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Only for medical professionals to read and refer to the latest guides and classic guides.
Who is your dish? Even for the same disease, different countries, and different years, the recommended preferences of treatment guidelines for different audiences are different, and even debated
.
The newly released "Guidelines for the Rational Use of Gout Primary Medicines in 2021" and the classic "Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout in China (2019)"/The uptodate controversy in the treatment of gout abroad are also the same
.
There is no need to argue about whether the guideline is "the newer the better" or "the more practical/rememberable the better".
This article focuses on the "Guidelines for the 2021 Gout Rational Use of Primary Gout" for primary doctors and the "Chinese Hyperuricemia and Gout" for specialists.
The “Diagnosis and Treatment Guide (2019)” made a horizontal comparison on the diagnosis and treatment of gout.
I hope that the process of clarifying the controversial ins and outs can inspire everyone
.
01 Diagnosis of Gout The 1977 Gout Classification Standard and the 2015 Gout Classification Standard jointly developed by the American College of Rheumatology (ACR) and the European Union Against Rheumatism (EULAR), both use the joint puncture fluid microscopy to find monosodium urate crystals as The gold standard for diagnosis
.
This grassroots guide emphasizes the "clinical diagnosis of gout" by grassroots doctors, and proposes that without arthroscopy and puncture: 1) grassroots hospitals and non-rheumatologists can rely on classification criteria for clinical diagnosis of gout, and the cumulative clinical manifestation score is ≥8 points
.
2) Or one of the following manifestations can be clinically diagnosed for gout: monoarthritis of the foot or ankle joint (especially the first metatarsophalangeal joint); previous episodes of similar acute arthritis; rapid joint swelling and pain symptoms (within 24h) Peak)
.
02 Timing of initiating uric acid-lowering drug therapy for gout patients For the timing of initiating uric acid-lowering drug therapy for gout patients, the "Guidelines for the Rational Use of Gout Primary-level Medications (2021)" and the specialty guidelines are slightly different: "Guidelines for the Rational Use of Gout Primary-level Medications (2021) ) "It is believed that medication for lowering uric acid can be started for gout patients who meet the following clinical conditions: ① Gouty arthritis attacks ≥ 2 times per year
.
②One attack of gouty arthritis combined with any of the following: tophi, urinary calculi, chronic kidney disease (CKD stage 3) or more
.
The following patients are recommended to determine uric acid-lowering treatment based on the opinions of specialists: 1 attack of gouty arthritis combined with any of the following: ①age <40 years; ②blood uric acid>480μmol/L (8.
0mg/dl); ③combined with hypertension, Patients with impaired glucose tolerance or diabetes, dyslipidemia, obesity, coronary heart disease, stroke, and cardiac insufficiency
.
The "Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" recommends that patients with gout start uric acid-lowering drug therapy when blood uric acid ≥480 μmol/L; when blood uric acid ≥420 μmol/L and any of the following conditions are combined, start uric acid-lowering drug treatment : Gout attacks ≥2 times/year, tophi, chronic gouty arthritis, kidney stones, chronic kidney disease, hypertension, diabetes, dyslipidemia, stroke, ischemic heart disease, heart failure and age of onset <40 Years old
.
In consideration of being easier to be memorized by non-specialist doctors, the indications for lowering uric acid in the "Guidelines for the Rational Use of Gout Primary Medications (2021)" are much narrower than those in the "Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout in China (2019)".
Refer to the primary doctors for more urgent cases in the treatment of gout
.
03 Differences in the initiation time and goals of uric acid-lowering drug treatment The "Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" pointed out that domestic and foreign scholars recommend that uric acid-lowering drug treatment be initiated 2 to 4 weeks after the onset of gout has been controlled; For patients taking uric acid-lowering drugs, it is not recommended to stop the drug during acute attacks
.
For special populations, including frequent gout (acute attacks ≥2 times/year), tophi, nephrolithiasis, age of onset <40 years, blood uric acid level>480μmol/L, and comorbidities (kidney damage, hypertension, Ischemic heart disease, heart failure), etc.
