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*Only for medical professionals to read for reference to fight gout, we are in action! April 20th is the "National Day for Gout", which is derived from the diagnostic criteria of hyperuricemia> 420μmol/L.
Gout is a crystal-associated arthropathy caused by the deposition of monosodium urate (MSU) in the joints.
It is directly related to hyperuricemia caused by purine metabolism disorders and decreased uric acid excretion, and belongs to the category of metabolic rheumatism.
.
In addition to joint damage, patients with gout can also be accompanied by kidney disease and other manifestations of metabolic syndrome.
At present, the prevalence of gout in my country is 1%~3%, and it is increasing year by year.
It is more common in men, and most women appear after menopause.
More than 50% of gout patients are accompanied by overweight or obesity.
The traditional natural course of gout is divided into asymptomatic hyperuricemia period, acute attack period, intermittent period and chronic gout disease period.
In particular, the acute attack of gout can be painful to the heart and tear the lungs.
The pain of being broken in love.
.
.
Take this special day, the editor will sort out the correct handling of acute gout attacks for everyone.
01What factors can induce an acute attack of gout? Binge eating, drinking, cold, excessive fatigue, nervousness, joint collision damage, and taking drugs that inhibit uric acid excretion (such as diuretics, low-dose aspirin, etc.
) can induce gout attacks and should be avoided as much as possible.
02What are the manifestations of acute gout? The acute onset of gout often occurs at night, with a rapid onset and progressive pain, reaching a peak around 12 hours.
The pain is unbearable, tear-like, knife-cut, or bite-like.
The affected joints and surrounding soft tissues are red and swollen, the skin temperature is elevated, and the tenderness is obvious.
Symptoms resolve spontaneously more than a few days or within 2 weeks.
Most patients have no progenitor symptoms before the onset, and some patients have signs of fatigue, general discomfort, and local tingling of joints before the onset.
The first attack is mostly a single joint involvement, and more than 50% occur in the first metatarsophalangeal joint.
Part of the severe cases may be accompanied by systemic symptoms, such as fever, chills, fatigue, and palpitations.
03How to deal with joint swelling, heat and pain? During the acute attack of gout, patients should be instructed to reduce their activities as much as possible, rest in bed, raise the affected limb, and take local ice (or magnesium sulfate wet compress), which can lower the temperature and relieve redness and pain.
In addition, topical diclofenac diethylamine emulsion also helps to reduce local pain.
Remember, massage and hot compresses are not allowed at this time.
Hot compresses will dilate blood vessels and aggravate local swelling and pain.
04How to choose analgesics during the acute attack of gout? The principle of acute treatment is to quickly control the symptoms and pain of arthritis.
In the acute phase, bed rest should be used, and the affected limb should be raised.
It is best to start to use drugs to control acute inflammation within 24 hours of the onset.
According to the "2016 Chinese Gout Diagnosis and Treatment Guidelines", there are three types of drugs to choose from during the acute attack: colchicine, non-steroidal anti-inflammatory drugs, and glucocorticoids.
The first-line treatment drugs include colchicine and non-steroidal anti-inflammatory drugs.
When there are contraindications or the treatment effect is not good, short-term application of glucocorticoid anti-inflammatory therapy can also be considered.
If the single-agent treatment effect is not good, the combination of the above-mentioned drugs can be selected.
When the above-mentioned drugs are intolerant or contraindicated, interleukin-1 (IL-1) receptor antagonists are also used abroad as the treatment of acute second-line gout.
There is currently no evidence that weak opioids and opioid analgesics are effective for acute attacks of gout.
(1) Colchicine: The latest international and domestic guidelines for the treatment of gout point out that the first choice to prevent recurrence is colchicine, with a dose of 0.
5 mg each time, 1-2 times a day.
It is recommended to start taking it within 12 hours of the onset of pain.
Generally, it will be effective within 24 to 48 hours.
After 36 hours, the curative effect decreased significantly.
When eGFR is 30~60 ml/min, the maximum dose of colchicine is 0.
5 mg/d; when eGFR is 15~30 ml/min, the maximum dose of colchicine is 0.
5 mg/2d; eGFR<15 ml/min or dialysis patients are forbidden.
Note: This drug may cause gastrointestinal adverse reactions, such as diarrhea, abdominal pain, nausea, and vomiting.
