TOPHI RESOLUTION 74% relative improvement in tophi resolution^1*

Okay, and here we go. 

My name is Bhavnish Bucktowarsing and I’m a nephrologist in Canton, Ohio. I take care of patients with chronic kidney disease, hypertension and other chronic illnesses. 

Gout is recognized mostly as a rheumatological issue, a joint issue, but if you look at it at its core, it’s more of a metabolic disease. People say hypertension and diabetes are silent killers, but you could probably put gout in that domain as well. Once you reach stage 3 kidney disease, your kidney is not doing well, you’re not filtering uric acid. Uric acid goes up, then that causes systemic inflammation. The most common thing I see, is the moment you have uncontrolled gout, those patients tend to have cardiac disease. They have of course chronic kidney disease. I would say a third to even more than that of my patients will have elevated uric acid when I first start seeing them. That’s where the conversation starts about how having a high uric acid level can aggravate those other risk factors around your kidneys. And it really is an eye opener for a lot of patients, they don’t realize it. When it comes to speed of resolution of gout it is very important because you’re in a constant state of systemic uric acid deposition. So, that itself means you’re chronically inflamed and the longer you let that process brew, the longer you’re at risk of having more and more complications from high uric acid levels.  

I think the first patient I had was already on 300mg allopurinol, he was flaring twice a year or even more and he had a uric acid of 9.5 when I saw him in the office. And he was miserable.  Of course he was seeing me for his kidneys, but every time he would come to me, he would complain about his joints, how they were hurting. This patient, he lived on a farm, he had to be active. Unfortunately, gout was preventing him from doing that. We talked about his joint mobility and how we can try to improve that with KRYSTEXXA infusion. As with many biologic therapies there is a risk of anaphylaxis and infusion reactions. After 2 or 3 months, he was feeling so much better, and he had a smile on his face after a while. I want the best outcome possible, so, I tell them that we’re going to shoot for a treatment time of a year. Really not that much of a time if you think that you’re going to be my patient moving forward pretty much for the rest of your life. Now that he’s finished treatment, it was a just a blip in time, as compared to the entire lifespan that I’m going to be seeing him for. He was able to walk around without having to take pain medications anymore and he was getting back to his activities on the farm. 

Well, I think if you look at the studies, especially Mirror RCT, there was an almost 80 – 90% relative improvement in efficacy when you give it with immunomodulation as compared with no immunomodulation, so I talk to them about methotrexate and my regimen would be starting them at 15mg once a week about 4 weeks prior to the first infusion. At 15mg once a week, you’re looking at just enough immunomodulation to control their immune system but it’s not enough to cause other negative side effects on their kidneys. We’re giving them that just so they can tolerate the drug and have better outcomes. So that really made me comfortable prescribing methotrexate.  

There’s a lot of aspects that we take care of as nephrologists, and I think that part of that means controlling gout. If you think about having a patient with kidney disease and their uric acid is elevated, it becomes the responsibility of the nephrologist to try to control that gout because the kidneys are not doing what they should be doing. Given the effects that has on other chronic illnesses, it should definitely be within our arsenal of things we can do for our patients to help them get better. 

I’m Dr. Bhavnish Bucktowarsing, I’m a nephrologist and these are our patients.