, should be considered for lowering uric acid treatment once the diagnosis is confirmed
.
It is recommended that patients with gout control blood uric acid <360μmol/L, and when combined with one of the above conditions, control the blood uric acid level <300μmol/L (2B); it is not recommended to keep blood uric acid under 180μmol for a long time
.
However, the "Guidelines for the Rational Use of Gout at Grassroots Level (2021)" believes that the starting time is to start uric acid-lowering treatment during the gout attack, and the effect is better than after the attack is controlled
.
It is recommended to continue drug treatment until the blood uric acid value is less than 360μmol/L (6.
0mg/dl)
.
04The priority of uric acid-lowering therapy drugs is different.
The Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019) recommend allopurinol, febuxostat, or benzbromarone as the first-line drugs for uric acid-lowering therapy for gout patients (1B) ; Recommend allopurinol or benzbromarone as the first-line medication for lowering uric acid in patients with asymptomatic hyperuricemia (1B)
.
However, the status of the aforementioned drugs has been challenged in the new guidelines
.
For allopurinol, the "Guidelines for the Rational Use of Gout at the Primary Level (2021)": It is recommended that allopurinol is the first-line medication for lowering uric acid in patients with gout, including patients with CKD≥3
.
When conditions permit, it is recommended to perform HLA-B*5801 genetic testing before using allopurinol.
If genetic screening is not possible, start with the minimum dose
.
Although allopurinol has significant curative effect and low price, special attention should be paid to allopurinol hypersensitivity when used in the Chinese population (the incidence of hypersensitivity in Taiwan, China is 2.
7%.
Once it occurs, the fatality rate is as high as 30%.
Fully consider the risk and pay attention to the minimum dose titration
.
) For febuxostat, the U.
S.
Food and Drug Administration (FDA) warns of its high price and potential cardiovascular risks.
Therefore, European and American guidelines often recommend febuxostat as an alternative to allopurinol.
Use when purol is intolerant or the effect is not good
.
However, with the decrease in the price of febuxostat and its increased risk of sudden cardiac death among Asians, there is insufficient evidence
.
The "Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" expert group recommends febuxostat as the first-line uric acid lowering drug for patients with gout.
The initial dose is 20 mg/d.
After 2 to 4 weeks, the blood uric acid level still does not reach the standard.
, It can be increased by 20 mg/d, and the maximum dose is 80 mg/d
.
However, it should be used with caution in the elderly with cardiovascular and cerebrovascular diseases and pay close attention to cardiovascular events
.
The "Guidelines for the Rational Use of Gout Primary Medications (2021)", however, believes that only when the patient does not respond to or cannot tolerate allopurinol treatment, medical staff can consider retaining febuxostat, that is, it needs to be fully evaluated by a specialist before taking the drug The patient's condition and risk of cardiovascular events are determined afterwards
.
For benzbromarone, because benzbromarone has been reported to cause fulminant hepatic necrosis in whites, European guidelines are mostly recommended as second-line drugs, but it is rarely reported in Asians and may be related to the CYP2C9 gene polymorphism in Asians.
Sex is different
.
In view of this, the expert group of "Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" recommends benzbromarone as the first-line drug for the treatment of hyperuricemia and gout.
The recommended starting dose is 25 mg/d, 2～ After 4 weeks, the blood uric acid level is still not up to the standard, it can be increased by 25 mg/d, and the maximum dose is 100 mg/d
.
It is recommended to closely monitor liver function during use
.
In patients with chronic liver disease, benzbromarone should be used with caution
.
However, the "Guidelines for the Rational Use of Gout (2021)" believe that uric acid excretion drugs are not recommended for first-line treatment, and are contraindicated in patients with CKD ≥3 stage or patients at high risk of kidney stones, although Asian people are due to cytochrome P450.
(CYP) 2C9 gene polymorphism is rarely reported of fulminant hepatic necrosis, but it is still recommended to closely monitor liver function during use.
Patients with chronic liver disease should use benzbromarone with caution
.
