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
Given the 10-fold increase in gout prevalence among patients with moderate to severe chronic kidney disease, more and more nephrologists are looking for and treating uncontrolled gout1
In this exclusive video, Dr Chris Gisler, board-certified nephrologist, discusses the connection between CKD and gout and the impact KRYSTEXXA has on his patients with uncontrolled gout.
CKD, chronic kidney disease.
My name is Dr. Payam Shakouri, I'm a nephrologist, and I practice in Hudson Valley, New York.
I'm constantly chasing hemoglobin level, anemia, phosphorus. Are they clearing enough? Is their eGFR low? I was trained gout is not my problem. Give it to the primary doctor or the rheumatologist. I don't have time. Why should I treat gout?
I saw data that showed one-third of patients with moderate-to-advanced kidney disease have gout. And when I saw this I said, “Well, that cannot be true. That means one out of three of my patients have gout?” And I pull up all the patients' medications lists, and to my surprise, one in four or one in three was on treatment for gout. Now that I look at it, it just makes sense. Uric acid is very hard to eliminate. Every time your kidney is impaired, your rate of deposition and reabsorption increases. So, it is disease of the kidney. And the worse the kidney disease, the worse the gout. And I looked at it and I thought, “Oh this makes sense, but I really don't have time. I have so much to do with my patients, I can't just add gout to it.” Until I had this patient, a very, very sick patient, sixty-seven-year-old lady with advanced kidney disease and heart failure. And, you couldn't see tophi, per se, but her joints were deformed, and they were swollen. Out of desperation I said, well she has joint disease. Let me just order a full rheumatological workup. And I look, and the only thing that's highlighted, it says her uric acid is 8. [//] And I said, [//] “Do you have gout?" She said, “Yeah I have gout. But you don't have to worry about that. [//] I'm on medication for it.” So, this is where it clicked. This patient thinks her gout is being treated because she's on medication for it. And I thought, well......let's try KRYSTEXXA on her.
We talked about the side effect profile and the drug profile. As with any urate-lowering therapy, there is a risk of flares. There is also a risk of anaphylaxis and infusion reactions. We started her on it and within a week, her uric acid level fell to zero. Zero. Just like that. Within a few weeks, she started having improvement in her [//] symptoms. Now as my understanding has evolved if I have a patient who even has one joint involvement, who's on treatment for allopurinol and who's getting flareups, which means he has uncontrolled gout, I would consider starting this patient on KRYSTEXXA.
Kidney disease makes gout worse, that is a fact, and we know that. So, it is the job of a nephrologist to treat it. That's the bottom line.
I am Dr. Payam Shakouri, I'm a nephrologist, and these are our patients.
KRYSTEXXA® (pegloticase) is indicated for the treatment of chronic gout in adult patients who have failed to normalize serum uric acid and whose signs and symptoms are inadequately controlled with xanthine oxidase inhibitors at the maximum medically appropriate dose or for whom these drugs are contraindicated.
KRYSTEXXA is not recommended for the treatment of asymptomatic hyperuricemia.
Anaphylaxis and infusion reactions have been reported to occur during and after administration of KRYSTEXXA.
Anaphylaxis may occur with any infusion, including a first infusion, and generally manifests within two hours of the infusion. However, delayed-type hypersensitivity reactions have also been reported. KRYSTEXXA should be administered in healthcare settings and by healthcare providers prepared to manage anaphylaxis and infusion reactions. Patients should be premedicated with antihistamines and corticosteroids.
Patients should be closely monitored for an appropriate period of time for anaphylaxis after administration of KRYSTEXXA. Monitor serum uric acid levels prior to infusions and consider discontinuing treatment if levels increase to above 6 mg/dL, particularly when 2 consecutive levels above 6 mg/dL are observed.
The risk of anaphylaxis and infusion reactions is higher in patients who have lost therapeutic response.
Concomitant use of KRYSTEXXA and oral urate-lowering agents may blunt the rise of sUA levels. Patients should discontinue oral urate lowering agents and not institute therapy with oral urate-lowering agents while taking KRYSTEXXA.
In the event of anaphylaxis or infusion reaction, the infusion should be slowed, or stopped and restarted at a slower rate.
Inform patients of the symptoms and signs of anaphylaxis, and instruct them to seek immediate medical care should anaphylaxis occur after discharge from the healthcare setting.
Screen patients for G6PD deficiency prior to starting KRYSTEXXA. Hemolysis and methemoglobinemia have been reported with KRYSTEXXA in patients with G6PD deficiency. Do not administer KRYSTEXXA to these patients.
An increase in gout flares is frequently observed upon initiation of anti-hyperuricemic therapy, including treatment with KRYSTEXXA. If a gout flare occurs during treatment, KRYSTEXXA need not be discontinued. Gout flare prophylaxis with a non-steroidal anti-inflammatory drug (NSAID) or colchicine is recommended starting at least one week before initiation of KRYSTEXXA therapy and lasting at least six months, unless medically contraindicated or not tolerated.
KRYSTEXXA has not been studied in patients with congestive heart failure, but some patients in the clinical trials experienced exacerbation. Exercise caution when using KRYSTEXXA in patients who have congestive heart failure and monitor patients closely following infusion.
The most commonly reported adverse reactions in clinical trials with KRYSTEXXA are gout flares, infusion reactions, nausea, contusion or ecchymosis, nasopharyngitis, constipation, chest pain, anaphylaxis, and vomiting.
Please see Important Safety Information, including Boxed Warning, throughout this video. Please click link provided for Full Prescribing Information.
Gout patients are our patients
“[Gout] is a disease of the kidney. And the worse the kidney disease, the worse the gout.”1
Dr Payam Shakouri outlines the key moments that led him to be adamant about treating uncontrolled gout and tells the story of his first KRYSTEXXA patient.