My name's Chris Gisler. I'm a board-certified nephrologist practicing in the Pittsburgh area. As a nephrologist, I feel that I'm responsible for the total care of my patients.
We’re already doing the best we can with chronic kidney disease, but our patients suffer from gout. There is actually a strong association between chronic kidney disease and gout... about a third of the patients that you’re taking care of have gout, most likely. It’s not just a disease of the big toe, not just a disease of the joints. We need to really consider this as a disease that’s affecting the whole body, multiple organ systems. We know that many different organs are affected, including the heart. We know that our patients with gout are at more risk for cardiovascular disease. To me, it does no good to prolong a patient’s life by managing their kidney disease if they’re absolutely miserable, right? If we treat gout, address gout, and do a better job with managing gout, we’re improving the patient’s overall functional status.
I met this patient that I had been following for chronic kidney disease. She was a bit on the obese side and so a lot of the joint pain that she complained to me about in her knees I attributed to osteoarthritis. She revealed to me that she had significant gout and actually had gone to the ER for a gout flare. We talked about it—she failed oral therapy with Allopurinol—and were able to prescribe her KRYSTEXXA. KRYSTEXXA is a biologic. As with many biologic therapies, there is a risk of anaphylaxis and infusion reactions. When we began managing her gout with KRYSTEXXA, she did have multiple flares at the beginning, which is a known effect of the gout treatment. Once she got through those first couple of treatments though, she really noticed improvement. The frequency and severity of flares were decreasing. Also, the pain she had just at baseline was markedly improved. She was able to ambulate more frequently and really was starting to get more and more of her life back. By treating with KRYSTEXXA we’re dramatically lowering the serum uric acid level, sort of draining the tub so that that serum uric acid level is zero, allowing that uric acid that was deposited into the joints to be pulled out. Many of the interventions we perform as nephrologists, patients don’t see a tangible benefit. With our patients on KRYSTEXXA, they start feeling better. I’m encouraging my patients to treat for at least 6 months. If they’re still seeing continued improvement, we’ll continue to treat. Now I do caution them that once you feel better that doesn’t necessarily mean that you are better. So, we know that in addition to flares for gout there’s also a subclinical gout. Damage is still being done to the joints even if they’re not actively flaring. And so, it’s very important to get gout under control.
I think for a nephrologist that would say, “Managing gout’s not my responsibility,” I would argue that it absolutely is. This is a disease process that we should be comfortable with. This is a disease process that kind of goes hand in hand with chronic kidney disease. Chronic kidney disease is a slow progressive disease where patients don’t necessarily see improvements. They say, “Doctor, I’m doing all the right things. I still don’t feel much better.” With gout, we can actually make interventions, so the patients come back and say they feel better. I think any time we can do something to make a patient feel better, to get them to become more active, to address an issue that they’re really concerned about, and to see marked improvement in it in a relatively short amount of time I think is really rewarding.
I'm Dr. Chris Gisler. These are our patients, and we need to take action.
The link between CKD and gout
In this exclusive video, Dr Chris Gisler, board-certified nephrologist, discusses the connection between CKD and gout and the impact KRYSTEXXA has had on his patients with uncontrolled gout.
CKD, chronic kidney disease.
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.
The risk of systemic inflammation
In this exclusive video, Dr Bhavnish Bucktowarsing, board-certified nephrologist, shares his perspective on gout as a silent killer and the risks of systemic inflammation as well as his experience prescribing KRYSTEXXA with methotrexate.