A new view of gout treatment, gout is a refractory disease that can be cured (2013 European Annual Meeting consensus). Since gout can be cured, why do so many people still have recurrent attacks and persistent treatment?
A. Avoid applying drugs that raise blood uric acid
1. Some drugs can cause elevated blood uric acid and should be avoided. Common drugs that can cause elevated blood uric acid include: aspirin (>2g/d), diuretics, cyclosporine, tacrolimus, nicotine, alcohol, levodopa, pyrazinamide, ethambutol, etc.
2.For patients who need to take diuretics and combined with hyperuricemia, avoid applying thiazide diuretics, while alkalinizing urine, drinking more water and keeping daily urine volume above 2000ml.
3. For patients with hypertension combined with hyperuricemia, choose antihypertensive drugs other than thiazide diuretics. Corsoa (coxsartan potassium tablets) is a proven antihypertensive drug that can both lower blood pressure and lower blood uric acid, and can be considered as a priority antihypertensive drug.
II. Use appropriate drugs to control blood uric acid to the target value
(A) Principles of drug treatment
1 of the following conditions should be satisfied.
Hyperuricemia (blood uric acid over 530μmol/L)
More than 1 acute attack of gout
Gout stone formation
Chronic persistent gouty arthritis
Uric acid nephrolithiasis with impaired renal function
MSUM microcrystals in the joint fluid during the attack
(II) Precautions for medication
1, medication should be used with caution, after the use of medication should be observed, abnormalities found in a timely manner to stop the drug, active treatment, to avoid adverse drug reactions.
2.Uric acid-lowering treatment should not be started during the gout attack, but anti-inflammatory and analgesic treatment should be given first until 1-2 weeks of remission, and then uric acid-lowering treatment should be given.
3.In the early stage of uric acid-lowering treatment, the acute attack of gout may be induced by the rapid decrease of blood uric acid concentration, at this time, there is no need to stop the drug, and non-steroidal anti-inflammatory drugs or colchicine can be added. Once you receive uric acid-lowering treatment, it is recommended not to stop. Most patients will benefit by meeting the standard treatment. Patients with refractory gout should lower their blood uric acid as much as possible as long as they can tolerate it.
(C) Blood uric acid control goal
Blood uric acid is controlled below the saturated serum concentration, not just at normal values. Blood uric acid >400 μmol/L only slows progression but does not reverse the disease.
In foreign data, effective uric acid-lowering therapy can shrink gout stones. The rate of gout stone reduction is closely related to the blood uric acid level, the lower the blood uric acid, the faster the gout stone reduction.
Ideal target value of uric acid 1: Blood uric acid <360μmol/L can effectively prevent the occurrence and recurrence of gout;
The ideal target value of uric acid 2: blood uric acid <300μmol/L can reduce and disappear gout stones, and can prevent joint destruction and kidney damage.
(D) Commonly used drugs to reduce blood uric acid
1.Inhibitors of uric acid production (allopurinol or febuxostat monotherapy is recommended)
Inhibits xanthine oxidase (XO) and prevents metabolism of hypoxanthine and xanthine to uric acid, thus reducing the production of uric acid.
Indicated for patients with excessive uric acid production (uric acid ≥ 1000mg/24h), impaired renal function, history of urinary stones, and ineffective uric acid elimination drugs.
Dosage.
Allopurinol: oral, adult dosage: initial dose of 50mg once, 1-2 times a day, can be increased by 50-100mg a week to 200-300mg a day, divided into 2-3 doses, every 2 weeks to test the blood and uric acid level, if the control target has been reached, then no further increase, if still high can be increased. However, the maximum amount should not be more than 600mg a day.
Febuxostat: Oral, starting dose of 40 mg once daily. If the blood uric acid level is still not lower than 360μmol/L after 2 weeks, it is recommended to increase the dose to 80mg once a day.
2.Pro-uric acid excretory drugs (recommended benzbromarone)
Inhibit the reabsorption of urate in the proximal renal tubule, suitable for those with good renal function, not effective when the endogenous creatinine clearance rate is less than 30ml/min, not suitable when uric acid is greater than 600mmol/d.