At the same time, liver and kidney damage and bone marrow suppression may occur.
Liver and kidney function and blood routine should be monitored regularly.
Patients who use potent P-glycoprotein and/or CYP3A4 inhibitors (such as cyclosporine or clarithromycin) should not use colchicine.
(2) Non-steroidal anti-inflammatory drugs: A sufficient amount of fast-acting formulations of non-steroidal anti-inflammatory drugs should be used as soon as possible for acute attacks of gout, including non-specific cyclooxygenase (COX) inhibitors and specific COX-2 inhibitors.
Precautions: Non-specific COX inhibitors should pay attention to gastrointestinal risks such as gastrointestinal ulcers, bleeding, and perforation; the gastrointestinal risks of specific COX-2 inhibitors are about 50% lower than that of non-specific COX inhibitors, but active digestion Tract bleeding and perforation are still contraindicated.
In addition, non-steroidal anti-inflammatory drugs can also cause renal damage.
Pay attention to monitoring renal function; patients with abnormal renal function should be fully hydrated and monitored for renal function.
Patients with eGFR<30 ml/min and not undergoing dialysis should not use it.
Specific COX-2 inhibitors may also increase the risk of cardiovascular events, and high-risk groups must be used with caution.
Commonly used non-steroidal anti-inflammatory drugs are shown in the chart below the table.
Table 1 The usage and dosage of commonly used non-steroidal anti-inflammatory drugs Note: COX is cyclooxygenase (3) Glucocorticoids: mainly used for acute gout attacks with systemic symptoms, or colchicine and non-steroidal anti-inflammatory drugs Ineffective or contraindicated, or patients with renal insufficiency.
It is generally recommended to stop taking prednisone 0.
5 mg·kg/d continuously for 5-10 days, or reduce the dose gradually after taking 2-5 days.
The total course of treatment is 7-10 days, and it is not suitable for long-term use.
If an acute attack of gout involves large joints, or if oral treatment is not effective, intra-articular or intramuscular injection of glucocorticoids can be given, but joint infections should be ruled out and repeated injections should be avoided in the short term.
Note: Use glucocorticoids to pay attention to adverse reactions such as hypertension, hyperglycemia, hyperlipidemia, water and sodium retention, infection, gastrointestinal risk, and osteoporosis.
For severe gout and severe pain, a combination of drugs can be used: such as colchicine + glucocorticoid, or colchicine + non-steroidal anti-inflammatory drugs.
The combination of non-steroidal anti-inflammatory drugs and glucocorticoids is not recommended, because both of them have obvious damage to the gastrointestinal mucosa and easily lead to gastrointestinal bleeding.
05What are the preventive measures for acute attacks of gout? 1.
Low-purine diet: strictly restrict high-purine foods such as animal offal, seafood and meat, encourage eating more fresh vegetables, and moderate consumption of beans and soy products.
2.
Drinking plenty of water: It can reduce the number of gout attacks and relieve the symptoms of gout.
If the heart and kidney function is normal, it is recommended to drink more water to maintain a daily urine output of 2000-3000 ml.
3.
Prohibition: Alcohol interferes with the metabolism of uric acid.
Rice wine, beer and white wine should be restricted.
The restriction on red wine is controversial.
4.
Weight loss: Obesity increases the risk of gout, and weight loss can reduce blood uric acid levels.
5.
Avoid catching cold: catching cold after being drunk is the most common cause of gout attacks.
6.
Avoid joint damage: strenuous exercise, excessive walking, etc.
lead to aseptic inflammation and induce gout.
7.
Try to avoid uric acid-increasing drugs: including diuretics, low-dose aspirin, immunosuppressive cyclosporine, anti-tuberculosis drug pyrazinamide, most chemotherapeutics, etc.
8.
Drug control of uric acid: Using uric acid-lowering drugs to control blood uric acid below 300μmol/L can greatly reduce the onset of gout. Reference materials: [1]Huang Yefei.
Practical guidelines for patients with hyperuricemia/gout[J].
Chinese Journal of Internal Medicine,2020,59(07):519-527.
[2]Zeng Xiaofeng.
2016 Chinese Gout Diagnosis and Treatment Guidelines[J] .
Chinese Journal of Internal Medicine, 2016,55(11):892-899.
[3]FitzGerald.
