Tophaceous Gout Treated with Krystexxa (uricase) and Anakinra (Il-1 inhibitor)

This 37yr old man had severe gout and first presented for treatment aged 26. Conventional management with Allopurinol failed over the years and when he re-presented to me at KHMC this young working father was severely affected, in great pain  and significantly disabled by widespread, tophaceous gout.  Gout is caused by an accumulation in joints and tissue of uric acid. In severe cases, the urate forms visible deposits called tophi. This is called tophaceous gout and is exceptionally difficult to treat conventionally.

Recently, Savient pharmaceuticals have released Krystexxa, a modern agent which dissolves uric acid and is capable of removing the excess uric acid even in tophi. It is not available in the UK due to cost but I was able to obtain a supply from Savient. Having read the research and understanding the complexity of the planned fortnightly infusion regime, my patient gave consent and we commenced treatment. His blood uric acid level fell from around 7 (v high) to zero and within 3 months most of the visible uric acid in his tophi was gone. However, as you mobilise uric acid out of the joints the patient suffers acute attacks of gout. In this case I could not control the pain with NSAID, Steroid and Colchicine.  The inflammation in gout is controlled by a chemical called Il-1. We have used an IL-1 blocker called Anakinra in Rheumatoid Arthritis and I was aware of a report by an ex-colleague, Prof Alex So, now in Lausanne that Anakinra was effective for the acute inflammation in otherwise untreatable gout. After consent, we obtained Anakinra from the Swedish manufacturers and daily injections were given. Response was prompt and with a few ups and downs me managed to complete the Krystexxa “debulking” of the uric acid in good comfort. In the end a second course of debulking with Anakinra cover was required and it now seems set fair for the patient to control his gout with a newer version of allopurinol (Febuxostat) and to look forward to a future without pain and disability.

 

Figure 1 gouty deposits on fingers before treatment

Figure 1 gouty deposits on fingers before treatment

Figure 2 After treatment showing resolution of gouty masses (tophi).

Figure 2 After treatment showing resolution of gouty masses (tophi).