QD Clinic: Addressing Severe Gout Flares Save
Dr. Eric Dein, Summit, NJ, discusses a difficult-to-treat case of gout.
Transcription
Hello. Welcome to RheumNow Gout Month. This is another cutie clinic brought to you by RheumNow. My name is Eric N. I'm a rheumatologist from Atlantic Health in New Jersey. I'm going to talk today about one of my most vexing, challenging cases that I've encountered with gout in clinical practice.
This is a man who's 47 years old. He's had an extensive long history of gout beginning around the age of 12. So certainly someone who has a severe predisposition to gout. He's had gout in many of his family members. Someone who I believe really has this genetic predisposition that has set him up to unfortunately have very severe tophaceous disease for many decades now.
He's had extensive treatments. He's had very difficult difficulty in getting appropriate care, getting to target. He's had severe tophi. The treatments and the NSAIDs and his other treatments have led him to have renal failure and now he has moderate CKD. So he's been in a really tough spot, and these recurrent flares have impacted his quality of life such that he's had depression and suicidal attempts. It's really been consuming of his life and he's someone who I've been really trying to find the appropriate treatment for.
He's been on allopurinol, which he's actually taken all the way up to 1,000 milligrams in the past. He's been on febuxostat. He was someone who sounds like a great candidate for pegloticase. He's actually received pegloticase. But unfortunately the second time he had the infusion he told me that he had his throat closing up and lost consciousness. So that's obviously a severe infusion reaction. We flirted with the idea of maybe even trying it in the ICU setting, of trying to see if there's a way that he could do it. But certainly that severe allergic reaction has been something that understandably we have been reluctant to go down that road again, despite his interest in it.
So we've had this individual with very severe tophaceous disease. How do you approach a case like this, particularly when it's been so impactful on his quality of life and so refractory, so resistant to treatments?
Firstly, we want to make sure that he is taking his medications as prescribed. The mental health side has been a challenge — he's been off of his therapies for certain periods of time before coming back to our clinic and getting back into it. He is currently back on the allopurinol 900 milligrams. When he does that and he is adherent, we can get him towards a goal. The goal would be certainly below five for tophaceous gout with maximal therapy. We've gotten him kind of in the sixes. We've talked about maybe, you know, do we add on other therapies — adding in febuxostat. It's very challenging when he is so refractory.
What has been most game-changing for him, and I think the teaching point for me on him — this is actually an off-label use — but we had started anakinra for his flares. He's had severe flares that have been disabling. We've been very cautious with prednisone use for him due to his comorbidities, both affecting his cardiovascular risk and his mental health when he's on higher doses of prednisone.
Anakinra has been really helpful to treat him during severe flares. He started receiving canakinumab as a preventative dose. So canakinumab — the brand name — is approved for abortive therapy. It's a great option if you have a flare: you get it and you get one dose that should help you for a month. That's a great way to stop a gout flare. He's actually been receiving it prophylactically, and that has been really helpful in preventing the inflammatory side of his gout attacks. Unfortunately, it doesn't actually bring down his uric acid — it just turns down the fire. So he still has significant symptoms related to the tophi. The tophi are still there, they're still bothersome, and he's had some surgeries to remove them. We're still working on the urate-lowering approaches for him.
But it has been game-changing for him that IL-1 inhibition has been preventing him from having these severe flares that have been disabling and causing him to have periods of immobilization. That has been a game changer in terms of his mental health, his mobility, and his activity — that by turning down the fire, sometimes that can be the best way to help these refractory cases.
Hope that was a helpful case, and tune in to RheumNow for lots more this month for gout.
This is a man who's 47 years old. He's had an extensive long history of gout beginning around the age of 12. So certainly someone who has a severe predisposition to gout. He's had gout in many of his family members. Someone who I believe really has this genetic predisposition that has set him up to unfortunately have very severe tophaceous disease for many decades now.
He's had extensive treatments. He's had very difficult difficulty in getting appropriate care, getting to target. He's had severe tophi. The treatments and the NSAIDs and his other treatments have led him to have renal failure and now he has moderate CKD. So he's been in a really tough spot, and these recurrent flares have impacted his quality of life such that he's had depression and suicidal attempts. It's really been consuming of his life and he's someone who I've been really trying to find the appropriate treatment for.
He's been on allopurinol, which he's actually taken all the way up to 1,000 milligrams in the past. He's been on febuxostat. He was someone who sounds like a great candidate for pegloticase. He's actually received pegloticase. But unfortunately the second time he had the infusion he told me that he had his throat closing up and lost consciousness. So that's obviously a severe infusion reaction. We flirted with the idea of maybe even trying it in the ICU setting, of trying to see if there's a way that he could do it. But certainly that severe allergic reaction has been something that understandably we have been reluctant to go down that road again, despite his interest in it.
So we've had this individual with very severe tophaceous disease. How do you approach a case like this, particularly when it's been so impactful on his quality of life and so refractory, so resistant to treatments?
Firstly, we want to make sure that he is taking his medications as prescribed. The mental health side has been a challenge — he's been off of his therapies for certain periods of time before coming back to our clinic and getting back into it. He is currently back on the allopurinol 900 milligrams. When he does that and he is adherent, we can get him towards a goal. The goal would be certainly below five for tophaceous gout with maximal therapy. We've gotten him kind of in the sixes. We've talked about maybe, you know, do we add on other therapies — adding in febuxostat. It's very challenging when he is so refractory.
What has been most game-changing for him, and I think the teaching point for me on him — this is actually an off-label use — but we had started anakinra for his flares. He's had severe flares that have been disabling. We've been very cautious with prednisone use for him due to his comorbidities, both affecting his cardiovascular risk and his mental health when he's on higher doses of prednisone.
Anakinra has been really helpful to treat him during severe flares. He started receiving canakinumab as a preventative dose. So canakinumab — the brand name — is approved for abortive therapy. It's a great option if you have a flare: you get it and you get one dose that should help you for a month. That's a great way to stop a gout flare. He's actually been receiving it prophylactically, and that has been really helpful in preventing the inflammatory side of his gout attacks. Unfortunately, it doesn't actually bring down his uric acid — it just turns down the fire. So he still has significant symptoms related to the tophi. The tophi are still there, they're still bothersome, and he's had some surgeries to remove them. We're still working on the urate-lowering approaches for him.
But it has been game-changing for him that IL-1 inhibition has been preventing him from having these severe flares that have been disabling and causing him to have periods of immobilization. That has been a game changer in terms of his mental health, his mobility, and his activity — that by turning down the fire, sometimes that can be the best way to help these refractory cases.
Hope that was a helpful case, and tune in to RheumNow for lots more this month for gout.
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