Gout and diabetes are both metabolic diseases and are called “diseases of affluence” together with hyperlipidemia, atherosclerosis, coronary heart disease, obesity and fatty liver. In recent years, with the improvement of people’s living standards, the incidence of gout and diabetes has increased year by year due to factors such as unreasonable diet structure, excess nutrition, excessive intake of purine-rich foods, excessive alcohol consumption, low exercise and obesity. At the same time, excessive intake of fat and sugar foods, combined with heavy alcohol consumption and lack of exercise have led to a rapid increase in obesity, which in turn has triggered hyperinsulinemia and insulin resistance, further aggravating the disorders of sugar, lipid and purine metabolism. According to the National Rheumatology Data Center, the incidence of hyperuricemia in adults in China is 7%-20%, the incidence of gout is 1%-3%, and the average age of gout patients is 48.28 years old and gradually getting younger. Compared with diabetes mellitus, the trend of gout becoming younger is more obvious. Both are prone to a variety of co-morbidities, and type 2 diabetes and gout with obesity, dyslipidemia and hypertension are significantly higher than other populations. The incidence of diabetes is significantly higher in gout patients than in non-gout patients, and gout has become an independent risk factor for the development of diabetes. Studies have shown that the prevalence of diabetes among gout patients is 20%-30%, however, the prevalence of gout among diabetic patients varies depending on factors such as blood glucose, weight, diabetes typing, ethnicity, age, geography, and genetics. The overall prevalence of gout in people with abnormal blood glucose (including type 1 diabetes, type 2 diabetes, patients with impaired fasting glucose regulation and hypoglycemia) is about 15%, with the prevalence of gout in type 1 diabetes being only about 1.2% and in type 2 diabetes up to 16% in patients with prediabetes (impaired fasting glucose regulation, IFT and hypoglycemia IGT) being about 14%. The prevalence of gout among diabetics varies significantly by geography and ethnicity.
Because the proportion of gout patients with combined diabetes is higher than that of non-gout patients, the choice of glucose lowering regimen for patients with gout combined with diabetes should take into account the blood uric acid level in addition to the effect of glucose lowering, because some glucose lowering drugs can lead to an increase in blood uric acid, which has the risk of triggering gout attacks. Details are as follows.
1.Insulin
However, insulin can promote the synthesis of hepatic uric acid and inhibit the excretion of renal uric acid, resulting in an increase in blood uric acid levels, so insulin should be used with caution in patients with gout and diabetes. If the diabetic condition requires long-term treatment with insulin, the necessary uric acid-lowering drugs should be used in combination with the blood uric acid level to prevent the recurrence of gout after the fluctuation of blood uric acid. Insulin analogues and human insulin should be reconsidered and carefully selected in gout combined with diabetes.
2.Sulfonylurea glucose-lowering drugs
Sulfonylurea hypoglycemic drugs are commonly used by diabetic patients, among which glibenclamide, glimepiride and gliclazide can affect the metabolism and excretion of uric acid and increase the blood uric acid level when taken for a long time. The first generation of sulfonylureas such as acetyl sulfonylurea has the dual effect of lowering blood sugar and blood uric acid, but because of its long half-life, easy to accumulate and cause hypoglycemia, and more adverse reactions than the second generation of sulfonylureas, it is not recommended for clinical use.
3.Mealtime glucose regulator
They can increase the serum insulin concentration and lead to hyperinsulinemia, while insulin can promote the reabsorption of uric acid by the kidney and cause the rise of blood uric acid, so they are not recommended for patients with gout and diabetes.
4.Biguanide hypoglycemic drugs
The glucose-lowering drugs of biguanide have the effect of lowering body weight, and in recent years, it has been found that these drugs have the effect of lowering uric acid with long-term use, so they are recommended for patients with gout and diabetes.
5.Insulin sensitizing drugs
Insulin-sensitizing drugs: pioglitazone and rosiglitazone have the effects of lowering uric acid and protecting the kidney, so they are recommended for patients with gout and diabetes mellitus.
6.α-glucosidase inhibitors
Alpha-glucosidase inhibitors: such as Acarbose (Bystolic) has no obvious effect on uric acid, and can be used by patients with gout and diabetes.
7.GLP-1.DPP-4
Enteroglucagon agonist (GLP-1) and dipeptidyl peptidase inhibitor (DPP-4): they can improve the function of pancreatic islets, reduce insulin resistance, and do not cause an increase in blood uric acid, and can even play a role in reducing blood uric acid by lowering serum insulin levels and reducing body weight.
In view of the above elaborated content, combined with the relevant literature guidance, the author recommends that gout combined with diabetes mellitus patients in clinical hypoglycemic drug therapy follow the following principles for reference.1 If there is no contraindication, insulin sensitizers and biguanide hypoglycemic drugs are preferred, followed by alpha-glucosidase inhibitors, and try not to choose insulin promoters or insulin.2 If insulin promoters must be used, glimepiride such as Amoril can be used. This drug is a 3rd generation sulfonylurea, with long duration of action and strong efficacy, as well as glucose-dependent hypoglycemia, low incidence of hypoglycemia, reduced endogenous insulin dosage up to 42%, while increasing insulin sensitivity and insignificant weight gain, and indirectly reducing blood uric acid levels, but the drug is best used in combination with biguanides or insulin sensitizers.3 If insulin must be used, it can be combined with insulin sensitizers, biguanides , alpha-glucosidase inhibitors, and long-acting insulins can also be combined with amoxicillin, thus reducing the amount of external insulin.
Summary
Among the glucose-lowering drugs, biguanides, TZDs, α-glucosidase inhibitors, GLP-1 and DPP-4 can improve islet function and reduce insulin resistance without causing an increase in blood uric acid, and can even play a role in reducing blood uric acid by lowering serum insulin levels and reducing body weight. In contrast, insulin stimulants (sulfonylureas and mealtime glucose regulators) and exogenous insulin can increase serum insulin concentration, leading to hyperinsulinemia, while insulin can promote renal reabsorption of uric acid, causing an increase in blood uric acid. Therefore, when choosing glucose-lowering drugs, gout patients should choose drugs that do not increase insulin concentration as much as possible, especially those who are obese, have obvious insulin resistance and have hyperinsulinemia, and choose biguanides, TZD, GLP-1, DPP-4 inhibitors and α-glucosidase inhibitors as much as possible. If the condition requires the application of pro-secretory drugs or insulin therapy, combine the above drugs as much as possible to reduce the dosage of insulin and, if necessary, combine small doses of uric acid-lowering drugs that promote uric acid excretion.
Please do not choose your own glucose-lowering drugs according to this article, but use them under the guidance of a specialist or pharmacist.