Control of hyperuricemia in subjects with refractory gout, and induction of antibody against poly(ethylene glycol) (PEG), in a phase I trial of subcutaneous PEGylated urate oxidase

PEG-modified recombinant mammalian urate oxidase (PEG-uricase) is being developed as a treatment for patients with chronic gout who are intolerant of, or refractory to, available therapy for controlling hyperuricemia. In an open-label phase I trial, single subcutaneous injections of PEG-uricase (4 to 24 mg) were administered to 13 such subjects (11 had tophaceous gout), whose plasma uric acid concentration (pUAc) was 11.3 +/- 2.1 mg/dl (mean +/- SD). By day seven after injection of PEG-uricase, pUAc had declined by an average of 7.9 mg/dl and had normalized in 11 subjects, whose mean pUAc decreased to 2.8 +/- 2.2 mg/dl. At doses of 8, 12, and 24 mg, the mean pUAc at 21 days after injection remained no more than 6 mg/dl. In eight subjects, plasma uricase activity was still measurable at 21 days after injection (half-life 10.5 to 19.9 days). In the other five subjects, plasma uricase activity could not be detected beyond ten days after injection; this was associated with the appearance of relatively low-titer IgM and IgG antibodies against PEG-uricase. Unexpectedly, these antibodies were directed against PEG itself rather than the uricase protein. Three PEG antibody-positive subjects had injection-site reactions at 8 to 9 days after injection. Gout flares in six subjects were the only other significant adverse reactions, and PEG-uricase was otherwise well tolerated. A prolonged circulating life and the ability to normalize plasma uric acid in markedly hyperuricemic subjects suggest that PEG-uricase could be effective in depleting expanded tissue stores of uric acid in subjects with chronic or tophaceous gout. The development of anti-PEG antibodies, which may limit efficacy in some patients, is contrary to the general assumption that PEG is non-immunogenic. PEG immunogenicity deserves further investigation, because it has potential implications for other PEGylated therapeutic agents in clinical use.     

Allantoxanamide: A potent new uricase inhibitor in vivo

Allantoxanamide (2,4-dihydroxy-6-carboxamide-1,3,5-triazine) was studied as a uricase inhibitor in the rat. Uricase activity $\text{in vitro}$ was inhibited 50% by allantoxanamide at 9 × 10- M concentration. A single 250 mg/kg i.p. dose in the rat gave rise to a serum uric acid level of 14 mg/dl 6 hr after dosing; serum uric acid was still elevated (10 mg/dl) after 24 hr. At this dose level, deposition of uric acid in kidney tubules was observed. Studies with [8-¹⁴ C] uric acid indicated that the effect of allantoxanamide on serum uric acid was due to inhibition of uricase. The allantoxanamide-treated rat may serve as a useful animal model for the study of problems related to purine biosynthesis, drug-induced hyperuricemia and hyperuricosuria, and associated nephropathy.     

Metabolic Syndrome in Primary Gout

Background and Objectives. Primary gout has traditionally been associated with obesity, arterial hypertension, and abnormal lipid and glucose homeostasis, but we do not know the prevalence of these vascular risk factors in patients with primary gout from a Mediterranean country. Patients and Method. All patients with primary gout and 2 or more acute arthritis episodes documented by a physician were selected for the study. The diagnosis of MS required ≥3 criteria (ATP III). Patients were classified in two groups: decreased (underexcretors) and normal (normoexcretors) uric acid excretion related to serum urate levels. Results. One hundred and four patients (mean age, 59 years; 100 males) with primary gout were included in the study. MS was diagnosed in 38 subjects (37%). The most frequent triad defining MS was an increased waist circumference, blood pressure, and trygliceride levels. The prevalence of type 2 diabetes mellitus (T2D) was significantly higher in patients with the MS (21/38, 55%) as compared with subjects without the MS (3/66, 5%; p < 0.001). Mean serum urate level in patients with and without MS was identical (8.1 mg/dL), but mean 24-hour uric acid excretion was significantly lower in the former than in the latter (444 ± 110 mg/24-hour/1,73 m² versus 546 ± 221 mg/day/1,73 m²; p = 0.009). Conclusions. The condition of the MS occurs in about one-third of the patients with primary gout. Increased waist circumference, blood pressure, and triglycerides levels is the most frequent MS triad. Diminished urinary uric acid excretion is more severe in gout patients with the MS.     