When the effect of lowering uric acid is insufficient, the "Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" recommends sufficient single-drug and full-course treatment.
For patients whose blood uric acid has not yet reached the standard, the combined application of two different mechanisms of action may be considered.
Uric acid drugs
.
However, the "Guidelines for the Rational Use of Gout at Grassroots Level (2021)" believes that the use of the maximum effective dose of xanthine oxidase inhibitors cannot make blood uric acid reach the target value, or frequent gout attacks or tophi persists, and other xanthine oxidases are recommended Inhibitors instead of using uric acid excretion drugs
.
In general, allopurinol>febuxostat (other xanthine oxidases are preferred if the effect is insufficient) + benzbromarone is not recommended as the first-line
.
The recommendation attitudes between the two are quite different, making it clear that they can't live with febuxostat and benzbromarone
.
05 The guidelines and consensus recommendations for the treatment of acute gout are basically the same.
Cold compresses are still controversial for the treatment of acute gout
.
The guidelines and consensus recommendations for the treatment of acute gout are basically similar .
"Guidelines for the Rational Use of Gout Primary Medications (2021)" recommends that colchicine or non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment drugs for acute arthritis attacks.
If the above drugs are contraindicated or have poor effects, consider choosing glucocorticoids Hormones control inflammation
.
If NSAIDs cannot be tolerated or contraindicated in patients with gout attacks, the use of interleukin-1 (IL-1) inhibitors is better than no treatment
.
"Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" For severe acute gout attacks (pain VAS ≥ 7), polyarthritis or involving ≥ 2 large joints, it is recommended to use 2 or more analgesics for treatment.
Including the combination of colchicine and NSAIDs, colchicine and oral glucocorticoids, and joint cavity glucocorticoid injections and any other combination
.
1.
Colchicine: For acute gout attacks, it is recommended that the first dose of colchicine is 1 mg, 0.
5 mg is added after 1 h, and it is changed to 0.
5 mg qd or bid after 12 h
.
"Guidelines for the Rational Use of Gout Medications (2021)"/"Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout in China (2019)"/Uptodate
.
2.
NSAIDs: It is recommended to use selective cyclooxygenase (COX)-2 inhibitors to significantly reduce the incidence of adverse reactions such as gastrointestinal tract and dizziness, especially for gout patients who need to take small doses of aspirin for a long time
.
"Guidelines for the Rational Use of Gout Medications (2021)"/"Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout in China (2019)"/Uptodate
.
3.
Glucocorticoids: The analgesic effect of glucocorticoids in the acute attack of gout is similar to that of NSAIDs, but it can better relieve joint pain
.
Currently, European and American guidelines mostly recommend glucocorticoids as first-line anti-inflammatory and analgesic drugs
.
In order to prevent hormone abuse and repeated use to increase the incidence of tophi, the expert group of "Guidelines for the Rational Use of Gout Primary Medications (2021)"/"Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" all recommend glucocorticoids as second-line Analgesic drugs.
Systemic glucocorticoid therapy is recommended only when multiple joints, large joints, or systemic symptoms are involved in an acute attack of gout
.
It is recommended to take prednisone 0.
5 mg/(kg ·d) orally, and stop the drug for 3 to 5 days; the usage of other hormones, such as dexamethasone and betamethasone, should be exchanged in accordance with the equivalent anti-inflammatory dose
.
When an acute attack of gout involves 1 to 2 large joints, it is recommended that those who have the conditions can aspirate the joint fluid and receive glucocorticoid therapy in the joint cavity
.
The "Guidelines for the Rational Use of Gout at the Grassroots Level (2021)" recommend: For patients who cannot use oral medications, glucocorticoids are recommended; topical ice is recommended to be better than no treatment
.
Whether cold compresses can be applied during an acute attack of gout is still controversial
.
According to the conventional treatment of acute joint swelling and pain, apply local ice during the attack to promote the contraction of small blood vessels, reduce local congestion and exudation, which can effectively relieve pain, reduce joint synovial fluid secretion, and reduce joint swelling
.
