(i) Treatment
Treatment is aimed at.
(1) termination of acute attacks with anti-inflammatory drugs
(2) Prophylactic application of colchicine daily to prevent recurrent acute attacks (if they are frequent);
(3) Prevention of further deposition of monosodium urate crystals and elimination of existing gout stones by reducing urate concentration in body fluids.
1. General treatment
Protein intake should be limited to about 1g/(kg?d), no high purine food (animal heart, liver, kidney, sardines, etc.), strict abstinence from alcohol, avoid triggering factors, encourage drinking more water, make the urine volume above 2000ml/d, when the urine H concentration is below 1000nmol/L (pH 6.0), it is advisable to take alkaline drugs, such as sodium bicarbonate 1~2g, 3 times/d, to make the urine H If the urine is acidic in the morning, take 250mg of acetazolamide at night to keep the urine alkaline, increase the solubility of uric acid and prevent stone formation.
2. Treatment of acute arthritis period
Absolute bed rest, elevation of the affected limb, avoiding weight-bearing of the affected joint, and gradual activity until about 72h after the relief of joint pain.
(1) Colchicine: It has significant efficacy in controlling gouty arthritis, and is preferred. Generally, the symptoms are relieved 6-12h after taking the drug, and more than 90% of patients can be relieved 24-48h. Intravenous colchicine can work quickly and has few gastrointestinal side effects, usage: colchicine 2mg, dissolved in 10ml saline, inject slowly (injection time not shorter than 5min), if the condition requires, 1mg can be given after 6h, generally the total 24h dose should be controlled within 3mg, but it should be noted: if the drug leaks out during intravenous injection, it can cause tissue necrosis and should be In addition, colchicine can cause gastrointestinal reactions, but also can lead to bone marrow suppression, hepatocellular damage, hair loss, mental depression, episodic paralysis, respiratory depression, etc. Therefore, the dose should be reduced by half for patients with bone marrow suppression and hepatic and renal impairment, and should be closely observed, and prohibited for those with reduced blood leukocytes.
(2) non-steroidal anti-inflammatory analgesics: especially for patients who cannot tolerate colchicine, such drugs can enhance the pain relief effect when combined with colchicine, but should be taken after meals to reduce gastrointestinal reactions, commonly used drugs are indomethacin, piroxicam (inflammation pain Xikang), naproxen, ibuprofen, pautaxone and hydroxybutazone, etc., of which indomethacin is the most widely used, this class of drugs generally in the beginning of treatment The dose of indomethacin is usually given near the maximum dose at the beginning of treatment to achieve maximum control of acute symptoms, and then gradually reduced when the symptoms are relieved.
Indomethacin: The initial dose is 50mg every 6 hours, gradually reduced to 25mg 2-3 times/d after the symptoms are relieved, which can have side effects such as gastrointestinal irritation, sodium retention, dizziness, rash, etc. It is prohibited for those with active peptic ulcer.
②Ibuprofen: the commonly used dose is 0.2-0.4g, 2-3 times/d, usually 2-3 days to control the symptoms, the side effects of this drug is small, occasionally can cause gastrointestinal reactions and liver transaminases increased, should be noted.
The initial dose is 0.2~0.4g, then 0.1g every 4~6 hours, after the symptoms improve, reduce to 0.1g, 3 times/d. This drug can cause gastritis and sodium retention, occasionally there is a decrease in white blood cells and platelets, and it is contraindicated in active ulcer disease and cardiac insufficiency.
Piroxicam (inflammation pain Xikang): long duration of action, 20mg/d, once a dose, occasional gastrointestinal reactions, long-term use should pay attention to peripheral blood leukocyte count and liver, kidney function.
Naproxen: strong anti-inflammatory and analgesic effect, but light gastrointestinal reactions, 0.25g orally, 2-3 times/d.
