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3 Human genetic evidence supports Fibroblast Growth Factor 21 (FGF21) as a novel therapeutic
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5 target for gout

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10 Sizheng Steven Zhao1, Daniel J Cuthbertson2,3, Uazman Alam3,4,5
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14 1 Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Science,
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16 School of Biological Sciences, Faculty of Biological Medicine and Health, The University of
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18 Manchester, Manchester Academic Health Science Centre, Manchester, UK.
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20 2 Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK.
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3 Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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25 4 Department of Cardiovascular and Metabolic Medicine, Liverpool Centre for Cardiovascular
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Science and the Pain Research Institute, University of Liverpool, Liverpool, UK
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29 5 Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University
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36 Correspondence to: Sizheng S Zhao. Centre for Musculoskeletal Research, Division of
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Musculoskeletal and Dermatological Science, School of Biological Sciences, Faculty of Biological
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39 Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre,
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41 Oxford Road, Manchester, M13 9LJ, UK. Email: Sizheng.zhao@manchester.ac.uk
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3 Gout is the most prevalent inflammatory arthritis among adults, affecting up to 7% of the population
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5 in developed countries [1]. Urate lowering therapies, e.g., xanthine oxidase inhibitors or uricosuric

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7 agents, form the cornerstone of gout management. Although effective for most patients, frequent
8 barriers to optimum urate control include drug intolerance and renal impairment; therefore, novel
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10 classes of urate lowering therapies are needed. Drugs targeting components of the metabolic
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12 syndrome are appealing because they may benefit concomitant cardiometabolic conditions.
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14 Fibroblast growth factor 21 (FGF21) has multiple roles in regulating energy balance and lipid
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16 homeostasis. FGF21 is implicated in the regulation of urate metabolism, and its levels are raised in
17 hyperuricaemia [2]. Several clinical trial programmes are evaluating FGF21 analogues for the
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19 treatment of obesity-related metabolic conditions, demonstrating clinically significant improvements
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21 in lipid profiles, and reductions in body weight, liver fat and fibrosis [3,4]. We aimed to investigate
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the association between FGF21 signalling with urate levels and gout, using human genetic data. We
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24 show evidence, for the first time, of its potential as a novel therapeutic agent for gout.
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Conceptually, this genetic instrumental variable analysis quasi-randomizes (because genetic variants
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28 are randomly assigned at conception) the population into strata with different FGF21 function (as
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30 reflected by liver fat content) and compares urate level and gout risk. We selected a protein coding
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single nucleotide polymorphism, rs739320, in the FGF21 gene that has been associated with liver fat
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33 to proxy lifelong FGF21 signalling. Liver fat was chosen as a downstream biomarker of FGF21
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35 perturbation. Genetic association data was taken from a study of magnetic resonance imaging-
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derived liver fat measurements among 32,974 individuals of European ancestry from the UK Biobank
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38 (UKB), with each C allele (frequency 60%) conferring 0.23% lower liver fat (p=6.5x10-4, F=12). Genetic
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40 association data for gout and urate were both obtained from a GWAS meta-analysis, including
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13,179 gout cases (self-reported, urate-lowering drugs or ICD codes for gout) and 750,634 controls.
43 Half of gout cases were from the UKB; 98% of cases were of European ancestry. We replicated
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45 findings using 9,568 ICD code derived cases in the FinnGen study and 262,844 controls. Urate data
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47 were available for 457,690 individuals. There was no overlap with the UKB but 37% were of non-
48 European ancestry; therefore, we additionally used a UKB-only dataset (n=343836). Exposure-
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50 outcome associations were estimated using the ratio method. Colocalization analysis was used to
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52 examine potential bias from genetic confounding. Full methods and references to datasets are
53 provided in supplementary materials and supplementary Table S1.
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56 FGF21 signalling was associated with lower urate level (-28.0 μmol/L; 95%CI -47.0, -9.0; p=0.004) and
57 reduced risk of gout (OR 0.31, 95%CI 0.11, 0.84; p=0.02). Results were consistent using replication
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Page 3 of 8 Rheumatology

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3 data for urate (-26.5 μmol/L; 95%CI -38.6, -14.3; p=2.1x10-5) and gout (OR 0.27;95%CI 0.09, 0.86;
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5 p=0.03). There was no statistical evidence for genetic confounding.