However, low temperature can stimulate local vasoconstriction and reduce blood flow, which is not conducive to the absorption and dissipation of inflammation
.
In addition, local low temperature, changes in the solubility of uric acid and blood flow may easily promote the deposition of urate, which may further aggravate local inflammation
.
06 Recommendations for prevention of gout attacks The "Guidelines for the Rational Use of Gout Primary Medications (2021)" uniformly recommend colchicine or NSAIDs: low-dose colchicine or NSAIDs are uric acid-lowering treatments (up to 3 to 6 months) initial prevention The first-line choice for recurrent gout
.
The "Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" recommends more detailed measures to prevent gout attacks in the initial stage of uric acid-lowering treatment for gout patients.
First, colchicine is recommended, and low-dose (0.
5-1 mg/d) colchicine is the first choice.
Alkali can prevent gout attacks for at least 3 to 6 months (1A); for patients with renal insufficiency, it is recommended to adjust the dosage of colchicine based on eGFR (2B); for patients who cannot tolerate colchicine, low-dose NSAIDs (no more than 50% of the conventional dose) or glucocorticoid (prednisone ≤10 mg/d) to prevent attacks, for at least 3 to 6 months (2B); it is recommended to start with low-dose uric acid-lowering drugs and increase slowly to avoid or Reduce gout attacks (2B)
.
The 2020 ACR guidelines support the use of colchicine prophylaxis for at least 3 to 6 months, and point out that the duration of treatment should be extended in the case of frequent and persistent attacks
.
07 The method and control goal of urine alkalization are still controversial.
The "Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" recommends that when the morning urine pH value of patients with hyperuricemia and gout is less than 6.
0, especially if they are taking uricosuric acid When excreting drugs, monitor the morning urine pH value (2C) regularly, and you can use a simple urine pH meter to monitor it yourself (2C)
.
When the pH value is less than 6.
0, it is recommended to take citric acid preparations and sodium bicarbonate to alkalize the urine to maintain the morning urine pH at 6.
2 to 6.
9 to reduce the risk of uric acid kidney stones and facilitate the dissolution of uric acid kidney stones ( 2C)
.
"Guidelines for the Rational Use of Gout Primary Medications (2021)" Patients with chronic renal insufficiency combined with hyperuricemia and/or gout, treated with uric acid excretion drugs, and uric acid kidney stones should alkalinize their urine if necessary, but attention should be paid Avoid excessive alkalization and increase the risk of other stones
.
Sodium bicarbonate is suitable for patients with chronic renal insufficiency and metabolic acidosis; citrate preparations are mainly used for patients with uric acid kidney stones, cystine stones and hypocitrateuria.
It is contraindicated in acute and chronic renal failure, severe Patients with acid-base imbalance and chronic urinary tract infection with ureolytic bacteria
.
The update of gout abroad does not take alkalization of urine as a routine.
The 2021 update of the treatment of uric acid kidney stones puts forward the following points: (1) For patients with uric acid kidney stones, we recommend alkalizing urine and increasing fluid intake.
Quantity (Level 1B): (2) Alkalization is usually carried out with potassium citrate or potassium bicarbonate, and the target urine pH should be between 6.
5 and 7
.
It is best to use potassium salt for alkalization, because the sodium load of sodium citrate or sodium bicarbonate may increase calcium excretion and promote the formation of calcium stones in some patients
.
(3) Patients with uric acid stones should be encouraged to drink enough fluids so that the urine output reaches at least 2 liters in 24 hours
.
Reference materials: [1] "Guidelines for Diagnosis and Treatment of Hyperuricemia and Gout in China (2019)" [2] "Guidelines for the Rational Use of Gout Medications (2021)" [3] Angelo L Gaffo, MD, MsPH, Treatment of gout flares, uptodate,2021.
6.
[4]Gary C Curhan,Kidney stones in adults:Uric acid nephrolithiasis,uptodate,2021.
[5]Fernando Perez-Ruiz,Pharmacologic urate-lowering therapy and treatment of tophi in patients with gout.
uptodate,2021.
