5 Questions About Anakinra Use in Gout, Pseudogout

Gout is the most common inflammatory arthritis among men and women and can be difficult to treat, according to previous studies.

In a new study¹, Julianna Desmarais, MD, instructor of medicine in the division of arthritis and rheumatic diseases at Oregon Health and Science University School of Medicine, and colleague Cong-Qiu Chu, MD, PhD, director of the Oregon Health and Science University Early Arthritis Clinic, evaluated data of hospitalized patients with acute gout (n = 77), pseudogout (n = 11), or both (n = 3) to determine how patients responded to anakinra and adverse effects.

They determined that anakinra is safe and effective for acute gout and pseudogout among hospitalized patients, including those with comorbidities.

Rheumatology Consultant caught up with Dr Desmarais to talk about the research.

RHEUMATOLOGY CONSULTANT: What prompted you to conduct your study?

 Julianna Desmarais: One day in clinic we were debating treatment for a gout patient who had comorbidities that limited our treatment options. We became engaged in a conversation about the evidence behind using anakinra, which had been used to treat patients at our institutions for years. From this idea came the research project to perform a chart review and evaluate our outcomes from using anakinra, since we had been using anakinra for years in those without other options for management of acute flares of gout and pseudogout.

RHEUM CON: What is the need for more treatment options for acute crystalline diseases, such as gout?

JD: We need treatment options for patients who have comorbidities, including renal failure and heart failure. One recent study² showed that the incidence of gout is increasing, but so too are comorbidities that may limit our treatment options. The goal of assessing anakinra in our gout patient population was to understand if it does help in patients who have conditions that limit other medications we can use. 

RHEUM CON: What different comorbidities did patients in your study experience that may have affected treatment/limited treatment choice? Was there one that stood out that rheumatologists should pay particular attention to when treating this patient population?

JD: One of the reasons patients may have a high uric acid and gout is renal failure, and in this patient population, NSAIDs are contraindicated and colchicine dose must be reduced. Often patients with heart failure need to limit their corticosteroids intake, and this was another problem that we frequently encounter in this population. It is important to look at the entire patient, who may have heart failure and hypertension with concomitant renal failure that limits what treatment options are available.

Study results >>

RHEUM CON: In your study, 92% of patients with gout flares responded to anakinra treatment compared with 79% of patients with pseudogout flares. Why do you think this is?

JD: The largest reported group of patients with pseudogout in whom anakinra was used was 16 patients, of whom 10 (62%) had what was considered a “good” response³. Other reports of patients with pseudogout are limited to single case reports or small series. It is not clear at this time why the pseudogout response rates are not as high as the gout response rates. Given that the options for treating pseudogout are limited⁴, it is still a pertinent finding that almost 4 of 5 patients with pseudogout had relief from using anakinra.

RHEUM CON: What is the next step in your research?

JD: We have a number of quality improvement initiatives and will be looking at patient outcomes such as the number of patients with gout on urate lowering therapy and what percentage of patients with gout have uric acid levels at goal. We will also look at whether patients with pseudogout will need a higher dose and/or longer treatment duration for a better response. 

References:

1. Desmarais J and Chu C-Q. Utility of anakinra in acute crystalline diseases: a retrospective study comparing a university hospital with a veteran’s affairs medical center. J Rheumatol. Published November 2018. https://doi.org/10.3899/jrheum.180393.
2. Elfishawi MM, Zleik N, Kvrgic Z, et al. The rising incidence of gout and the increasing burden of comorbidities: a population-based study over 20 years. Published April 2018. J Rheumatol. https://www.jrheum.org/content/45/4/574.
3. Ottaviani S, Brunier L, Sibilia J, et al. Efficacy of anakinra in calcium pyrophosphate crystal-induced arthritis: a report of 16 cases and review of the literature. Published March 2013. Joint Bone Spine. https://www.sciencedirect.com/science/article/pii/S1297319X12001935?via%3Dihub.
4. Andres M, Sivera F, Pascial E. Therapy for CPPD: options and evidence. Published April 2018. Curr Rheumatol Rep. https://link.springer.com/article/10.1007%2Fs11926-018-0739-z.