Brian LaMoreaux, MD, MS: Improving Outcomes for Patients With Gout

Rheumatology Network sat down with Brian LaMoreaux, MD, MS, to discuss the recent study entitled, Improving outcomes for patients hospitalised with gout: a systematic review . LaMoreaux is the Medical Director of Medical Affairs at Horizon Therapeutics. He explains why he believes hospital admissions for gout flares have increased despite the availability of effective medication, how clinicians can use their time with a patient hospitalized for gout to educate them on their treatment options, and how missing these opportunities can potentially increase the risk of flare as well as more hospitalizations.

Rheumatology Network: Why do you believe hospital admissions for gout flares have increased in recent years, despite effective medications for the treatment and prevention of flares?

Brian LaMoreaux, MD, MS: So, gout flares are increasing for a lot of reasons. These patients are usually complex, and they have a lot of comorbidities, things like diabetes, and hypertension. And some can be on the older side, though not all of them are, along with certainly renal disease. And then we have the same tools to manage gout that we've had for quite a while. We do have effective, good tools, but they're just not being used. And so, a lot of gout patients, in fact, the majority in the US, are under treated, which means that we're not lowering their uric acid levels enough to remove their gout crystals. And so, then they remain at risk for flares. And when a patient like that, with renal disease, diabetes, or hypertension, when they show up to an ER, with a warm, swollen joint that is probably a gout flare, it's a tough thing for an ER doctor to know that and be able to send them home with just something for the flare. It could be an infection; it could be septic arthritis. And so oftentimes these patients get admitted to the hospital for a few days to kind of sort that out.

RN: Referring to the recent study, what were the results?

BL: So, the study we’re talking about in particular, is from a group named from Russell et all 2021. What they did essentially was they looked at everything they could find on interventions for hospitalizations of gout flares. So, gout patients that had a flare, went to the ER, and got admitted. And then they reviewed and kind of organized all of the studies and looked at what happened to those patients. And some of them are comparing different things to treat flares: non-steroidal anti-inflammatory drugs (NSAIDs) versus prednisolone, interleukin (IL)-1 inhibition, and all of those work. Others of the studies they reviewed compared to starting a medicine to lower uric acid levels: allopurinol versus waiting until after they're out of the hospital to start. And, you know, the reason we don't do this all the time automatically is because if you start something to lower uric acid levels, there's a bit of a risk that you might prolong the flare, or confuse the patient with too many medicines, but they didn't see any of that in these particular reviews. If you started allopurinol while they were hospitalized, the patients took it and it didn't make their flare any worse. And there were a few others where they looked at what's the effect of having a protocol for someone admitted for a gout flare. And having a protocol really seemed to help. Medicines, like allopurinol were continued, the patient's got more follow up, uric acid levels were checked more often. And then the final thing they looked at was studies that examined “what if rheumatology is consulted for a gout flare in the hospital versus when they're not consulted?” What happens there when rheumatology was involved in these hospitalizations? It didn't lead to a quicker discharge, but it did lead to the patient's having more consistent rheumatology follow ups and better and more frequent use of urine lowering therapies. And this does seem to be valuable, but overall, only about 40% of patients that go to the hospital actually get a rheumatology consultant. Some hospitals don't have access to this, or it's a challenge, but the ones that do it seems to make sense.

RN: Did these results surprise you?

BL: Well, I think what surprised me most overall was how little there was out there on this particular topic. I mean, gout flares have been around forever. And we've been trying to avoid patients going into the hospital for a very long time. When you go to the hospital, you're at risk for infections, things that we call nosocomial, or hospital induced infections. You can get acute kidney injury, which would prolong your hospitalization. You can get any number of problems just from being in the hospital. So, the overall goal with most conditions is to avoid going to the hospital in the first place. And gout is a place where we can do that. We have available pharmacological therapies that are highly effective. And we know if you can lower the patient's uric acid enough, you can prevent them from getting more flares. And so that's the main goal. But that's not really happening out there. What we can do, especially as a result of this research, is we can capitalize on these admissions even though we don't want them to happen. Gout is not like high blood pressure, where it's sometimes hard to convince the patient to take their medicine because they don't feel it. If your blood pressure is high, you're not going to notice that. But with gout flares, patients notice. They go to the hospital because they're in pain and they want to feel better. And so having rheumatology come by and visit them and say, “Listen, I can help you to not have this happen again, I'm going to give you medicine for it, and I want you to come see me in clinic. And if you have this problem, again, you can call me.” Rheumatologists can often manage gout flares as an outpatient basis. They can add the patient at the end of the day, they can call in some medicine for them. There are things that rheumatologists can do that will prevent more of these admissions. And again, rheumatologists are motivated. The gout patients, because the flares, they're so painful, they're motivated. I think overall, we just need a little more systemic type of research on this topic.