Who is your dish? Even for the same disease, different countries, and different years, the recommended preferences of treatment guidelines for different audiences are different, and even debated
.
The newly released "Guidelines for the Rational Use of Gout Primary Medicines in 2021" and the classic "Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout in China (2019)"/The uptodate controversy in the treatment of gout abroad are also the same
.
There is no need to argue about whether the guideline is "the newer the better" or "the more practical/rememberable the better".
This article focuses on the "Guidelines for the 2021 Gout Rational Use of Primary Gout" for primary doctors and the "Chinese Hyperuricemia and Gout" for specialists.
The “Diagnosis and Treatment Guide (2019)” made a horizontal comparison on the diagnosis and treatment of gout.
I hope that the process of clarifying the controversial ins and outs can inspire everyone
.
01 Diagnosis of Gout The 1977 Gout Classification Standard and the 2015 Gout Classification Standard jointly developed by the American College of Rheumatology (ACR) and the European Union Against Rheumatism (EULAR), both use the joint puncture fluid microscopy to find monosodium urate crystals as The gold standard for diagnosis
.
This grassroots guide emphasizes the "clinical diagnosis of gout" by grassroots doctors, and proposes that without arthroscopy and puncture: 1) grassroots hospitals and non-rheumatologists can rely on classification criteria for clinical diagnosis of gout, and the cumulative clinical manifestation score is ≥8 points
.
2) Or one of the following manifestations can be clinically diagnosed for gout: monoarthritis of the foot or ankle joint (especially the first metatarsophalangeal joint); previous episodes of similar acute arthritis; rapid joint swelling and pain symptoms (within 24h) Peak)
.
02 Timing of initiating uric acid-lowering drug therapy for gout patients For the timing of initiating uric acid-lowering drug therapy for gout patients, the "Guidelines for the Rational Use of Gout Primary-level Medications (2021)" and the specialty guidelines are slightly different: "Guidelines for the Rational Use of Gout Primary-level Medications (2021) ) "It is believed that medication for lowering uric acid can be started for gout patients who meet the following clinical conditions: ① Gouty arthritis attacks ≥ 2 times per year
.
②One attack of gouty arthritis combined with any of the following: tophi, urinary calculi, chronic kidney disease (CKD stage 3) or more
.
The following patients are recommended to determine uric acid-lowering treatment based on the opinions of specialists: 1 attack of gouty arthritis combined with any of the following: ①age <40 years; ②blood uric acid>480μmol/L (8.
0mg/dl); ③combined with hypertension, Patients with impaired glucose tolerance or diabetes, dyslipidemia, obesity, coronary heart disease, stroke, and cardiac insufficiency
.
The "Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" recommends that patients with gout start uric acid-lowering drug therapy when blood uric acid ≥480 μmol/L; when blood uric acid ≥420 μmol/L and any of the following conditions are combined, start uric acid-lowering drug treatment : Gout attacks ≥2 times/year, tophi, chronic gouty arthritis, kidney stones, chronic kidney disease, hypertension, diabetes, dyslipidemia, stroke, ischemic heart disease, heart failure and age of onset <40 Years old
.
In consideration of being easier to be memorized by non-specialist doctors, the indications for lowering uric acid in the "Guidelines for the Rational Use of Gout Primary Medications (2021)" are much narrower than those in the "Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout in China (2019)".
Refer to the primary doctors for more urgent cases in the treatment of gout
.
03 Differences in the initiation time and goals of uric acid-lowering drug treatment The "Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" pointed out that domestic and foreign scholars recommend that uric acid-lowering drug treatment be initiated 2 to 4 weeks after the onset of gout has been controlled; For patients taking uric acid-lowering drugs, it is not recommended to stop the drug during acute attacks
.
For special populations, including frequent gout (acute attacks ≥2 times/year), tophi, nephrolithiasis, age of onset <40 years, blood uric acid level>480μmol/L, and comorbidities (kidney damage, hypertension, Ischemic heart disease, heart failure), etc.
