Do you know all the 16 details of gout "drug treatment"?

Gout is the most common metabolic disease
in clinical practice after diabetes.
According to the "Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout 2019" released by the Endocrinology Branch of the Chinese Medical Association, the overall prevalence of hyperuricemia in China is 13.
3% and gout is 1.
1%.

For gout patients, in addition to usually paying attention to alcohol avoidance, limiting high-purine food intake, and actively controlling weight, the scientific and reasonable use of drugs is also a very important part of the entire treatment, among which there are many details that need to be paid attention to
.

First, during the acute attack of gout, "analgesics" need to be used as soon as possible

According to the 2019 edition of the Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout, "non-steroidal anti-inflammatory drugs" and "colchicine" are the first-line anti-inflammatory and analgesic drugs in the acute phase of gout, and "glucocorticoids" are second-line drugs
.

The earlier these symptomatic treatment drugs are used, the better the effect, and it is best to give them within 6~12 hours of onset to stop the onset
of acute arthritis as soon as possible.

Second, take "non-steroidal anti-inflammatory drugs", pay attention to protect the digestive tract

The commonly used clinical "non-steroidal anti-inflammatory drugs" mainly include ibuprofen, diclofenac sodium (Voltaline), celecoxib (Celebrex), etoricoxib (Ankangxin), etc.
, advocating early and sufficient use, that is, giving double the conventional dose in the first 1~2 days of the attack, in order to quickly control inflammation and pain, and quickly reduce to the conventional amount after the symptoms are relieved, and the course of treatment is 4~10 days
.

In order to reduce the irritation of the digestive tract and prevent gastrointestinal bleeding, they can be combined with drugs that inhibit gastric acid secretion (such as omeprazole) or gastric mucosal protectors (such as sucralfate).

Third, "colchicine" advocates the use of "low-dose therapy"

"Colchicine" is a specific drug to stop the acute attack of gout, and the disadvantage is that diarrhea, vomiting and other digestive tract reactions are large
.
Compared with the traditional "high-dose method", the "low-dose dosing" method is equally effective but the gastrointestinal reaction is significantly reduced
.

Specific usage: 2 tablets (1mg) immediately taken orally during a gout attack, and then 1 tablet (0.
5mg) after 1 hour; after 12 hours, change to 0.
5mg, 1~2 times / day until the symptoms are relieved
.
The course of treatment is generally no more than two weeks, and patients with renal insufficiency need to reduce the dose
as appropriate.

Fourth, "glucocorticoids" are limited to second-line medication

When non-steroidal anti-inflammatory drugs, colchicine and other first-line analgesics are ineffective or contraindicated (such as patients with renal insufficiency at the same time), glucocorticoids can be used for a short time, such as prednisone (ie "prednisone") 20~30mg/d (0.
5mg/kg·d), taken in the morning, and the drug can be gradually reduced and stopped after the symptoms are relieved, with a total course of treatment of 7~10 days
.

5.
If the effect of single-drug pain relief is not good, a combination of drugs can be taken

For patients with gout who do not respond well to monotherapy and have severe pain, a combination of drugs such as "colchicine + glucocorticoid hormones" or "colchicine + nonsteroidal anti-inflammatory drugs"
can be taken.

However, "non-steroidal anti-inflammatory drugs + glucocorticoid hormones" are generally not taken, because the combination of these two types of drugs has obvious damage to the gastrointestinal mucosa and can easily lead to gastrointestinal bleeding
.

6.
For those with a greater risk of gastrointestinal bleeding, topical painkillers can be selected

Topical analgesics such as Voltaren latex, piroxicam patch, or ketoprofen may also be an option for gout patients at high risk of bleeding (e.
g.
, active peptic ulcer) who are not candidates for oral anti-inflammatory analgesics.

7.
During the acute attack of gout, it is not appropriate to temporarily add urate-lowering drugs

If the patient has been taking urate-lowering drugs before the acute onset of gout, continue to take it without stopping; However, if you have not taken urate-lowering drugs before, do not add urate-lowering drugs in the acute phase to avoid recurrence or aggravation
due to significant fluctuations in blood uric acid.

8.
If the diet treatment does not meet the standard, uric acid lowering drugs should be used

Studies have confirmed that relying solely on a low-purine diet can only reduce blood uric acid levels by 10%~15% (70~90umol/L), therefore, most gout patients can not control blood uric acid control by diet alone, and need to take urate-lowering drugs
for a long time.

In general, patients with new-onset gout should start urate-lowering drug therapy
2 weeks after the symptoms of gout have been relieved in the acute phase of gout.