RN: Why is it so critical for a rheumatologist to be consulted in the hospital setting to discuss appropriate education and therapies?

BL: As I as I mentioned a little bit before, what rheumatologists do when they get involved in the hospital is they make sure that all the right labs are done, the right medicines are started, and they can provide the patient with follow-up often with the same doctor they meet in the hospital. A lot of rheumatologists, most of their practice is outpatient in clinic and a lot of them go to the hospital just to see a few inpatient consults and bring those patients to their clinic. So, involving the rheumatologist while the patient is in the hospital is a good time to meet the arthritis specialists, the rheumatologist so to speak, because the patient knows something went very wrong. And the rheumatologist can provide education at that exact time. The patient's not going to be distracted, because they're in the hospital. They're not rushing out to get their kids to a soccer game or getting home for their TV program. They're just there in the hospital. And usually, they're quite receptive to the teaching that can be provided right there. And so again, I think these are all strong benefits of involving rheumatology while the patients are in the hospital.

RN: How do missed opportunities potentially increase the risk of more gout hospitalizations?

BL: If a patient comes to the hospital for gout, and this is going to happen, right? It's not possible to avoid all of these hospitalizations. But you know, if a medicine to lower their uric acid level is not started, and rheumatology is not consulted, then they're just going to get anti-inflammatory medicines for this particular gout flare, which will make the inflammation subside. All gout flares will stop eventually. And the patient will go back to their life, but without education on what they shouldn't do, and without appropriate medicines to help them feel better and lower their uric acid, they're at high risk for ongoing flares. And so, if all these things aren't done when you have the opportunity, the patients may very well come back to the hospital with another gout flare. And the more times this happens, obviously, the more healthcare resources are being consumed, but also the higher risk the patient has for something else bad to happen, which we don't want. We want to avoid that.

RN: How has Horizon supported the gout community through ongoing and prospective studies?

BL: Recent interest and involvement in gout sort of began when we got pegloticase about 5 and a half years ago, in January 2016. And this was a molecule that had a bit of a rocky history before we got it. But Horizon invested a lot in supporting important research projects and really understanding what the rheumatology community thought of this medicine and figuring out how we could make it work better. And so, the recent research that we've done has involved adding immunomodulatory therapies which are essentially, slightly immune-dampening therapies. What they do is they prevent the immune system from reacting to the medicine, Pegloticase is a very powerful medicine for gout. It lowers the uric acid drastically to around 0 or 1 in most patients. And as a result of that profound urate lowering, tophi go away, the uric burden resolves, and the patients feel a lot better. But some patients, maybe up to half of them, can only get a limited course of pegloticase therapy because their immune system develops anti-drug antibodies. And what we started to figure out was if you use an immunomodulating therapy, you can prevent these antibodies from forming and help more patients get a full response to the medicine, which is really important for a medicine like pegloticase, which is often the last one used for patients that have uncontrolled gout. So, you know, the continued investment in time and resources, trying to understand where rheumatologists are and what they think about this medicine, and really understand the science and how we can invest to make the molecule work better for as many patients as possible. I would say there are a lot of things that Horizon has done and continues to do to support the community.

RN: Is there anything else you'd like to add before we wrap up?

BL: Well, again, I'll just reiterate something I mentioned, which is, I think we owe it to our patients to just do a little better at every stage of the disease: using the available tools to effectively treat these patients, educating the patients so they know why they're taking each of the medicines, and getting them that follow-up maybe in in 2 to 3 months instead of 6 to 8 months so that we can keep adjusting their medicine get that uric acid level down. And then, in light of the recent Russell publication, it seems clear that more research is needed on what inpatient gout management looks like, not just while the patients are in the hospital, but also when they go home. What makes them higher risk to possibly come back with another gout flare? Understanding that will really help us to prevent it from happening in the future. I mean, aside from the obvious, just effectively treating the gout the first time around, that's not always going to happen. Gout remains kind of an underserved disease and Horizon, and I and my colleagues have certainly made great efforts to try to change that over time, and we do think we're making meaningful progress.