Do Disease-Modifying Antirheumatic Drugs (DMARDs) like Cellcept (Mycophenolate) affect gout?

DMARDs like Cellcept (Mycophenolate) Do Not Directly Affect Gout

DMARDs like Cellcept (mycophenolate) are not indicated for gout treatment and do not directly affect gout pathophysiology or serum uric acid levels. 1

Understanding DMARDs and Gout

• DMARDs (Disease-Modifying Antirheumatic Drugs) are primarily used to treat rheumatoid arthritis and other inflammatory conditions by modifying the disease process and immune response 2, 3
• Gout is a distinct condition caused by hyperuricemia (serum uric acid >6.8 mg/dL) leading to monosodium urate crystal deposition in joints and soft tissues 1, 4
• The primary treatments for gout focus on urate-lowering therapies (ULTs) that either reduce uric acid production or increase its excretion, not on immunosuppression with DMARDs 1, 4

Gout Treatment Approach

• The Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN) strongly supports a treat-to-target approach for gout, aiming to lower serum urate levels below 6 mg/dL 1
• Urate-lowering drugs are generally safer and better tolerated than frequently used anti-inflammatory drugs, particularly in patients with comorbidities commonly associated with gout 1
• Clinical benefits are observed when patients achieve long-term serum urate lowering to sub-saturation concentrations, leading to improvements in flares and tophi size 1

DMARDs in Special Gout Scenarios

• While not directly affecting gout pathophysiology, immunosuppressive agents like mycophenolate have been used in very specific scenarios:
  • As adjunctive therapy to prevent anti-drug antibodies when using pegloticase (a biologic urate-lowering therapy) for refractory tophaceous gout 5
  • In this context, immunosuppressives like azathioprine may help prevent pegloticase immunogenicity and treatment failure 5

Medication Effects on Uric Acid Levels

• Some medications prescribed for conditions other than gout can affect serum uric acid levels, either raising or lowering them 6, 7
• Certain drugs like losartan, fenofibrate, and some NSAIDs can decrease serum uric acid levels by increasing renal urate excretion 6
• However, DMARDs like mycophenolate are not among the medications known to significantly alter uric acid metabolism or excretion 6, 7

Clinical Implications

• When treating patients with both rheumatoid arthritis and gout, it's important to understand that DMARDs prescribed for RA will not adequately address gout 1, 3
• Separate urate-lowering therapy should be considered for gout management, with a target serum uric acid level below 6 mg/dL 1, 4
• Monitoring serum uric acid levels is essential in gout management, regardless of concurrent DMARD therapy for other conditions 4

Potential Pitfalls

• A common clinical pitfall is assuming that immunosuppressive therapy with DMARDs will adequately control gout flares or affect uric acid levels 8
• Another pitfall is initiating urate-lowering therapy during an acute gout attack; these agents should be started after resolution of the acute flare 8
• When starting urate-lowering therapy, it should be initiated at a low dose with gradual increments to achieve a serum uric acid level between 5 and 6 mg/dL 8, 4

In summary, while DMARDs like mycophenolate are effective for various rheumatic conditions, they do not directly affect gout pathophysiology or uric acid metabolism. Patients with gout require specific urate-lowering therapies targeted at reducing serum uric acid levels below 6 mg/dL.