, should be considered for lowering uric acid treatment once the diagnosis is confirmed
.
It is recommended that patients with gout control blood uric acid <360μmol/L, and when combined with one of the above conditions, control the blood uric acid level <300μmol/L (2B); it is not recommended to keep blood uric acid under 180μmol for a long time
.
However, the "Guidelines for the Rational Use of Gout at Grassroots Level (2021)" believes that the starting time is to start uric acid-lowering treatment during the gout attack, and the effect is better than after the attack is controlled
.
It is recommended to continue drug treatment until the blood uric acid value is less than 360μmol/L (6.
0mg/dl)
.
04The priority of uric acid-lowering therapy drugs is different.
The Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019) recommend allopurinol, febuxostat, or benzbromarone as the first-line drugs for uric acid-lowering therapy for gout patients (1B) ; Recommend allopurinol or benzbromarone as the first-line medication for lowering uric acid in patients with asymptomatic hyperuricemia (1B)
.
However, the status of the aforementioned drugs has been challenged in the new guidelines
.
For allopurinol, the "Guidelines for the Rational Use of Gout at the Primary Level (2021)": It is recommended that allopurinol is the first-line medication for lowering uric acid in patients with gout, including patients with CKD≥3
.
When conditions permit, it is recommended to perform HLA-B*5801 genetic testing before using allopurinol.
If genetic screening is not possible, start with the minimum dose
.
Although allopurinol has significant curative effect and low price, special attention should be paid to allopurinol hypersensitivity when used in the Chinese population (the incidence of hypersensitivity in Taiwan, China is 2.
7%.
Once it occurs, the fatality rate is as high as 30%.
Fully consider the risk and pay attention to the minimum dose titration
.
) For febuxostat, the U.
S.
Food and Drug Administration (FDA) warns of its high price and potential cardiovascular risks.
Therefore, European and American guidelines often recommend febuxostat as an alternative to allopurinol.
Use when purol is intolerant or the effect is not good
.
However, with the decrease in the price of febuxostat and its increased risk of sudden cardiac death among Asians, there is insufficient evidence
.
The "Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" expert group recommends febuxostat as the first-line uric acid lowering drug for patients with gout.
The initial dose is 20 mg/d.
After 2 to 4 weeks, the blood uric acid level still does not reach the standard.
, It can be increased by 20 mg/d, and the maximum dose is 80 mg/d
.
However, it should be used with caution in the elderly with cardiovascular and cerebrovascular diseases and pay close attention to cardiovascular events
.
The "Guidelines for the Rational Use of Gout Primary Medications (2021)", however, believes that only when the patient does not respond to or cannot tolerate allopurinol treatment, medical staff can consider retaining febuxostat, that is, it needs to be fully evaluated by a specialist before taking the drug The patient's condition and risk of cardiovascular events are determined afterwards
.
For benzbromarone, because benzbromarone has been reported to cause fulminant hepatic necrosis in whites, European guidelines are mostly recommended as second-line drugs, but it is rarely reported in Asians and may be related to the CYP2C9 gene polymorphism in Asians.
Sex is different
.
In view of this, the expert group of "Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" recommends benzbromarone as the first-line drug for the treatment of hyperuricemia and gout.
The recommended starting dose is 25 mg/d, 2～ After 4 weeks, the blood uric acid level is still not up to the standard, it can be increased by 25 mg/d, and the maximum dose is 100 mg/d
.
It is recommended to closely monitor liver function during use
.
In patients with chronic liver disease, benzbromarone should be used with caution
.
However, the "Guidelines for the Rational Use of Gout (2021)" believe that uric acid excretion drugs are not recommended for first-line treatment, and are contraindicated in patients with CKD ≥3 stage or patients at high risk of kidney stones, although Asian people are due to cytochrome P450.
(CYP) 2C9 gene polymorphism is rarely reported of fulminant hepatic necrosis, but it is still recommended to closely monitor liver function during use.
Patients with chronic liver disease should use benzbromarone with caution
.
When the effect of lowering uric acid is insufficient, the "Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" recommends sufficient single-drug and full-course treatment.