2020 American College of Rheumatology Guideline for the Management of Gout.
Arthritis Rheumatol.
2020 Jun;72(6):879-895.
Gout is a crystal-associated arthropathy caused by the deposition of monosodium urate (MSU) in the joints.
It is directly related to hyperuricemia caused by purine metabolism disorders and decreased uric acid excretion, and belongs to the category of metabolic rheumatism.
.
In addition to joint damage, patients with gout can also be accompanied by kidney disease and other manifestations of metabolic syndrome.
At present, the prevalence of gout in my country is 1%~3%, and it is increasing year by year.
It is more common in men, and most women appear after menopause.
More than 50% of gout patients are accompanied by overweight or obesity.
The traditional natural course of gout is divided into asymptomatic hyperuricemia period, acute attack period, intermittent period and chronic gout disease period.
In particular, the acute attack of gout can be painful to the heart and tear the lungs.
The pain of being broken in love.
.
.
Take this special day, the editor will sort out the correct handling of acute gout attacks for everyone.
01What factors can induce an acute attack of gout? Binge eating, drinking, cold, excessive fatigue, nervousness, joint collision damage, and taking drugs that inhibit uric acid excretion (such as diuretics, low-dose aspirin, etc.
) can induce gout attacks and should be avoided as much as possible.
02What are the manifestations of acute gout? The acute onset of gout often occurs at night, with a rapid onset and progressive pain, reaching a peak around 12 hours.
The pain is unbearable, tear-like, knife-cut, or bite-like.
The affected joints and surrounding soft tissues are red and swollen, the skin temperature is elevated, and the tenderness is obvious.
Symptoms resolve spontaneously more than a few days or within 2 weeks.
Most patients have no progenitor symptoms before the onset, and some patients have signs of fatigue, general discomfort, and local tingling of joints before the onset.
The first attack is mostly a single joint involvement, and more than 50% occur in the first metatarsophalangeal joint.
Part of the severe cases may be accompanied by systemic symptoms, such as fever, chills, fatigue, and palpitations.
03How to deal with joint swelling, heat and pain? During the acute attack of gout, patients should be instructed to reduce their activities as much as possible, rest in bed, raise the affected limb, and take local ice (or magnesium sulfate wet compress), which can lower the temperature and relieve redness and pain.
In addition, topical diclofenac diethylamine emulsion also helps to reduce local pain.
Remember, massage and hot compresses are not allowed at this time.
Hot compresses will dilate blood vessels and aggravate local swelling and pain.
04How to choose analgesics during the acute attack of gout? The principle of acute treatment is to quickly control the symptoms and pain of arthritis.
In the acute phase, bed rest should be used, and the affected limb should be raised.
It is best to start to use drugs to control acute inflammation within 24 hours of the onset.
According to the "2016 Chinese Gout Diagnosis and Treatment Guidelines", there are three types of drugs to choose from during the acute attack: colchicine, non-steroidal anti-inflammatory drugs, and glucocorticoids.
The first-line treatment drugs include colchicine and non-steroidal anti-inflammatory drugs.
When there are contraindications or the treatment effect is not good, short-term application of glucocorticoid anti-inflammatory therapy can also be considered.
If the single-agent treatment effect is not good, the combination of the above-mentioned drugs can be selected.
When the above-mentioned drugs are intolerant or contraindicated, interleukin-1 (IL-1) receptor antagonists are also used abroad as the treatment of acute second-line gout.
There is currently no evidence that weak opioids and opioid analgesics are effective for acute attacks of gout.
(1) Colchicine: The latest international and domestic guidelines for the treatment of gout point out that the first choice to prevent recurrence is colchicine, with a dose of 0.
5 mg each time, 1-2 times a day.
It is recommended to start taking it within 12 hours of the onset of pain.
Generally, it will be effective within 24 to 48 hours.
After 36 hours, the curative effect decreased significantly.
When eGFR is 30~60 ml/min, the maximum dose of colchicine is 0.
5 mg/d; when eGFR is 15~30 ml/min, the maximum dose of colchicine is 0.
5 mg/2d; eGFR<15 ml/min or dialysis patients are forbidden.
Note: This drug may cause gastrointestinal adverse reactions, such as diarrhea, abdominal pain, nausea, and vomiting.
At the same time, liver and kidney damage and bone marrow suppression may occur.
Liver and kidney function and blood routine should be monitored regularly.
