Exploratory Study of Radiographic Change in Patients With Tophaceous Gout Treated With Intensive Urate-Lowering Therapy


  • Nicola Dalbeth,

    Corresponding author
    1. University of Auckland, Auckland, New Zealand
    • Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand. E-mail: n.dalbeth@auckland.ac.nz

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    • Dr. Dalbeth has received consulting fees, speaking fees, and/or honoraria (less than $10,000 each) from Ardea, Menarini, Metabolex, Savient, and Takeda.

  • Anthony J. Doyle,

    1. University of Auckland, Auckland, New Zealand
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  • Fiona M. McQueen,

    1. University of Auckland, Auckland, New Zealand
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  • John Sundy,

    1. Duke University Medical Center, Durham, North Carolina
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    • Dr. Sundy has received consulting fees (less than $10,000 each) from Ardea, Metabolex, Pharmos, and Savient.

  • Herbert S. B. Baraf

    1. Center for Rheumatology and Bone Research, Wheaton, Maryland
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    • Dr. Baraf has received consulting fees and/or speaking fees (less than $10,000) from Ardea and (more than $10,000 each) from Savient and Takeda.



Tophi are strongly associated with structural damage in gout, and urate-lowering therapy reduces tophus size. Pegloticase leads to dramatic reductions in serum urate and subcutaneous tophi in treatment responders. The aim of this analysis was to examine whether profound urate lowering can alter radiographic findings in gout.


Serial plain radiographs of the hands and feet were obtained from 8 patients with tophaceous gout treated with pegloticase. Radiographs were scored for erosion and joint space narrowing (JSN) according to the gout-modified Sharp/van der Heijde method. Scorers were blinded to each other's scores and to the clinical characteristics of the patients (including the clinical response to pegloticase). A detailed qualitative site-by-site analysis was undertaken to define additional changes observed from baseline.


All patients experienced a profound urate-lowering response (serum urate level <1 mg/dl) during pegloticase treatment. For the entire group, the median total radiographic scores reduced from 69.25 (range 1.5–138) at baseline to 57.25 (range 1.5–110) at 12 months (P = 0.02). Median erosion scores reduced over 1 year (P = 0.008), but JSN scores did not change (P = 0.50). Further reductions were observed in total scores and erosion scores in 5 patients with 24-month followup films (one-way analysis of variance P = 0.009 for total score, 0.02 for erosion, and 0.95 for JSN). Qualitative site-by-site analysis identified regression of soft tissue masses, increased sclerosis, and filling in of erosions in the followup films.


This exploratory study suggests that profound urate lowering can lead to improvement in structural damage, particularly bone erosion, in patients with tophaceous gout.