(3) Glucocorticoids: have a rapid relieving effect on acute arthritis attacks, but easy to relapse after discontinuation, and long-term application is prone to diabetes, hypertension and other complications, so it is not suitable for long-term application, only for colchicine, non-steroidal anti-inflammatory drug treatment is ineffective, can not tolerate or have a contraindication, can be considered for short-term use, generally prednisone (prednisone) tablets 10mg, 3 times / d, after symptom relief Gradually reduce the dosage to avoid recurrence.
(4) Aspiration of joints and fluid, followed by injection of corticosteroid esters can also control acute attacks of gout. Depending on the size of the affected joints, injection of prednisone tert-butyl ester 10~50mg, ACTH80u single dose intramuscular injection is a very effective treatment method, and like intravenous colchicine, it is especially suitable for patients with gout attacks who cannot take medication after surgery, and for multi-joint attacks, short-term application of Prednisone, such as 20~30mg/d, and occasionally several drugs need to be applied in combination to treat acute attacks of gout.
(5) In addition to special therapy, rest, large intake of fluids to prevent dehydration and reduce the deposition of urate in the kidneys, patients should eat soft food, and sometimes codeine 30-60mg is needed for pain control, and splinting the inflammation site is also helpful.
3. Treatment of intermittent and chronic period
In spite of the above treatment, the symptoms should not be controlled and recurrent patients should be treated with small doses of colchicine, 0.5~1.0mg/d. During the course of treatment, close attention should be paid to the possible inhibitory effect of colchicine on bone marrow and regular review of liver and kidney function. mol/L (6mg/dl) or less.
These two types of drugs have no anti-inflammatory and analgesic effects, and are usually selected according to the patient’s renal function and 24h uric acid excretion. If the renal function is normal and the 24h uric acid excretion is less than 3.75 mmol, drugs that promote uric acid excretion can be used; if the renal function is reduced and the 24h uric acid excretion is greater than 3.75 mmol, drugs that inhibit uric acid synthesis should be applied.
(1) Drugs that inhibit uric acid synthesis: mainly allopurinol, an inhibitor of xanthine oxidase, can inhibit xanthine oxidase, so that hypoxanthine and xanthine cannot be oxidized to uric acid, thus rapidly reducing the concentration of blood uric acid, reducing the formation of gout stones and uric acid stones, if combined with drugs that promote uric acid excretion, can accelerate the decline of blood uric acid levels, and mobilize the uric acid salts deposited in the tissue, dissolving The common dose is 100mg, 2-4 times/d, which can be increased to 200mg, 3 times/d when needed, until the blood uric acid concentration drops to 360μmol/L (6mg/dl), then gradually reduce the dose, the initial use of the drug may induce acute arthritis attack due to the increase of blood uric acid metastasis, at this time, colchicine can be added to the treatment, a few patients using this drug can occur allergic syndrome, manifested as fever, allergic skin. Fever, allergic rash, abdominal pain, diarrhea, leukocytosis and thrombocytopenia may occur in a small number of patients. Therefore, patients with renal impairment, the use of dose should be reduced as appropriate and closely observed, in addition, elderly patients should also use this drug with caution.
(2) Drugs to promote uric acid excretion: These drugs mainly reduce blood uric acid level by inhibiting uric acid reabsorption from renal tubules and increasing uric acid excretion, which is suitable for patients with normal renal function and low daily uric acid excretion, but for patients with 24h uric acid excretion greater than 3.57mmol (600mg) or with existing uric acid stones, the application of these drugs may cause urinary tract obstruction or promote the formation of uric acid stones. In order to avoid kidney damage and kidney stones caused by a sharp increase in urinary uric acid excretion after medication, care should be taken to start with small doses, and at the same time, oral sodium bicarbonate 3-6g/d should be taken to alkalize the urine; and drink more water to keep the urine volume above 2000ml/d. Certain drugs such as thiazide diuretics, furosemide, ethambutol, pyrazinamide, niacin, etc. can inhibit the excretion of uric acid and should be avoided at the same time.
The maximum dose should not exceed 2g/d. Side effects such as rash, fever and gastrointestinal reactions may occur in about 5% of patients.
