The key to the treatment of gout lies in the continuous uric acid attainment, and the key to the continuous uric acid attainment lies in the adherence to the standard treatment. As a severe painful joint disease caused by hyperuricemia, the treatment of gout is divided into two parts: the acute treatment of gout attack and the uric acid-lowering treatment of gout remission, which need to be organically combined.
Acute treatment]
Patients who have had a gout attack must have a very memorable experience of gout attack, and even at the time of consultation, patients can precisely recall the time of the attack. Acute gout attacks are usually treated within 24 hours, and if the patient endures the pain through the acute phase, the gout will resolve itself, which is typical of the initial gout attack. However, as the course of the disease lengthens, without standard treatment, the interval between attacks of gout will shorten, while the duration of the attack will lengthen and the pain characteristics will become less typical.
The three main assets of the acute phase of gout: colchicine, non-steroidal anti-inflammatory drugs, and glucocorticoids.
Colchicine: starting dose 1 mg (2 tablets), 0.5 mg (1 tablet) after 1 hour, 0.5 mg (1 tablet) after 12 hours, then 1 tablet twice or three times a day until pain relief. Side effects are gastrointestinal reactions and are related to the dose used.
Non-steroidal anti-inflammatory drugs: Use the non-extended release form. Side effects are peptic ulcers, which can be combined with proton pump inhibitors such as omeprazole, etc. Use with caution in patients with renal insufficiency.
Prednisone: 0.5mg/kg (if the patient weighs 60kg, use 30mg prednisone), once a day in a dose, use 5-10 days, can be stopped directly.
Use of uric acid-lowering drugs.
①If the patient is already on uric acid-lowering therapy and has a gout attack in the process of lowering uric acid, there is no need to stop using uric acid-lowering drugs at this time.
②If the patient has never used uric acid-lowering drugs, uric acid-lowering is usually started 2 weeks after the gout attack is in remission.
[Prevention and treatment of gout in remission].
In the process of lowering uric acid, gout can often be triggered due to fluctuations in blood uric acid, and it is a great pity if patients lose confidence in treatment because of this, so some means of preventing gout attacks are also necessary and can be carried out simultaneously with uric acid-lowering treatment.
The three main tools remain: colchicine, non-steroidal anti-inflammatory drugs, and glucocorticoids, maintained in smaller doses.
The first-line choice is colchicine and NSAIDs. The dosage of colchicine at this time is one tablet once or twice daily. If the patient is unfit for colchicine and NSAIDs due to gastrointestinal reactions or renal insufficiency, prednisone may be used, usually at a dose less than or equal to 10 mg per day.
[uric acid-lowering treatment for gout in remission].
The mechanism of action of uric acid-lowering drugs can be divided into two categories, one is to inhibit uric acid synthesis and the other is to increase uric acid excretion. The representative drugs of the former are allopurinol and febuxostat. The representative drugs of the latter category are Ligurian.
The main adverse effects are allergy and liver and kidney damage. In case of renal insufficiency, the dosage should be adjusted under the guidance of physician. Allergy is the more serious adverse reaction and has been clearly linked to the HLA-5801 gene, which is carried in about 1% of Asian populations. Therefore, if allopurinol is to be used, the HLA-5801 gene must be tested first.
Febuxostat is a new generation drug that inhibits uric acid synthesis, and is used at doses of 40-80mg/d. It does not have the allergic reaction of allopurinol, and also has almost no effect on renal function as only 3% is excreted through the kidneys. The main side effect is liver damage, and is discontinued if liver enzymes rise by more than 2 times.
Raglanoxan can be used in renal insufficiency with endogenous creatinine clearance less than 20 ml/min. The starting dose is 50mg/d, adjusted to 50-100mg/d after 1-3 weeks according to the blood uric acid level, taken after breakfast with baking soda to alkalize the urine and monitor the urine PH value to maintain at 6.2-6.9. The main contraindication to use is urinary stones.
[Choice of drugs].
If the patient’s 24-hour uric acid is less than 600mg and there are no kidney stones, the main choice is the uric acid excretory drug Ligurian. If the patient’s 24-hour uric acid is greater than 1000mg, or if there are kidney stones, or if Raglanxan is not effective, then the synthetic inhibiting drug febuxostat or allopurinol should be used.
The treatment of gout is a dynamic and comprehensive assessment process, and it is important to adhere to it. Sometimes there are still gout attacks during the treatment process, but patients should have confidence in the treatment and adhere to the regular treatment, and eventually they can stay away from gout.