A radiochemical-high-performance liquid chromatographic assay for urate oxidase in human plasma

Polyethylene glycol-modified urate oxidase (PEG-uricase) holds promise as a hypouricemic agent for treating gout and as an adjunct to cytolytic therapy of hematologic malignancies. Spectrophotometric assays of urate oxidase are not sensitive enough for pharmacokinetic evaluation of PEG-uricase in clinical trials. We have therefore developed a more sensitive radiochemical-HPLC assay for urate oxidase activity in untreated plasma, in which 14C in urate and in the reaction product, allantoin, is monitored in the uv detector effluent with a flow-through scintillation counter. The assay is linear with amount of enzyme and time of incubation and can detect less than 1 x 10(-5) U/ml uricase in plasma. The assay accounts for plasma samples of widely differing urate content.     

Polyethylene terephthalate membrane as a support for covalent immobilization of uricase and its application in serum urate determination

A method is described for covalent immobilization of uricase onto polyethylene terephthalate (PET) membrane with a conjugation yield of 4.44 μg/cm² and 66.6% retention of initial activity of free enzyme. The enzyme exhibited an increase in optimum pH from pH 7.0 to 8.5 and K_m for uric acid from 0.075 mM to 0.13 mM but slight decrease in temp. for maximum activity from 37 °C to 35 °C after immobilization. A colorimetric method for determination of serum uric acid was developed using immobilized uricase, which is based on measurement of H₂O₂ by a color reaction consisting of 3,5-dichlorobenzene sulphonic acid (DHBS), 4-aminoantipyrine and peroxidase as chromogenic system. Minimum detection limit of the method was 0.05 mM. Analytical recovery of added uric acid (5 mg/dl and 10 mg/dl) was 94.3% and 89.8%, respectively. Within and between batch coefficient of variation (CV) were <3.2% and <4.3%, respectively. A good correlation (r = 0.98) was found between uric acid values by standard enzymic colorimetric method and the present method. The immobilized uricase was reused 100 times during the span of 60 days without any considerable loss of activity, when stored in reaction buffer at 4 °C. The support chosen for the present study was biocompatible, antimicrobial, inert, impact resistant, light weight and had good shelf life.     

Genetic influence on variation in serum uric acid in American Indians: the strong heart family study

Hyperuricemia is associated with the metabolic syndrome, gout, renal and cardiovascular disease (CVD). American Indians have high rates of CVD and 25% of individuals in the strong heart family study (SHFS) have high serum uric acid levels. The aim of this study was to investigate the genetic determinants of serum uric acid variation in American Indian participants of the SHFS. A variance component decomposition approach (implemented in SOLAR) was used to conduct univariate genetic analyses in each of three study centers and the combined sample. Serum uric acid was adjusted for age, sex, age × sex, BMI, estimated glomerular filtration rate, alcohol intake, diabetic status and medications. Overall mean ± SD serum uric acid for all individuals was 5.14 ± 1.5 mg/dl. Serum uric acid was found to be significantly heritable (0.46 ± 0.03 in all centers, and 0.39 ± 0.07, 0.51 ± 0.05, 0.44 ± 0.06 in Arizona, Dakotas and Oklahoma, respectively). Multipoint linkage analysis showed significant evidence of linkage for serum uric acid on chromosome 11 in the Dakotas center [logarithm of odds score (LOD) = 3.02] and in the combined sample (LOD = 3.56) and on chromosome 1 (LOD = 3.51) in the combined sample. A strong positional candidate gene in the chromosome 11 region is solute carrier family22, member 12 (SLC22A12) that encodes a major uric acid transporter URAT1. These results show a significant genetic influence and a possible role for one or more genes on chromosomes 1 and 11 on the variation in serum uric acid in American Indian populations.     