For patients whose blood uric acid has not yet reached the standard, the combined application of two different mechanisms of action may be considered.
Uric acid drugs
.
However, the "Guidelines for the Rational Use of Gout at Grassroots Level (2021)" believes that the use of the maximum effective dose of xanthine oxidase inhibitors cannot make blood uric acid reach the target value, or frequent gout attacks or tophi persists, and other xanthine oxidases are recommended Inhibitors instead of using uric acid excretion drugs
.
In general, allopurinol>febuxostat (other xanthine oxidases are preferred if the effect is insufficient) + benzbromarone is not recommended as the first-line
.
The recommendation attitudes between the two are quite different, making it clear that they can't live with febuxostat and benzbromarone
.
05 The guidelines and consensus recommendations for the treatment of acute gout are basically the same.
Cold compresses are still controversial for the treatment of acute gout
.
The guidelines and consensus recommendations for the treatment of acute gout are basically similar .
"Guidelines for the Rational Use of Gout Primary Medications (2021)" recommends that colchicine or non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment drugs for acute arthritis attacks.
If the above drugs are contraindicated or have poor effects, consider choosing glucocorticoids Hormones control inflammation
.
If NSAIDs cannot be tolerated or contraindicated in patients with gout attacks, the use of interleukin-1 (IL-1) inhibitors is better than no treatment
.
"Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" For severe acute gout attacks (pain VAS ≥ 7), polyarthritis or involving ≥ 2 large joints, it is recommended to use 2 or more analgesics for treatment.
Including the combination of colchicine and NSAIDs, colchicine and oral glucocorticoids, and joint cavity glucocorticoid injections and any other combination
.
1.
Colchicine: For acute gout attacks, it is recommended that the first dose of colchicine is 1 mg, 0.
5 mg is added after 1 h, and it is changed to 0.
5 mg qd or bid after 12 h
.
"Guidelines for the Rational Use of Gout Medications (2021)"/"Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout in China (2019)"/Uptodate
.
2.
NSAIDs: It is recommended to use selective cyclooxygenase (COX)-2 inhibitors to significantly reduce the incidence of adverse reactions such as gastrointestinal tract and dizziness, especially for gout patients who need to take small doses of aspirin for a long time
.
"Guidelines for the Rational Use of Gout Medications (2021)"/"Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout in China (2019)"/Uptodate
.
3.
Glucocorticoids: The analgesic effect of glucocorticoids in the acute attack of gout is similar to that of NSAIDs, but it can better relieve joint pain
.
Currently, European and American guidelines mostly recommend glucocorticoids as first-line anti-inflammatory and analgesic drugs
.
In order to prevent hormone abuse and repeated use to increase the incidence of tophi, the expert group of "Guidelines for the Rational Use of Gout Primary Medications (2021)"/"Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" all recommend glucocorticoids as second-line Analgesic drugs.
Systemic glucocorticoid therapy is recommended only when multiple joints, large joints, or systemic symptoms are involved in an acute attack of gout
.
It is recommended to take prednisone 0.
5 mg/(kg ·d) orally, and stop the drug for 3 to 5 days; the usage of other hormones, such as dexamethasone and betamethasone, should be exchanged in accordance with the equivalent anti-inflammatory dose
.
When an acute attack of gout involves 1 to 2 large joints, it is recommended that those who have the conditions can aspirate the joint fluid and receive glucocorticoid therapy in the joint cavity
.
The "Guidelines for the Rational Use of Gout at the Grassroots Level (2021)" recommend: For patients who cannot use oral medications, glucocorticoids are recommended; topical ice is recommended to be better than no treatment
.
Whether cold compresses can be applied during an acute attack of gout is still controversial
.
According to the conventional treatment of acute joint swelling and pain, apply local ice during the attack to promote the contraction of small blood vessels, reduce local congestion and exudation, which can effectively relieve pain, reduce joint synovial fluid secretion, and reduce joint swelling
.