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7 This genetic investigation provides novel evidence supporting FGF21’s potential as a therapeutic
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9 target for gout management. Given the recognised clinical effects of FGF21 analogues on
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11 dyslipidaemia, liver fat [3,4], and potential effects on cardiovascular disease [5,6], these agents may
12 represent an attractive therapeutic option for gout with additional clinical benefit for related
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14 comorbidities. The precise mechanistic pathway through which FGF21 influences serum urate levels
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16 and gout risk remains unclear. Prior genetic evidence suggested that FGF21 may have pleiotropic
17 effects, including altered macronutrient consumption, renoprotection, reduced inflammation, with
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19 potential benefits on cardiovascular and venous thromboembolism risk [5,6]. Clinical trials with
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21 FGF21 analogues or receptor agonists should examine serum urate levels and gout risk to confirm
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our findings. In conclusion, genetically proxied FGF21 signalling is associated with reduced urate
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24 levels and lower gout risk and may represent a new pathway to treat gout.
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29 Acknowledgements
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31 SSZ is supported by a National Institute for Health Research (NIHR) Clinical Lectureship and works in
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centres supported by Versus Arthritis (grant no. 21173, 21754 and 21755) and the NIHR Manchester
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34 Biomedical Research Centre (NIHR203308). The views expressed are those of the author(s) and not
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36 necessarily those of the NIHR or the Department of Health and Social Care.
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38 Data availability statement
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All data used in this study are publicly available, with relevant citations detailed in the main text or
42 supplementary materials.
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Patient consent for publication
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47 Not required, as publicly available summary data that had already obtained informed participant
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49 consent were used.
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51 Ethics approval
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53 This analysis used publicly available summary statistics that had already obtained ethical approval.
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56 Patient and Public Involvement
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58 Patients or the public were not involved in the design, or conduct, or reporting, or dissemination
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3 Conflicts of Interest
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5

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6 All authors declare no relevant conflicts of interest that could bias this work.
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8
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11
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13 References
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15 1. Dehlin M, Jacobsson L, Roddy E. Global epidemiology of gout: prevalence, incidence, treatment
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17 patterns and risk factors. Nat Rev Rheumatol 2020;16:380–90.
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19 2. Geng L, Lam KSL, Xu A. The therapeutic potential of FGF21 in metabolic diseases: from bench to
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21 clinic. Nat Rev Endocrinol 2020;16:654–67.
22
23
24 3. Gaich G, Chien JY, Fu H, Glass LC, Deeg MA, Holland WL, et al. The effects of LY2405319, an
25
FGF21 analog, in obese human subjects with type 2 diabetes. Cell Metab 2013;18:333–40.
26
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28 4. Talukdar S, Zhou Y, Li D, Rossulek M, Dong J, Somayaji V, et al. A Long-Acting FGF21 Molecule,
29
30 PF-05231023, Decreases Body Weight and Improves Lipid Profile in Non-human Primates and
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Type 2 Diabetic Subjects. Cell Metab 2016;23:427–40.
32
33
34 5. Larsson SC, Gill D. Genetic Evidence Supporting Fibroblast Growth Factor 21 Signalling as a
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36 Pharmacological Target for Cardiometabolic Outcomes and Alzheimer’s Disease. Nutrients
37
2021;13:1504.
38
39
40 6. Giontella A, Zagkos L, Geybels M, Larsson SC, Tzoulaki I, Mantzoros CS, et al. Renoprotective
41
42 effects of genetically proxied fibroblast growth factor 21: Mendelian randomization, proteome-
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wide and metabolome-wide association study. Metabolism 2023;145:155616.
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Page 5 of 8 Rheumatology

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3 Supplementary materials for:
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6 Human genetic evidence supports Fibroblast Growth Factor 21 (FGF21) as a novel therapeutic
7 target for gout
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10 Sizheng Steven Zhao1, Daniel J Cuthbertson2,3, Uazman Alam3,4,5
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12 1 Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Science,
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14 School of Biological Sciences, Faculty of Biological Medicine and Health, The University of
15 Manchester, Manchester Academic Health Science Centre, Manchester, UK.
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18 2 Department of Cardiovascular and Metabolic Medicine, University of Liverpool, Liverpool, UK.
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20 3 Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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4 Department of Cardiovascular and Metabolic Medicine, Liverpool Centre for Cardiovascular
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24 Science and the Pain Research Institute, University of Liverpool, Liverpool, UK
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5 Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University
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Correspondence to: Sizheng S Zhao. Centre for Musculoskeletal Research, Division of
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35 Musculoskeletal and Dermatological Science, School of Biological Sciences, Faculty of Biological
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37 Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre,
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Oxford Road, Manchester, M13 9LJ, UK. Email: Sizheng.zhao@manchester.ac.uk
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3 Methods
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6 Valid instrumental variables are defined by three assumptions [1]. A genetic variant can be
7 considered as a valid instrumental variable for an exposure if it satisfies the instrumental variable
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9 assumptions: it is associated with the exposure in a specific way (assumption 1) that does not affect
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11 the outcome except via the exposure (assumption 3), and it is not associated with the outcome due
12 to confounding (assumption 2) (Figure S1).
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17 Figure S1: Illustration of instrumental variable assumptions.
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33 We estimated the F statistic using square of the beta divided by square of the standard error [2],
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35 with F >10 being suggestive of adequate instrument strength [3].
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37 Confounding arising from underlying population structure was reduced through use of European
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39 ancestry populations. Confounding is also possible through linkage disequilibrium (LD), i.e., a variant
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41 that causes the outcome via an alternate pathway closely correlated with the true causal variant.
42 Correlation is more likely when using instruments from a single gene region, while traditional
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44 sensitivity analyses for violation of MR assumptions can be limited in this setting [4]. We performed
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46 Bayesian colocalization analysis to examine potential for such genetic confounding. Colocalization as
47 a sensitivity analysis in the context of MR is discussed in detail in reference [7]. We used default
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49 prior probabilities of 10-4, 10-4 and 10-5 for a variant within the relevant genomic locus being
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51 associated with the exposure trait, outcome trait, or both traits, respectively. Prior probabilities
52 stated above were originally recommended for analyses of expression quantitative trait loci (eQTL)
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54 [8] and are conservative for hypothesis driven analyses. The output of interest is the probability of
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56 colocalization conditional on the presence of a causal variant for the outcome (H4/(H3+H4)), which
57 was 99% in for the primary analysis.
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3 Variants should not affect the outcome except through the risk factor. We used the Integrative
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5 Epidemiology Unit Open GWAS project PheWAS database to search for associations between