PEG-ing down (and preventing?) the cause of pegloticase failure

Pegloticase is a powerful but underutilized weapon in the rheumatologist’s armamentarium. The drug’s immunogenicity leads to neutralizing antibody formation and rapid loss of efficacy in roughly one-half of all patients, which remains an impediment to broader use. New data, however, suggest that drug survival might improve with concomitant immunosuppressive agent (s), which merits further study. Efficacy appears to be unchanged when pegloticase is infused at 3-week (rather than 2-week) intervals. Stretching the time between infusions may also improve patient adherence and allow for earlier identification of transient responders.In the previous issue of Arthritis Research and Therapy, Hershfield and colleagues published a study putting forth a number of novel and potentially important findings regarding pegloticase, a powerful but underutilized weapon in the small but growing anti-hyperuricemic arsenal [1].The study examined the efficacy of pegloticase in a cohort of 30 patients with severe gout (93% tophaceous) utilizing an every 3-week infusion regimen, rather than the every 2-week schedule employed in previously published phase 3 trials. Despite the longer interval between infusions in the current study, the effectiveness of pegloticase is no worse (17/30 patients are persistent responders), and the pharmacokinetics of the drug suggest this should come as no surprise. The authors correctly note that a 3-week interval would be significantly more convenient for patients, and notably that such a regimen would also prove less costly to payors. Hershfield and colleagues’ dosing schedule would also help to identify transient responders earlier in the course of treatment – only four of 12 transient responders had uric acid >6 mg/dl 2 weeks after the first infusion (three of whom had previously been exposed to pegloticase in earlier phase 1 and 2 studies), whereas 11 of 12 transient responders had uric acid >6 mg/dl at 3 weeks (vs. only one of 17 persistent responders). For the reasons just elaborated upon, the paper demonstrates that dosing every 3 weeks may not just be as good as the current protocol, but may in some ways be superior.Hershfield and colleagues also upend the assumption that neutralizing antibodies to pegloticase are formed against uricase itself. Their paper clearly demonstrates that neutralizing antibodies develop in response to the polyethylene glycol (PEG) moiety of the drug, a finding that rebuffs a recent commentary which suggested antibodies to PEG are not pathogenic [2]. A septe and larger study (169 patients exposed to pegloticase) published in the previous issue Arthritis Research and Therapy by Lipsky and colleagues reaches the same conclusion regarding anti-pegloticase antibodies: anti-PEG antibodies are responsible for loss of efficacy rather than antibodies to the uricase enzyme itself, the latter of which rarely occur (positive more than once in only 11 subjects) and occur much later during the course of treatment, long after neutralizing anti-pegloticase antibodies have developed [3]. This larger study also demonstrates that an anti-pegloticase antibody titer >1:2,430 generally predicts loss of efficacy to the drug.Finally, and not least of all, Hershfield and colleagues’ smaller study included post-transplant patients (who were excluded from the phase 3 studies), a population particularly susceptible to developing gout. Of seven post-transplant subjects in the study, six proved to be persistent responders (86%) [1]. Although this is an admittedly small number of patients upon which to base any conclusion, it does raise the intriguing question of whether immunosuppression might lead to less of a mounted antibody response against pegloticase, and thus to more favorable outcomes. This is no small point; patients who are placed on pegloticase generally have severe, long-standing, and refractory gout, and should be given every chance to optimize their response to a potentially transformative therapy.While this signal is worth pursuing, some questions are immediately raised: how immunosuppressed must patients be to prevent neutralizing anti-PEG antibody formation, and with what should this be accomplished? Of the small subcohort in this trial, all patients were on cyclosporine or mycophenolate mofetil, and five of seven patients were on a combination of immunosuppressive agents. In choosing an immunosuppressant for the express purpose of preventing neutralizing antibodies, the risk of these drugs would very probably outweigh any proposed benefit (cyclosporine in particular might be the least desirable immunosuppressant for a patient with severe gout, because it both increases serum uric acid levels and decreases the glomerular filtration rate).If a trial was designed to investigate this line of query, a reasonable immunosuppressive agent of choice might be methotrexate. This drug has been shown to effectively prevent neutralizing antibodies from forming against monoclonal antibodies to anti-tumor necrosis factor [4,5]. Methotrexate’s inhibitory effect may not extend to preventing antibody formation against PEG, although methotrexate has also been shown to inhibit antibody formation against the polysaccharide 23-valent pneumococcal vaccine [6]. Methotrexate might also yield the unintended benefit of acting as an anti-inflammatory agent to suppress gouty attacks. However, because patients with severe gout have multiple comorbidities that place them at higher risk for medication side effects, methotrexate should not be considered in the clinical setting in the absence of data to support its use [7]. Nevertheless, methotrexate therapy is an avenue of inquiry that is clinically relevant and needs exploration to increase the likelihood that patients who begin this powerful drug can remain on it.     

