While Uloric, a novel but familiar drug has successfully carved a niche into the gout market, Zurampic, the drug with the innovative mechanism of action has stumbled
The gout treatment landscape has expanded and advanced significantly over the last 10 years.
The majority of advances in gout drug treatment have focused on reducing serum uric acid (SUA) to prevent further attacks - most notably the development of Takeda’s Uloric, Horizon Pharma’s Krystexxa, Ironwood’s Zurampic and Duzallo.
How have these modern advanced fared in real word uptake?
Allopurinol is still the dominant urate lowering therapy and had been the first choice drug since it was first approved in 1966. Allopurinol belongs to the Xanthine oxidase inhibitor (XOI) drug class that inhibits an upstream process from creating SUA. We found that in a real-word cohort of U.S. gout patients with commercial insurance, 85% were treated with allopurinol (in Q2 2017). Allopurinol is cheap and sits firmly atop of the treatment algorithm.
Branded therapies in the chronic gout space compete for a slice of market share in patients intolerant of allopurinol or unable to control SUA with allopurinol monotherapy. The second-most prescribed urate lowering drug is another XOI, Feburic. Compared with allopurinol, Feburic is more potent and has more modern, more robust clinical trial data to support its use. Given the price differential with generic allopurinol, and the feeling from physicians that the two drugs are highly similar, Feburic is confined to second-line use.
The launch of Ironwood’s Zurampic (lesinurad) in 2016 was an exciting development in the gout space, it represented a new gout drug class with a new biological target, a SUA transport protein in the kidney.
Zurampic was positioned and was approved for use only in combination with a XOI, and has a label warning against use without a XOI.
However, in contrast with Uloric, a novel but familiar drug that successfully carved a niche into the gout market, Zurampic, the drug with the innovative mechanism of action has stumbled.
Our data indicate that Zurampic use is very low and the majority of Zurampic prescriptions (75%, n=12) do not comply with the label restriction to combination use. Indeed, across chronic gout treatment, the data show that combination use is virtually non-existent.
Perhaps the launch of Duzallo (Ironwood Pharmaceuticals), a fixed-dose oral combination of lesinurad (Zurampic) and allopurinol, will help drive the message that only combination use is appropriate.
A black box warning of severe renal failure and contraindications in various renal disease states have paralyzed Zurampic and it looks destined to be a niche product. Despite a cluster of advances in a previously dormant indication, the entrenched chronic treatment practices in gout have remained largely unchanged.
Data shown above is taken from DRG’s Treatment Algorithms: Claims Data Analysis In Gout. One in a series of real-world data driven research analyses of drug usage across different lines of therapy.