However, low temperature can stimulate local vasoconstriction and reduce blood flow, which is not conducive to the absorption and dissipation of inflammation
.
In addition, local low temperature, changes in the solubility of uric acid and blood flow may easily promote the deposition of urate, which may further aggravate local inflammation
.
06 Recommendations for prevention of gout attacks The "Guidelines for the Rational Use of Gout Primary Medications (2021)" uniformly recommend colchicine or NSAIDs: low-dose colchicine or NSAIDs are uric acid-lowering treatments (up to 3 to 6 months) initial prevention The first-line choice for recurrent gout
.
The "Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" recommends more detailed measures to prevent gout attacks in the initial stage of uric acid-lowering treatment for gout patients.
First, colchicine is recommended, and low-dose (0.
5-1 mg/d) colchicine is the first choice.
Alkali can prevent gout attacks for at least 3 to 6 months (1A); for patients with renal insufficiency, it is recommended to adjust the dosage of colchicine based on eGFR (2B); for patients who cannot tolerate colchicine, low-dose NSAIDs (no more than 50% of the conventional dose) or glucocorticoid (prednisone ≤10 mg/d) to prevent attacks, for at least 3 to 6 months (2B); it is recommended to start with low-dose uric acid-lowering drugs and increase slowly to avoid or Reduce gout attacks (2B)
.
The 2020 ACR guidelines support the use of colchicine prophylaxis for at least 3 to 6 months, and point out that the duration of treatment should be extended in the case of frequent and persistent attacks
.
07 The method and control goal of urine alkalization are still controversial.
The "Chinese Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout (2019)" recommends that when the morning urine pH value of patients with hyperuricemia and gout is less than 6.
0, especially if they are taking uricosuric acid When excreting drugs, monitor the morning urine pH value (2C) regularly, and you can use a simple urine pH meter to monitor it yourself (2C)
.
When the pH value is less than 6.
0, it is recommended to take citric acid preparations and sodium bicarbonate to alkalize the urine to maintain the morning urine pH at 6.
2 to 6.
9 to reduce the risk of uric acid kidney stones and facilitate the dissolution of uric acid kidney stones ( 2C)
.
"Guidelines for the Rational Use of Gout Primary Medications (2021)" Patients with chronic renal insufficiency combined with hyperuricemia and/or gout, treated with uric acid excretion drugs, and uric acid kidney stones should alkalinize their urine if necessary, but attention should be paid Avoid excessive alkalization and increase the risk of other stones
.
Sodium bicarbonate is suitable for patients with chronic renal insufficiency and metabolic acidosis; citrate preparations are mainly used for patients with uric acid kidney stones, cystine stones and hypocitrateuria.
It is contraindicated in acute and chronic renal failure, severe Patients with acid-base imbalance and chronic urinary tract infection with ureolytic bacteria
.
The update of gout abroad does not take alkalization of urine as a routine.
The 2021 update of the treatment of uric acid kidney stones puts forward the following points: (1) For patients with uric acid kidney stones, we recommend alkalizing urine and increasing fluid intake.
Quantity (Level 1B): (2) Alkalization is usually carried out with potassium citrate or potassium bicarbonate, and the target urine pH should be between 6.
5 and 7
.
It is best to use potassium salt for alkalization, because the sodium load of sodium citrate or sodium bicarbonate may increase calcium excretion and promote the formation of calcium stones in some patients
.
(3) Patients with uric acid stones should be encouraged to drink enough fluids so that the urine output reaches at least 2 liters in 24 hours
.
Reference materials: [1] "Guidelines for Diagnosis and Treatment of Hyperuricemia and Gout in China (2019)" [2] "Guidelines for the Rational Use of Gout Medications (2021)" [3] Angelo L Gaffo, MD, MsPH, Treatment of gout flares, uptodate,2021.
6.
[4]Gary C Curhan,Kidney stones in adults:Uric acid nephrolithiasis,uptodate,2021.
[5]Fernando Perez-Ruiz,Pharmacologic urate-lowering therapy and treatment of tophi in patients with gout.
uptodate,2021.
