I looked at new therapies for gout when I reviewed Arcalyst as a potential new treatment of gout pain.

When I first became aware of gout, over 15 years ago, there were two different approaches to gout management: treat the pain, or treat the excess uric acid. Now we know that simply treating pain is not enough. It is good to be pain free, but dangerous if your gout is getting worse.

We now understand a lot more about how uric acid crystals destroy joints and damage other tissues. Professional medical advice is clear. We must lower uric acid to a safe target, and we will probably need pain relief for a few months until all crystals are gone.

There is a simple basic formula for medical treatment of gout that works for most gout patients. You take enough allopurinol to reach a safe target uric acid level, and take colchicine for a few months to prevent gout attacks. There are one or two complications in that approach, but for most people it is very simple. However, I explained in the Arcalyst article that some people cannot tolerate mainstream gout pain medication. Similarly, some people cannot tolerate mainstream uric acid lowering medication.

For people who cannot tolerate either allopurinol or Uloric (febuxostat), or find they are ineffective, scientists are seeking new alternatives. Earlier this year, Crittenden and Pillinger reviewed the current situation in New therapies for gout, published in January 2013 by Annual Review of Medicine. They review three new pain relief therapies that I mentioned in my Arcalyst feature (canakinumab, rilonacept, anakinra). They also review three new therapies for lowering uric acid.

I have already written about Krystexxa (pegloticase), and I will write about lesinurad soon. That leaves BCX4208, which I will review here.

BCX4208 is the initial project name for a drug that is now called ulodesine. This uric acid lowering drug is currently undergoing trials. Allopurinol and Uloric (febuxostat) lower uric acid by inhibiting the process of turning purines into uric acid. Ulodesine is similar, but it inhibits the building blocks that create purines (nucleotides).

Ulodesine is being developed by BioCryst, and there is some interesting information about how it works on their website. More importantly, there are some trial results that show significant reduction in uric acid. Interestingly, ulodesine works even better when it is taken alongside allopurinol. The two gout medicines together work better than either individually.

This is great news for gout patients who find that allopurinol is not getting uric acid low enough. It may also be an alternative for those who cannot tolerate allopurinol. There is still plenty of testing and research to do before it becomes available. If you believe you are a suitable candidate now, there are extensive clinical trials running, and you might be eligible for a place. You should discuss this with your rheumatologist, or ask in the gout support forum.

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