therefore, methotrexate/pegloticase co-therapy may safely allow more patients to benefit from a full treatment course, likely through ADA attenuation.

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Journal

Journal ID (nlm-ta): Cureus

Journal ID (iso-abbrev): Cureus

Journal ID (issn): 2168-8184

Title: Cureus

Publisher: Cureus (Palo Alto (CA) )

ISSN (Electronic): 2168-8184

Publication date (Electronic, pub): 25 August 2022

Publication date (Electronic, collection): August 2022

Volume: 14

Issue: 8

Electronic Location Identifier: e28390

Affiliations

[1 ] Internal Medicine, Hackensack Meridian Ocean Medical Center, Brick, USA

[2 ] Internal Medicine, Ocean University Medical Center, Brick, USA

[3 ] Rheumatology, Valley Health System, Ridgewood, USA

[4 ] Internal Medicine, Hackensack Meridian Health Ocean Medical Center, Brick, USA

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Dina Alnabwani dina.alnabwani@ 123456hmhn.org

Article

DOI: 10.7759/cureus.28390

PMC ID: 9508863

SO-VID: 98a47513-9c72-4915-9bdc-3eba47421d3d

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This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date accepted : 25 August 2022

A Case Report of Successful Management of Refractory Polyarticular Gout With Pegloticase

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Most cited references 5

Gout: An old disease in new perspective – A review

The Rising Incidence of Gout and the Increasing Burden of Comorbidities: A Population-based Study over 20 Years

Increased Efficacy and Tolerability of Pegloticase in Patients With Uncontrolled Gout Co-Treated With Methotrexate: A Retrospective Study

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