Biologics fill ‘very unique niches’ in gout management
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SCOTTSDALE, Ariz. — Although many rheumatologists may not reach for biologic therapies for gout management, interleukin-1 and 6 inhibitors may have utility in managing mobilization flares, according to a speaker here.
“Biologics and gout seem like an odd pairing,” Brian F. Mandell, MD, PhD, professor and chair of academic medicine in the department of rheumatic and immunologic diseases at the Cleveland Clinic, told attendees at the Basic and Clinical Immunology for the Busy Clinician symposium. “However, the fact is that biologics actually do work and fill very unique niches in this disease.”
According to Mandell, the IL-1 receptor antagonist anakinra (Kineret, Swedish Orphan Biovitrum) has shown efficacy in targeting gout flares.
“It is a short-acting drug,” he said. “Efficacy has been reported in small studies, although some failures have been reported.”
However, despite minimal research data, clinical experience for anakinra in gout flares has been positive, Mandell added.
“There is extensive clinical experience in hospitalized patients,” he said. “It is far and away the most common drug we use in our service.”
Similarly, canakinumab (Ilaris, Novartis) also has shown enough efficacy in managing mobilization flares that it has gained both FDA and European Medicines Agency approval for this indication.
“However, there is little clinical experience outside of trials,” Mandell said.
That said, a trial examining flare resolution demonstrated the superiority of canakinumab over triamcinolone in this endpoint, along with pain resolution.
“The interesting part is how long these patients stayed flare-free after getting the single dose,” Mandell said. “[Canakinumab] was incredibly effective over a long period of time.”
Another IL-1-targeting medication that may target mobilization flares is rilonacept (Arkalyst, Kiniksa). Although data on this medication are also limited, Mandell said he believes that it is “likely” effective at treating acute gout flares.
Shifting gears, IL-6 inhibition with tocilizumab (Actemra, Genentech) may also have utility in the acute gout flare setting, according to Mandell.
“There are a couple of reports,” he said.
Completing the list of biologic approaches in gout flare management are tumor necrosis factor inhibitors.
“There were a couple of reports that TNF inhibitors were effective for acute flares,” Mandell said.
However, further investigation is necessary to confirm the efficacy of TNF inhibition in gout flares, he added.
The bottom line, though, according to Mandell, is that clinicians are failing to prescribe biologic medications to manage gout flares enough.
“The elephant in the room is a low utilization based on how we think about gout patients,” he said. “But, obviously, the cost of biologic medications comes into play, as well.”
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Mandell B. Crystal Clear: Critically Appraising the Role of Biologic Therapies in Crystal-Related Diseases. Presented at Basic and Clinical Immunology for the Busy Clinician, Feb. 17-18, 2024; Scottsdale, Arizona (hybrid meeting).
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