9.
Before taking allopurinol for the first time, it is recommended to do HLA-B*5801 gene testing

Allopurinol may cause severe skin allergic reactions such as exfoliative dermatitis, with a case fatality rate of up to 30%.

It has been confirmed that this is closely related to HLA-B*5801 gene, and about 10%~20% of Han people carry this gene
.
If possible, it is recommended to test allopurinol before taking allopurinol, and the result is negative before using allopurinol to ensure that the medication is safe
.

10.
Patients with gout with cardiovascular disease should use febuxostat with caution

Febuxostat is a novel xanthine oxidase inhibitor that has fewer allergic reactions and less impact on the liver and kidneys than allopurinol, and is suitable for patients with gout who are allergic to allopurinol or have mild to moderate renal insufficiency
.

In recent years, the cardiovascular safety of the drug has attracted much attention, and the research conclusions are not completely consistent, and it is recommended that patients with gout with cardiovascular disease should be used
with caution.

11.
During taking uric acid excretion drugs, pay attention to drinking plenty of water

"Benzbromarone" and "probenecid" are both uric acid excretion drugs, after taking such drugs, a large amount of uric acid is excreted with urine, the concentration of uric acid in the urine increases, easy to form urate crystals, causing urinary tract stones
.

Therefore, patients must pay attention to drinking more water (more than two liters per day) during taking such drugs to increase urine output, promote the excretion of uric acid, and avoid the formation of urate crystals
.
In addition, phenbromarone is contraindicated in patients with gout with moderate or severe renal insufficiency or urinary stones and allergy to benzbromarone
.

12.
Rational use of alkaline drugs

Commonly used alkaline drugs in clinical practice include sodium bicarbonate, potassium citrate, etc
.
By alkalizing urine, it can promote the dissolution of urate crystals and the excretion of uric acid, preventing the formation of urinary tract stones
.

However, it is not that the higher the PH value, the better, to maintain the urine pH at 6.
2~6.
9 is appropriate, urine excessive alkalinization (urine pH> 7.
0), not only will lead to alkalosis, but also easy to form calcium salt stones.

Therefore, during the administration of urate-stimulating drugs (eg, benzbromarone), the pH of the patient's urine should be monitored regularly, and alkaline drugs
should be added and adjusted as appropriate according to the test results.

13.
Uric acid lowering drugs should start from a small dose and adjust the dose gradually

Large fluctuations in blood uric acid have been shown to be an important trigger for
gout attacks.
The faster and more dramatic the decrease in blood uric acid concentration, the higher
the risk of "metastatic gout" in the patient.

Therefore, urate-lowering drugs must start from a small dose and gradually increase the dose
.
For example, febuxostat should start from 20~40mg/day, and after 2 weeks, blood uric acid does not meet the standard, the dose can be gradually increased, the maximum dose is 80 mg/day; Allopurinol should start from 50~100mg/day and gradually increase to a conventional treatment amount of 300mg/day
.

In addition, in order to prevent gout attacks induced by blood uric acid fluctuations caused by the use of urate-lowering drugs, it can be maintained for 3~6 months
in the early stage of urate-lowering treatment, combined with oral small doses of colchicine.

14.
Uric acid-lowering drugs shall not be stopped without authorization

Like chronic diseases such as diabetes and high blood pressure, gout patients often need long-term maintenance medication
.
Stopping the drug without authorization is likely to cause uric acid to rise and the disease to recur.

Patients should be guided by a specialist physician and cooperate with lifestyle interventions to control blood uric acid in the target range with the minimum dose to reduce possible drug side effects and treatment costs
.

15.
Do a good job of regular review and beware of the side effects of uric acid-lowering drugs

All uric acid-lowering drugs (such as allopurinol, febuxostat, benzbromarone, etc.
) have certain side effects, during the medication, it is necessary to regularly review blood routine, liver and kidney function and urinary ultrasound to observe whether there is skin damage, bone marrow suppression, abnormal liver and kidney function and urinary stones, once the problem is found to be dealt with
in time.

16.
Patients with gout with "three highs" need to consider the impact on uric acid when choosing drugs

Many patients with gout have "three highs" at the same time, and it is recommended to give preference to therapeutic drugs
with urate-lowering effects.

➤ When hypertension is comorbid, it is recommended that losartan and (or) calcium channel blockers are preferred for antihypertensive drugs;

➤ When hypertriacylglyceridemia is combined, fenofibrate is recommended for lipid-modifying drugs;

➤ When hypercholesterolemia is combined, lipid-modifying drugs recommend that atorvastatin calcium is preferred;

➤ When diabetes mellitus is combined, it is recommended to give preference to SGLT-2 inhibitors, metformin, GLP-1 receptor agonists, DPP-4 inhibitors, etc
.