Blood Coagulation and Platelet Economy in Subjects with Primary Gout

Previous studies have suggested that there is an increased incidence of degenerative vascular disease in patients with gout and an increased rate of turnover of blood platelets in patients and animals with atherosclerosis. A disturbed uric acid metabolism and “secondary” gout have long been known to occur with bone marrow diseases. A study of platelet economy and blood clotting factors in subjects with primary gout was therefore undertaken.Twenty-two male subjects with gout but with no clinical evidence of vascular disease were studied. Half of these had a negative family history for vascular disease and half had less fortunate ancestors. The most striking differences were found when gouty patients with a negative family history for vascular disease were compared with similar control subjects. The mean platelet half-life was 2.85 days in the gouty subjects and 3.74 days in the controls. The mean platelet turnover (number/c.mm./day) was 58,750 in gouty subjects, 42,370 in controls. Platelet adhesiveness and plasma thromboplastic activity were correspondingly increased in the gouty subjects. Control subjects with a positive family history all showed relatively active clotting system and platelet turnover, similar to the values found in atherosclerotic subjects. The data indicated that there is increased platelet destruction and production in some patients with primary gout. The relation between this anomaly and the vascular disease, and disturbed urate metabolism in gouty subjects, remains to be investigated.     

Analysis of uric acid and oxypurines in normal subjects and in gout patients

The behavior of plasma and urine oxypurines (hypoxanthine and xanthine) and of uric acid has been studied in normal subjects and in gout patients. Oxypurines and uric acid were increased in the plasma of gout patients but only the urinary excretion of hypoxanthine was higher in this group. The interpretation of the observed variations is discussed.     

尿酸酶－鲁米诺化学发光传感器

研制了依赖于鲁米诺化学发光反应和固定化尿酸酶柱的测定血清尿酸的生物传感器。其测定血清样品响应时间47s。测定每份样品需时1．5min,样品体积17μl。工作曲线的线性范围1~20mg／dl。批内不精密度3．22％～4.36％,批间6.18%～7．8%。测定值回收率为93％～109％。与医院常规酶试剂盘方法比较相关系数r=0.9909。固定化尿酸酶柱室温使用,4℃冰箱保存,连续使用5个半月测定样品2000次以上,仍保持原酶柱活力的94%。     

An amperometric uric acid biosensor based on multiwalled carbon nanotube-gold nanoparticle composite

An amperometric uric acid biosensor was fabricated by immobilizing uricase (EC 1.7.3.3) onto gold nanoparticle (AuNP)/multiwalled carbon nanotube (MWCNT) layer deposited on Au electrode via carbodiimide linkage. Determination of uric acid was performed by oxidation of enzymically generated H₂O₂ at 0.4 V. The sensor showed optimal response within 7 s at 40 °C in 50 mM Tris–HCl buffer (pH 7.5). The linear working range of the biosensor was 0.01–0.8 mM. The limit of detection (LOD) was 0.01 mM. The sensor measured uric acid levels in serum of healthy individuals and persons suffering from gout. The analytical recoveries of the added uric acid, 10 and 20 mg L^–1, were 98.0% and 96.5%, respectively. Within- and between-batch coefficients of variation were less than 5.6% and less than 4.7%, respectively. A good correlation (r = 0.998) was obtained between serum uric acid values by the standard enzymic colorimetric method and the current method. A number of serum substances had practically no interference. The sensor was used in more than 200 assays and had a storage life of 120 days at 4 °C.     

