10/10/2023    Allen Jacobs, DPM

Krystexxa and Gout (Keith L. Gurnick, DPM)

Horizon has marketed a number of products to
podiatrists, including a variety of anti
inflammatory medications as well as Krystexxa.
They have regularly providdd speakers to Podiatric
seminars, both physicians and podiatrists. Prior
to the acquisition of Krystexxa by Horizon, I had
the opportunity to meet with the prior
manufacturers in New York. Those attending the
meeting included multiple APMA officers as well as
other podiatrists.

Krystexxa is an IV administered medication with a
not insignificant risk of infusion reaction and
anaphylaxis. It is used to treat hyperuricemia.
Although we as podiatrists diagnose gout and treat
the acute exacerbations, the etiology of
hyperuricemia and lowering of uric acid or the
treatment of the underlying disorders causing
hyperuricemia are not what we as podiatrists do.

The drug appears to be remarkable effective for
the treatment of tophaceous gout. Our job is to be
familiar with the availability of the medication,
its indications, and to make appropriate referrals
of patients for this therapy when indicated.

In my opinion, it is no different than our
referrals to other healthcare providers for
diagnostic and therapeutic services our patients
require and which services we do not generally
provide.

I recall the marketing of tapentadol for post-
operative pain. The studies were performed on
patients recovering from bunion surgery. The
investigators all MDs. Look at the studies on
topical antifungals marketed to podiatrists. The
studies published overwhelmingly authored by MDs.
Do you prescribe Jublia?

Yes there are many exceptions, particularly in the
area of wound care and some aspects of surgery.
However podiatrists are seldom the authors or
original researchers of studies used to gain FDA
approvals. Our colleges are not centers of
research. Residencies no longer require research
and publication of critical works. As a
profession, we tend to publish case series and
reviews.

At least we are recognized as a potential market
by industry. There was a time when podiatrists
were seldom marketed by the health care industry.
However, reality is reality. Even in the surgical
arena, we tend to be followers not leaders. Look
at the number of DPM vs. non-DPM authors in JFAS,
let alone the many other foot and ankle journals,
and other journals in areas such as plastic
surgery, vascular disease, orthopedics,
dermatology, etc.

In my waiting room, you will find procured
discussing spinal cord stimulation for pain
management which make no mention of podiatry. You
will find pamphlets on Krystexxa which do not
mention podiatry. You will find handouts regarding
new medications for treating diabetes which do not
mention podiatry. I am not insulted. Rather, I am
pleased to be viewed as a healthcare provider
capable of recognizing and referring patients in
need of services we do not generally provide.

Allen Jacobs, DPM, St. Louis, MO

Other messages in this thread:

---

10/12/2023    Allen Jacobs, DPM

RE: Krystexxa and Gout (Keith L. Gurnick, DPM)

Sadly, I must respond to the sophomoric comments
recently made in PM News regarding my comments on
Krystexxa. Krystexxa is utilized to lower serum
uric acid and for the treatment of chronic
tophaceous gout. The goal of treatment is to lower
the uric acid to less than 6. It is not used to
manage acute gout. It is a drug which typically
requires multiple IV administrations. It is not a
drug typically utilized by podiatrists. The
comments made were a classic example of not
knowing what you do not know.

I did not suggest that podiatrists do not or
should not treat acute gout or in fact any acute
monoarticular disorder. Rather, if you would read
my comment rather than embark on an inaccurate
diatribe, my point is that Horizon does and has
participated in podiatry education. They do not
appear to ignore podiatry. However, they
accurately conclude that Krystexxa is a medication
appropriately employed by rheumatologists in the
majority of cases. There is more to gout than
treating the acute episode. Do podiatrists
evaluate the patient for secondary causes of
elevated uric acids? I think not. When you
diagnose a patient with peripheral neuropathy as
having previously undiagnosed diabetes do you the
prescribe medications to manage diabetes?

As for my reference to Jublia, I suggest Dr.
Gurnick learn to correctly interpret what he
reads. What I stated was that in many if not most
circumstances, e.g. Jublia, the pharmaceutical
companies use MDs, DOs, PhDs for the initial
research utilized for FDA approval, with
podiatrists often consulted after the fact. Buying
you dinner, or providing lectures at our meetings
are for the purpose of marketing as well as
education. Are you so naive that you do not
understand this? There is nothing wrong with
staying in your lane.

Allen Jacobs, DPM, St. Louis, MO