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09/02/2017    John Cozzarelli, DPM, RPh

Treatment for Severe and Painful Gouty Tophi (Elliot Udell, DPM)

I have had the opportunity to treat over 30
patients with multiple IV infusions of Krsyrtexxa
at the Gout Institute of America in Belleville,
NJ. I agree with Dr. Udell that the efficacy of
pegloticase is tremendous. In each patient I have
infused the patient's serum uric acid levels have
dropped after the first infusion to almost
undetectable levels and the process of dissolving
the tophi begins.

This is due to the fact that pegloticase is the
enzyme that turns uric acid into allantoin, a
water soluble end product that is excreted via the
kidneys. Pegloticase also mobilizes crystals out
of the joints, kidneys and wherever else the tophi
is present. This is best visualized with a DECT
scan before and after treatment.

Where I disagree with Dr. Udell is with the safety
profile. In my experience, when infusing a patient
I have always adhered to the protocol of
premedicating the patient with Tylenol, Solumedrol
and Benadryl. It is also mandatory that serum uric
acid levels be checked between every infusion.
The reason being that FDA clinical trials have
shown that 99% of all infusion reactions can be
avoided in patients where antibodies do not
develop.

What is known is that when uric acid levels are
low antibodies are not formed. When serum uric
acid levels rise above 6 for two consecutive
infusions treatment is halted. In regards to
surgical management of gouty tophi in the foot, it
becomes questionable if surgery should be
performed when this drug is available and can
liquefy the tophus.

I have personally witnessed in multiple patients
the dissolution of tophi from joints. In 2008, in
the Journal of Rheumatology there is an article
written by Kirshman illustrating that there were
973 million visits to doctors that year. Of those
visits four million were for gout. The
demographics showed that 60% were male. 70% went
to the primary care doctor. 10% went to
cardiologists. 16% went to other doctors
(podiatrists, nephrologists). That 16% is 640,000
visits nationwide for gout. Less than 3% went to
rheumatologists.

When looking at uricolytic therapy, 8 million
suffer from gout yearly and is rising. As
podiatrists we don’t realize we are seeing
refractory gout on a daily basis far more than a
rheumatologist. In an article written by Becker,
MA, et al. N Engl J Med. 2005;353:2450-2461 is 79%
of patients (n=251) on 300 mg allopurinol/day did
not meet target sUA <6.0 mg/dL. 47% of patients
(n=255) on 80 mg febuxostat/day for 52 weeks did
not meet target sUA<6.0 mg/dL.

My point is that patients even on uricolytic
therapy may not be able to achieve control of gout
and Krystexxa is a safe option.

John Cozzarelli, DPM, RPh, Belleville, NJ

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