Detail 1: Do not ignore “intermittent” uric acid-lowering treatment
Once the symptoms are relieved and the course of the disease enters the intermittent period, the disease is not taken seriously and no uric acid-lowering drugs are taken or used during the intermittent period, which will inevitably lead to recurrent gout attacks.
Gout is a chronic disease, the course of the disease is characterized by repeated alternation between attacks and remissions, acute attacks can be self-relieving symptoms, but this does not mean that gout has been completely self-healing. In fact, although intermittent patients do not have obvious symptoms, but the blood uric acid level is often high, if no treatment to lower uric acid, allowing the long-term existence of hyperuricemia, future gout attacks may become more and more frequent, each attack symptoms continue longer and longer, more and more affected joints, uric acid salt deposited around the joints to form gout stones, the disease process into the chronic phase, the symptoms persist, and eventually cause joint and kidney organic damage. The disease process enters the chronic phase, the symptoms persist, and eventually cause organic damage to the joints and kidneys.
Therefore, in order to prevent or reduce recurrence, we must not relax the intermittent uric acid-lowering treatment, especially for gout patients with obvious tendency of recurrence, we should strive to control the blood uric acid level below 360μmol/L (6.1mg/dL).
Detail 2: Rational selection of uric acid-lowering drugs and timing of administration
Uric acid-lowering drugs are mainly used in the treatment of intermittent and chronic gout to prevent acute attacks of gout as well as chronic complications of gout such as joints and kidneys by correcting hyperuricemia.
According to the different mechanisms of action, uric acid-lowering drugs are divided into two main categories.
1.Drugs that promote uric acid excretion
Representative drugs such as propofol and benzbromarone. These drugs inhibit the reabsorption of uric acid in the proximal renal tubules to facilitate uric acid excretion.
They are suitable for patients with increased blood uric acid, good renal function, 24-hour uric acid excretion less than 600mg, no urinary tract stones and gouty nephropathy. It should be contraindicated when the patient has significantly reduced renal function (creatinine clearance <30mL/min) or when urinary stones are present.
2. Drugs that inhibit uric acid production
The drug should be used in patients with significant renal failure (creatinine clearance <30mLmin) or in the presence of urinary stones. These drugs reduce uric acid production by inhibiting xanthine oxidase and blocking the conversion of xanthine into uric acid.
It is suitable for gout patients with excessive uric acid production, impaired kidney function, gout stones and urinary tract stones. The representative drug is allopurinol 100mg once daily, gradually increasing to 100-200mg three times daily. For those with renal insufficiency, the dosage should be reduced. Liver and kidney function, blood and urine routine should be checked regularly during medication.
Choice.
Since most patients with gout belong to the type with reduced uric acid excretion and the side effects of pro-uric acid excretory drugs are less frequent and milder than those of drugs inhibiting uric acid production, in the absence of contraindications, clinically, pro-uric acid excretory drugs are usually preferred, followed by drugs inhibiting uric acid production. For those who do not have good results with one class of drugs alone, a combination of two classes of drugs can also be used.
Timing.
The timing of uric acid-lowering therapy is also important. Remember: additional uric acid-lowering drugs should not be used during acute attacks of gout. Such drugs should be started after 1-2 weeks of acute inflammation control, and they should be started in small doses and gradually increased to appropriate doses.
Detail 3: You can’t be in a hurry to lower uric acid
Hyperuricemia is the main culprit of gout attacks. Therefore, in the treatment of gout, people hope to bring down the blood uric acid level as soon as possible, so they increase the dose of medication without permission, but the result is often contrary to their wishes, which can easily induce an acute gout attack. This is because when the high level of blood uric acid decreases rapidly, the uric acid in the joint fluid is not transferred to the blood in time, resulting in a huge difference in the concentration of uric acid in the joints and blood, resulting in the release of insoluble uric acid crystals already deposited in the joints and surrounding tissues, causing the blood uric acid to rise and fluctuate, resulting in a recurrence of the disease or “metastatic gout”.
During the initial treatment with uric acid-lowering drugs, it is not uncommon for the speed of uric acid reduction to cause rebound acute attacks of gout. New European and American gout treatment guidelines suggest that patients can start uric acid-lowering therapy with a small dose of colchicine (0.6 mg/d) or non-steroidal anti-inflammatory drugs, and continue to apply them for several months after serum uric acid is controlled below 360 μmol/L (6 mg/dL) to avoid causing acute gouty arthritis.
Detail 4: High blood uric acid ≠ long-term uric acid-lowering drugs
It is undeniable that hyperuricemia is an important factor leading to gout, and uric acid-lowering treatment can prevent acute attacks of gout and prevent or reduce the harm of chronic complications of gout. However, long-term use of uric acid-lowering drugs will, after all, produce certain side effects (such as liver and kidney damage, bone marrow suppression, drug rash, etc.), so it is important to weigh the pros and cons and fully consider the risk/benefit ratio of medication, and not to take uric acid-lowering drugs as soon as you see high blood uric acid.
Clinically, pharmacological intervention is only indicated for those with a family history of gout and persistent blood uric acid greater than 535 μmol/L (9 mg/dL) despite strict dietary control; those with acute episodes of arthritis more than 2-3 times per year; those with gout stones, chronic gouty arthritis, urinary stones and chronic gouty nephropathy. Otherwise, long-term use of uric acid-lowering drugs is not necessary. However, diet should be controlled, triggers should be avoided and closely followed up.