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7 rs739320 and other traits that may represent pleiotropic pathways – none were identified.
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14 Table S1. Summary of genome-wide association studies.
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16 Sample size
17 Population genetic
Author Phenotype (case vs controls for
18 ancestry
binary traits)
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European Magnetic resonance imaging-derived
20 Haas [8] 36,703
21 100% UKB liver fat percentage
22 Tin [9] 98% European Gout defined by self-reported, urate-
13,179 / 750,634
23 Approx. half UKB lowering drugs or ICD codes
24 FinnGen [10] European Gout defined by ICD code 9,568 / 262,844
25 Tin [9] 63% European Urate (mg/dL, multiplied by 59.5 to
26 457,690
no UKB convert to μmol/L)
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European
28 UK Biobank [11] Urate (μmol/L) 343,836
29 100% UKB
30 ICD, International Classification of Diseases; UKB, UK Biobank.
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2
3 References
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5 1. Davies NM, Holmes MV, Smith GD. Reading Mendelian randomisation studies: a guide, glossary,

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6 and checklist for clinicians. BMJ [Internet] 2018 [cited 2020 Jul 30];362. Available from:
7
https://www.bmj.com/content/362/bmj.k601
8
9
10
2. Li B, Martin EB. An approximation to the F distribution using the chi-square distribution.
11 Computational Statistics & Data Analysis 2002;40:21–6.
12
13 3. Burgess S, Thompson SG, CRP CHD Genetics Collaboration. Avoiding bias from weak instruments
14 in Mendelian randomization studies. International Journal of Epidemiology 2011;40:755–64.
15
16 4. Zuber V, Grinberg NF, Gill D, Manipur I, Slob EAW, Patel A, et al. Combining evidence from
17 Mendelian randomization and colocalization: Review and comparison of approaches. Am J Hum
18 Genet 2022;109:767–82.
19
20 5. Giambartolomei C, Vukcevic D, Schadt EE, Franke L, Hingorani AD, Wallace C, et al. Bayesian Test
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for Colocalisation between Pairs of Genetic Association Studies Using Summary Statistics. PLOS
22
23 Genetics 2014;10:e1004383.
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25 6. Staley JR, Blackshaw J, Kamat MA, Ellis S, Surendran P, Sun BB, et al. PhenoScanner: a database
26 of human genotype-phenotype associations. Bioinformatics 2016;32:3207–9.
27
28 7. Kamat MA, Blackshaw JA, Young R, Surendran P, Burgess S, Danesh J, et al. PhenoScanner V2: an
29 expanded tool for searching human genotype-phenotype associations. Bioinformatics
30 2019;35:4851–3.
31
32 8. Haas ME, Pirruccello JP, Friedman SN, Wang M, Emdin CA, Ajmera VH, et al. Machine learning
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enables new insights into genetic contributions to liver fat accumulation. Cell Genom
34
35
2021;1:100066.
36
37 9. Tin A, Marten J, Halperin Kuhns VL, Li Y, Wuttke M, Kirsten H, et al. Target genes, variants,
38 tissues and transcriptional pathways influencing human serum urate levels. Nat Genet
39 2019;51:1459–74.
40
41 10. FinnGen. Access results. [Internet]. [cited 2023 May 26];Available from:
42 https://www.finngen.fi/en/access_results
43
44 11. Bycroft C, Freeman C, Petkova D, Band G, Elliott LT, Sharp K, et al. The UK Biobank resource with
45 deep phenotyping and genomic data. Nature 2018;562:203–9.
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49
50
51
52
53
54
55
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57
58
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