Preinfusion Glucocorticoid Reduction and Elimination in Patients With Uncontrolled Gout on Pegloticase and Methotrexate: A Case Series

OBJECTIVE: Pegloticase, an infused pegylated uricase enzyme, rapidly lowers serum urate (SU) in patients with uncontrolled gout. Preinfusion intravenous glucocorticoids (GCs) are typically administered before pegloticase to reduce risks of infusion reactions (IRs); however, they may exacerbate comorbidities in this patient population, and thus minimizing GC exposure is desirable. This study examined preinfusion GC dose reduction and elimination in patients with uncontrolled gout receiving pegloticase and methotrexate (MTX) co-therapy. METHODS: This retrospective case series of medical data (January 1, 2020, to April 1, 2023) from 1 rheumatology practice included patients receiving pegloticase (8 mg every 2 wk) with MTX co-therapy and undergoing preinfusion methylprednisolone dose reduction and elimination. The percentage of patients with SU <6 mg/dL (pegloticase responders) was assessed at 6 months and study completion; safety was assessed by frequency and severity of adverse events. RESULTS: Twelve patients with multiple comorbidities were evaluated (male, 92%; White, 58%; mean [SD] age, 60.3 [11.0] years; mean [SD] baseline SU, 8.8 [1.9] mg/dL). Patients received a mean (SD) of 14.3 (4.2) pegloticase infusions and discontinued GCs after a mean (SD) of 7.6 (1.3) infusions. At 24 weeks, 10/12 (83%) patients were responders and 9/12 (75%) continued to respond following GC reduction and elimination; 3/12 (25%) had an SU rise and discontinued pegloticase. The most common adverse event was gout flare (10/12 [83%] patients); no patients experienced IRs. CONCLUSIONS: This study demonstrated that preinfusion GC reduction and elimination are possible in patients with uncontrolled gout receiving pegloticase and MTX co-therapy.