The initial dose is generally 50mg, 2 times/d, gradually increase to 100mg, 3 times/d, the maximum dose is 600mg/d. This drug has irritating effect on gastric mucosa and should be used with caution in patients with ulcer disease.
(3) Benzbromarone: It has strong diuretic effect, commonly used dose is 25-100mg, 1 time/d, with mild side effects, few rashes, fever and gastrointestinal reactions.
(3) Adjunctive therapy: All patients with gout need to consume large amounts of fluid, at least 3L per day, especially in patients with previous chronic uric acid stones, and take sodium bicarbonate or trisodium citrate 5g 3 times daily to alkalize the urine, and acetazolamide 50mg before bedtime, which can effectively alkalize the morning urine, taking care to avoid over-alkalization of the urine, as this may promote calcium oxalate crystallization deposition, as the drug completely It can effectively reduce the serum urate concentration, so it is usually not necessary to strictly restrict the purine content in the diet. In the resting phase of gout, attempts should be made to reduce the weight of obese patients. Giant gout stones in the normal skin area can be surgically removed, while all other gout stones should be slowly resolved by appropriate blood uric acid lowering therapy, and extracorporeal ultrasonic lithotripsy can be considered for the disintegration of kidney stones.
4. Treatment of concurrent acute renal failure
In addition, allopurinol should be given as early as possible, with an initial dose of 8mg/(kg?d), and then reduced to 100-300mg/d in 3-4 days. In addition, allopurinol should be given as early as possible, with an initial dose of 8 mg/(kg?d), reduced to 100-300 mg/d in 3-4 days.
In addition to allopurinol and alkalinization of urine, percutaneous nephrostomy can be performed to relieve urinary tract obstruction and then remove urinary tract stones after the condition is stabilized.
5. Dietary control
Reduce exogenous purine sources, avoid eating purine-containing diet such as animal offal, fish, shrimp, meat, peas, etc.; prevent overweight, generally do not advocate drinking alcohol, advocate drinking more water, keep the daily urine volume above 2000ml.
(II) Prognosis
Gout is a lifelong disease, without renal impairment or joint deformity can generally maintain normal life and work with effective treatment, and will not affect life expectancy, but if improperly treated, recurrent attacks of acute arthritis can cause greater pain, and those with joint deformity and nephrolithiasis will have a certain impact on quality of life, and those with serious renal impairment will have a poor prognosis.
Nowadays, gout has spread all over the world, which is closely related to the development of society, economic progress and education, but it cannot be neglected because gout is an old disease, and the more advanced countries are now, the higher the incidence, especially in economically rich countries and regions.
Gout patients should pay attention to the following points in their daily life, in addition to applying appropriate drugs under the guidance of doctors.
(1) Diet: ① Pork, beef, mutton, ham, sausage, chicken, duck, goose, rabbit and various animal offal (liver, kidney, heart, brain), bone marrow, etc. contain high purine and should be avoided as much as possible; fish and shrimp, spinach, beans, mushrooms, shiitake mushrooms, peanuts, etc. also have a certain amount of purine and should be eaten sparingly; most vegetables, various fruits, milk and dairy products, eggs, rice, sugar, etc. can be eaten. ② Drink more water, to keep the daily urine volume above 2000ml, because the occurrence of urinary stones and urine uric acid concentration and urine pH, if necessary, alkaline drugs can be taken to prevent the occurrence of urinary stones. ③Avoid overeating or starvation. ④ Moderation of smoking and alcohol, especially not alcohol abuse. ⑤ Do not drink strong tea, coffee and other beverages.
(2) Properly deal with triggering factors and disable or reduce the use of drugs that affect uric acid excretion: such as penicillin, tetracycline, high-dose thiazides and diuretics such as aminoglutethimide, vitamins B1 and B2, insulin and small doses of aspirin (less than 2g per day).
(3) Obese people should actively lose weight and reduce weight, which is quite important to prevent the occurrence of gout.
(4) Pay attention to the combination of work and rest, avoid overwork, mental stress, infection, surgery, and generally do not advocate gout patients to participate in running and other strong physical exercise, or long-distance walking tours