Effect of surfactants and inducers on increased uricase production under submerged fermentations by Bacillus cereus

Uricase is a clinical enzyme used for the oxidation of uric acid crystals in gout disease. The present study aimed to increase the suitable surfactant-mediated uricase production on induction by different concentrations of inducers. The efficiency of Bacillus cereus to produce extracellular uricase enzyme was studied in uric acid-containing agar plates. Among the studied inducers, uric acid is the potential inducer for uricase production under submerged fermentations (SMF), which induced 19.41?U/ml uricase in medium containing 2.0?g/L of uric acid, however further increase in the uric acid concentration decreased uricase production, which could be because of substrate inhibition. The physical parameters including agitation speed (rpm) and time duration (h) of uricase production were optimized and found to produce optimum uricase at 150?rpm in 26?h of SMF. Among the studied surfactants, nonionic surfactant, polyvinyl alcohol has shown a remarkable increase in the uricase production of 31.58?U/ml, which is a 61% increase under optimized conditions in SMF. The stability of produced uricase was found at pH 7.5 and temperature 30°C. Also the effects of various metal ions (1?mM) on the uricase activity were studied and observed to be inhibitory in nature in the descending order K⁺?>?Ca²⁺?>?Zn²⁺?>?Fe³⁺?>?Ni²⁺?>?Mg²⁺?>?Mn²⁺?>?Cu²⁺.     

In vitro and in vivo activity of soluble cross-linked uricase-albumin polymers: A model for enzyme therapy

The possibility of using soluble cross-linked enzyme-albumin polymers as a means of enzyme therapy for the treatment of certain enzyme deficiency diseases is investigated. The hyperuricemic Dalmatian coach hound is used as an experimental animal and the enzyme uricase (urate oxidase) as the administered enzyme. Chemically cross-linking uricase with an excess of canine albumin yields a soluble enzyme polymer that is significantly more heat stable and resistant to proteolytic activity than the native enzyme. Intravenous administration of similar amounts of enzyme in the native or polymeric form indicated that the “solubilized” enzyme survived in the circulation for a longer period of time (clearance half-time of 26 hours as opposed to 4 hours for the native enzyme) and was more effective in lowering plasma uric acid levels for longer periods. In vivo administration of the native enzyme lowered uric acid levels by about 35% with a return to normal levels with a half-time of about 24 hours. Subsequent injections of native uricase proved less effective and produced a severe hypersensitivity reaction following the third injection. No such adverse reactions or decreased activity of the administered “solubilized” uricase-albumin polymers were observed. The plasma uric acid levels were decreased by about 40% and only after 48 hours did the substrate levels begin to rise towards their resting levels.     

Modified colorimetric assay for uricase activity and a screen for mutant Bacillus subtilis uricase genes following StEP mutagenesis.

This study describes a modified colorimetric assay for uricase activity in flexible 96-well microtiter plates using the uricase/uric acid/horseradish peroxidase/4-aminoantipyrine/3,5-dichloro-2-hydroxybenzene sulfonate colorimetric reaction. The utility of this assay was demonstrated in a screen for mutant uricase enzymes derived from the uricase gene of the thermophilic bacterium Bacillus subtilis by a modified staggered extension process (StEP) mutagenesis. An Escherichia coli library of StEP-derived uricase mutant clones was screened yielding two identical active mutant uricase genes. Two motifs conserved in eukaryotic and prokaryotic uricases are highly conserved in the mutant uricase. The mutant uricase protein was found to exhibit high uricase activity (13.1 U.mg(-1)). Finally, the modified colorimetric method is much more efficient than the conventional ones and greatly reduces assay time from 4 days to less than 20 h.     