Patients who use potent P-glycoprotein and/or CYP3A4 inhibitors (such as cyclosporine or clarithromycin) should not use colchicine.
(2) Non-steroidal anti-inflammatory drugs: A sufficient amount of fast-acting formulations of non-steroidal anti-inflammatory drugs should be used as soon as possible for acute attacks of gout, including non-specific cyclooxygenase (COX) inhibitors and specific COX-2 inhibitors.
Precautions: Non-specific COX inhibitors should pay attention to gastrointestinal risks such as gastrointestinal ulcers, bleeding, and perforation; the gastrointestinal risks of specific COX-2 inhibitors are about 50% lower than that of non-specific COX inhibitors, but active digestion Tract bleeding and perforation are still contraindicated.
In addition, non-steroidal anti-inflammatory drugs can also cause renal damage.
Pay attention to monitoring renal function; patients with abnormal renal function should be fully hydrated and monitored for renal function.
Patients with eGFR<30 ml/min and not undergoing dialysis should not use it.
Specific COX-2 inhibitors may also increase the risk of cardiovascular events, and high-risk groups must be used with caution.
Commonly used non-steroidal anti-inflammatory drugs are shown in the chart below the table.
Table 1 The usage and dosage of commonly used non-steroidal anti-inflammatory drugs Note: COX is cyclooxygenase (3) Glucocorticoids: mainly used for acute gout attacks with systemic symptoms, or colchicine and non-steroidal anti-inflammatory drugs Ineffective or contraindicated, or patients with renal insufficiency.
It is generally recommended to stop taking prednisone 0.
5 mg·kg/d continuously for 5-10 days, or reduce the dose gradually after taking 2-5 days.
The total course of treatment is 7-10 days, and it is not suitable for long-term use.
If an acute attack of gout involves large joints, or if oral treatment is not effective, intra-articular or intramuscular injection of glucocorticoids can be given, but joint infections should be ruled out and repeated injections should be avoided in the short term.
Note: Use glucocorticoids to pay attention to adverse reactions such as hypertension, hyperglycemia, hyperlipidemia, water and sodium retention, infection, gastrointestinal risk, and osteoporosis.
For severe gout and severe pain, a combination of drugs can be used: such as colchicine + glucocorticoid, or colchicine + non-steroidal anti-inflammatory drugs.
The combination of non-steroidal anti-inflammatory drugs and glucocorticoids is not recommended, because both of them have obvious damage to the gastrointestinal mucosa and easily lead to gastrointestinal bleeding.
05What are the preventive measures for acute attacks of gout? 1.
Low-purine diet: strictly restrict high-purine foods such as animal offal, seafood and meat, encourage eating more fresh vegetables, and moderate consumption of beans and soy products.
2.
Drinking plenty of water: It can reduce the number of gout attacks and relieve the symptoms of gout.
If the heart and kidney function is normal, it is recommended to drink more water to maintain a daily urine output of 2000-3000 ml.
3.
Prohibition: Alcohol interferes with the metabolism of uric acid.
Rice wine, beer and white wine should be restricted.
The restriction on red wine is controversial.
4.
Weight loss: Obesity increases the risk of gout, and weight loss can reduce blood uric acid levels.
5.
Avoid catching cold: catching cold after being drunk is the most common cause of gout attacks.
6.
Avoid joint damage: strenuous exercise, excessive walking, etc.
lead to aseptic inflammation and induce gout.
7.
Try to avoid uric acid-increasing drugs: including diuretics, low-dose aspirin, immunosuppressive cyclosporine, anti-tuberculosis drug pyrazinamide, most chemotherapeutics, etc.
8.
Drug control of uric acid: Using uric acid-lowering drugs to control blood uric acid below 300μmol/L can greatly reduce the onset of gout. Reference materials: [1]Huang Yefei.
Practical guidelines for patients with hyperuricemia/gout[J].
Chinese Journal of Internal Medicine,2020,59(07):519-527.
[2]Zeng Xiaofeng.
2016 Chinese Gout Diagnosis and Treatment Guidelines[J] .
Chinese Journal of Internal Medicine, 2016,55(11):892-899.
[3]FitzGerald.
2020 American College of Rheumatology Guideline for the Management of Gout.
Arthritis Rheumatol.
2020 Jun;72(6):879-895.