Drink more water during the medication period, keep the urine volume at 2000ml/d, and take 3-6g/d of sodium bicarbonate.
Dosage.
Benzbromarone: The starting dose for adults is 50mg once daily after breakfast. 1-3 weeks later, the dose is adjusted to 50-100mg daily according to the blood uric acid level. 50mg once daily is recommended for renal insufficiency (Ccr<60ml/min).
(E) Long-term maintenance treatment after the blood uric acid standard is reached
1.After the blood uric acid reaches the standard and the gout symptoms (signs) disappear, all treatments should be continued to ensure the long-term maintenance of blood uric acid in the target value range.
2.After the blood uric acid reaches the standard, you can try to reduce the dosage, if the blood uric acid is still within the target value range, you can try to reduce the dosage again until you find the minimum maintenance dose suitable for you.
(F) New drug information (febuxostat, uricase, oxybutynin)
1.Febuxostat: a new type of xanthine oxidase inhibitor with better efficacy than allopurinol and less side effects.
2.Uricase: It can make uric acid oxidized rapidly into allantoic acid, which is no longer absorbed by renal tubules and excreted. It is effective in nodular gout, urinary calculi and hyperuricemia due to renal failure.
3.Oxipurinol: the active metabolite of allopurinol, suitable for patients who are intolerant to allopurinol, the drug can be cleared by hemodialysis.
4.Excite: a new broad-spectrum polymer adsorbent, which can adsorb creatinine, non-protein nitrogen and uric acid in the intestinal tract.
Self-management and regular review
Self-management and regular review is a very important part of the standardized treatment of gout, which is an important means to improve the treatment effect and quality of life.
(A) Self-management
1.Knowledge of the pathogenesis, process and treatment of gout.
2.Understand your comprehensive treatment plan, measures, goals and prognosis.
3.Prevent and monitor the possible adverse drug reactions and various acute and chronic complications.
4.Relax and incorporate psychological adjustment into daily life.
Many people who have gout complain about God and are negative and pessimistic, believing that once they have the disease, they will suffer for life. In fact, otherwise, early understanding of the standardized treatment plan, adhere to the standardized treatment, you can avoid the harm and complications caused by high blood uric acid.
5. Reasonable adjustment of diet structure.
What to eat? How much to eat? It is a big problem for all patients.
The quality, origin, maturity and moisture content of food will affect the purine content of food, and some foods do not have data on purine content measurement. Various factors such as age, work intensity, height and weight of patients determine that the diet structure of patients cannot be uniform.
A low purine diet control must take into account a reasonable balance of high quality protein, carbohydrates and calories. How to adjust the diet structure to meet the nutritional needs of the body, while controlling the blood uric acid standard and minimizing the amount of maintenance medication? The following are shared with you.
①Prefer foods with low purine content.
②Do not eat animal offal, beer, gravy, thick soup and other foods with high purine content.
③Eat as little or as much as possible of mushrooms, beans and soy products.
④Purines are easily soluble in water. Cook meat first before consumption.
⑤Adjust the amount of food according to your needs to ensure adequate nutrition.
⑥Use the minimum dose of medication to control so that the blood uric acid reaches the standard.
(7) Check blood uric acid regularly, and use the test results to infer whether the diet structure and medication are reasonable, and have a suitable recipe for yourself after control and stability.
6. Disease file retention and management.
Keep the various examination reports and records of each time to give reference for future diagnosis.
(II) Regular review
1.In the process of adjusting uric acid-lowering drugs, uric acid should be measured every 2-5 weeks. Uric acid measurement is the basis for adjusting drug doses and is also helpful to judge patients’ compliance with treatment drugs.
2.Regular review of the prescribed items and close attention to the indicators can reduce the use of drugs, reduce the harm of drug side effects and improve the treatment effect.
3.Review the items once in 3-6 months: blood routine, urine routine, kidney function.
4, 6-12 months to review the items: liver function, blood sugar, blood pressure, digestive system ultrasound, urinary system ultrasound.
5.Blood pressure and blood sugar need to be monitored daily if they are abnormal.