Thursday, 19 Jul 2018

You are here

Febuxostat Works in Early Gout But Fails to Protect from Xray Damage

Dalbeth and colleagues have published a novel report in Arthritis & Rheumatology, novel in that it is a trial of early gout patients that looks at clinical and radiographic outcomes. They showed that febuxostat improves magnetic resonance imaging (MRI) measures of synovitis and reduced gout flares, but failed to alter X-ray progression with 2 years follow-up. 

This double-blind, placebo-controlled study enrolled 314 early gout patients with serum uric acid [SUA] levels  ≥7.0 mg/dl. Patients were randomized to receive either placebo (PBO) or febuxostat 40 mg (that could be increased to 80 mg if the SUA level was ≥6.0 mg/dl on day 14.  Early gout was defined as only 1 or 2 prior gout flares.

The primary efficacy end point was the mean in the modified Sharp/van der Heijde erosion score for the index joint over 24 months.   They also looked at gout flares, and serum UA levels and the Rheumatoid Arthritis Magnetic Resonance Imaging Scoring (RAMRIS) scores for synovitis, erosion, and edema in the single affected joint.

On plain radiographs febuxostat did not alter joint erosion score over 2 years. In both treatment groups, the mean change from baseline to month 24 in the modified Sharp/van der Heijde erosion score for the single affected joint was minimal, with no between-group differences.

Febuxostat significantly improved the RAMRIS synovitis score at month 24 compared with placebo treatment (change from baseline -0.43 versus -0.07; P <0.001). 

Gout flares were signficantly fewer (than placebo) between months 6 and 14. Overall the incidence of gout flares was less with febuxostat (29.3% versus 41.4%; P < 0.05).  At months 12 and 24, febuxostat had more patients with a SUA < 6.0 mg/dl ( 64.3%, and 62.8%) compare to those on placebo (1.7%, and 5.7%) (P < 0.001).

Urate-lowering therapy with febuxostat improved magnetic resonance imaging-determined synovitis and reduced the incidence of gout flares in subjects with early gout.

The shortcomings of this trial included both a high dropout rate (only 57-59% completed 2 years) and the observation that flare rate benefits were only evident after the first 6 months.

The current trial points to several difficulties inherent in gout studies, including a nomadic (unreliable) study population, high flare rates with the iniation of urate-lowering therapy and the lack of an ideal endpoint. 

This study shows the SUA to be a modestly effective biomarker that can be achieved in the face of ongoing synovitis. 

This study proves the sensitivity of MRI, but shows surprisingly disappointing erosion outcomes with plain radiographs. 

Lastly, long-term trials of symptoms, joint integrity and comorbidities would be ideal in gout, but would appear to be difficult to do as a prospective randomized clinical trial.

The author has no conflicts of interest to disclose related to this subject

Add new comment

More Like This

Immunophysiology of the Gout Attack

Gout may be an ancient disease, with arthritis of the big toe having been described in Egypt in 2,600 BC, but only now are the underlying pathophysiologic events being elucidated and understood.

Obesity, Hypertension and Diuretics Drive Gout Risk

A recent metanalysis suggests that obesity, hypertension and diuretic use are associated with a two-fold increased risk of incident gout.

From a potential of 9923 articles, researchers analyzed 11 studies with data suitable for the meta-analysis.

Gout was 2.24 times more likely to occur in individuals with body mass index ≥ 30 kg/m2 (adjusted relative risk 2.24 (95% confidence interval) 1.76–2.86).

Public Citizen Pressures FDA to Pull Febuxostat

Public Citizen has petitioned the U.S. Food and Drug Administration (FDA) to remove Takeda's drug febuxostat (Uloric) from the market, citing the FDA's own warnings and evidence of serious cardiovascular harms. This follows on a recent FDA safety warning and NEJM paper citing cardiovascular concerns over febuxostat.

Gout Takeaways

The annual EULAR meeting just came to an end today. Rooms are gradually emptying out. People look both content to have updated their knowledge and relieved that four very busy days have concluded. Time to summarize.

Sons of Gout Study

The genetics and heritability of gout has suggested a higher risk in certain families.  A UK cohort study examined the prevalence of gout and monosodium urate (MSU) crystal deposition among those at risk (sons of gout patients) for gout and found a high incidence of hyperuricemia and MSU crystal deposition.