Recombinant uricases provide an exciting new therapeutic option for gout, but there are limited data for their use in the elderly.
Recombinant uricases provide an exciting new therapeutic option for gout, but there are limited data for their use in the elderly, according to a recent review article on managing gout in an elderly patient population. Although the agents may be particularly useful in patients with a high urate burden they may precipitate a severe flare of gout that will require treatment in its own right, researchers from the University of Otago in Christchurch, New Zealand, concluded in the study, which was published in Drugs & Aging.
Although gout is common in the elderly, managing the condition is frequently complicated by the presence of co-morbid conditions and medications prescribed for other conditions. The researchers point out that the management of gout is two-fold. The first goal is the treatment of the acute attack to rapidly resolve the pain and inflammation, and the second is long-term urate-lowering therapy (ULT) to prevent episodes of gout.
“NSAIDs [non steroidal anti-inflammatory drugs], colchicine, corticosteroids, and more recently, interleukin (IL)-1 inhibitors, are effective treatments for acute gout,” the researchers wrote in the study abstract. “The choice of agent is determined by the patient’s age, comorbidities, and concomitant medications. Renal impairment is of particular concern in the elderly and may preclude the use of NSAIDs and colchicine. The IL-1 inhibitors are rapidly effective, but data in the elderly are limited.”
When considering ULT as a treatment option for gout, it is critical for long-term management to aim for a serum urate of <0.36 mmol/L or lower in severe tophaceous gout. “Urate lowering can be achieved by inhibiting the production of uric acid through xanthine oxidase inhibition (allopurinol, febuxostat), increasing uric acid excretion via the kidneys (uricosuric agents: probenecid, benzbromarone), or dissolving uric acid to the more water soluble allantoin (recombinant uricases: pegloticase, rasburicase),” the authors noted in the study abstract.
Although allopurinol is the most commonly used ULT, there is no consensus on dosing in renal impairment. “Febuxostat is effective at lowering serum urate, but there are limited data in the elderly and patients with renal impairment. Furthermore, there are concerns about cardiovascular safety. Probenecid is ineffective in patients with renal impairment (creatinine clearance <60 mL/min), and the availability of benzbromarone is limited because of concerns about its hepatotoxicity,” the authors wrote.
Careful consideration of the patient’s concomitant medications is crucial, as many drugs increase serum urate. Successful urate lowering will ultimately reduce gout flares and improve patient quality of life.