Recent developments in our understanding of the renal basis of hyperuricemia and the development of novel antihyperuricemic therapeutics

Although dietary, genetic, or disease-related excesses in urate production may contribute to hyperuricemia, impaired renal excretion of uric acid is the dominant cause of hyperuricemia in the majority of patients with gout. The aims of this review are to highlight exciting and clinically pertinent advances in our understanding of how uric acid is reabsorbed by the kidney under the regulation of urate transporter (URAT)1 and other recently identified urate transporters; to discuss urate-lowering agents in clinical development; and to summarize the limitations of currently available antihyperuricemic drugs. The use of uricosuric drugs to treat hyperuricemia in patients with gout is limited by prior urolothiasis or renal dysfunction. For this reason, our discussion focuses on the development of the novel xanthine oxidase inhibitor febuxostat and modified recombinant uricase preparations.     

Clearance of oxypurines in normal subjects and in gout patients subjected to a purine-free diet. Effects of allopurinol

The clearance of uric acid, hypoxanthine and xanthine has been examined in gout patients and in normal subjects compared to creatinine, after a purine-free diet. The treatment decreased the clearance in normal subjects, but showed an opposite effect in gout patients. The clearances both of uric acid, hypoxanthine and xanthine were enhanced by allopurinol. The interpretation of the observed variations is discussed.     

Determination of uric acid in biological fluids by high-pressure liquid chromatography

A high-pressure liquid chromatographic assay for uric acid in biological fluids has been developed. Blood uric acid can be analyzed in as little as 20 μl of plasma. The mean and range of plasma uric acid concentrations in healthy adults determined by high-pressure liquid chromatography were similar to these obtained by enzymatic analysis. One of the advantages of the present method is that naturally occurring metabolites in biological fluids or drugs do not interfere with the analysis. Data are presented for blood and urine specimens obtained from mice fed a known uricase inhibitor, potassium oxonate. Comparisons are made between the present method and methods previously employed for uric acid determination.     

Effect of acarbose on the increased plasma concentration of uric acid induced by sucrose ingestion

Sucrose is converted fructose and glucose, which may increase plasma uric acid concentration (pUA) through increased purine degradation and/or decreased uric acid (UA) excretion. To investigate effects of acarbose, an inhibitor of alpha-glucosidase, on the increased pUA from sucrose administration, we measured pUA and urinary UA excretion in 6 healthy subjects before and after administering sucrose, with and without co-administration of acarbose. Sucrose raised pUA by 10% (p < 0.01). However, excretion and fractional clearance of UA were unchanged. Sucrose and acarbose coadministration also increased pUA, but less than did sucrose alone (sucrose: 4.9 to 5.4 mg/dl; sucrose + acarbose, 4.7 to 4.9 mg/dl, p < 0.05) without changes in urinary excretion and fractional clearance of UA. Acarbose appears to attenuate the rise in pUA by sucrose ingestion by inhibiting sucrose absorption.     

Purification, and properties of a bovine uricase

Uricase from bovine kidney, purified to homogeneity level, had a molecular weight of 70 kDa. The apparent K(m) and V(max) values for uric acid hydrolysis were 0.125 mM and 102 IU mg(-1) protein respectively. The activation energy requirement for uric acid hydrolysis by uricase and inactivation of enzyme were 11.6 and 14.5 kJ/M respectively. Both enthalpy (Delta H*) and entropy of activation (Delta S*) for uricase activity were lower than those reported for some thermostable enzymes.     

Separation and quantitation of oxypurines by isocratic high-pressure liquid chromatography: application to xanthinuria and the Lesch-Nyhan syndrome

An isocratic HPLC technique has been developed for the separation and measurement of urine and plasma oxypurines in a patient with xanthinuria. The case history and laboratory data are presented. Xanthine excretion was 172 mg/g creatinine and hypoxanthine was 45 mg/g creatinine. Uric acid was too small to be measured but uricase determination showed only 3 mg/24 hr. Serum oxypurine analysis showed hypoxanthine 0.87 mg/dl and xanthine 0.35 mg/dl. Uric acid was not seen in this patient's serum but could be readily measured in normal control subjects. The technique can also be used to separate nucleotides from purine bases, and we have demonstrated its application to the measurement of erythrocyte hypoxanthine guanine phosphoribosyl transferase and adenine phosphoribosyl transferase in a kindred associated with the Lesch-Nyhan syndrome.