Acute attacks of gout are one of the common causes of sudden joint swelling. I often see such patients in my clinic, and in order to provide the most comprehensive treatment recommendations for such patients at present, for your reference. We recommend that you must pay attention to the treatment of the chronic phase after resolving the acute attack, and generally go to the rheumatology or endocrinology department for standardized medical treatment.
Gout is one of the most common inflammatory joint diseases, with a prevalence of 1% to 2% in Western men. Gout is caused by the deposition of urate crystals in joints and other tissues, and is an important disease that leads to disability and reduced quality of life for patients. Timothy Huang, Department of Orthopedics, Second Xiangya Hospital
Lowering blood uric acid levels, dissolving urate crystals, reducing acute gout attacks and ultimately curing the disease are important goals of gout treatment. Although there are several versions of guidelines and recommendations for the treatment of gout, they are not perfect.
In recent years, the introduction of new drugs for the treatment of gout, the concept of targeted therapy and the application of new technologies have led to significant developments in the diagnosis and treatment of gout. As a result, 474 rheumatologists from 14 countries reached a new consensus on the diagnosis and treatment of gout after a comprehensive no literature review and discussion vote over a 2-year period, summarized in 10 recommendations, as follows.
1. Finding urate crystals can clearly diagnose gout
If urate crystals cannot be examined, the diagnosis can be assisted by typical clinical features (e.g., typical clinical manifestations in the foot, gout stones, rapid and effective colchicine treatment) and/or characteristic imaging changes (especially joint ultrasound and dual-energy CT). A definitive diagnosis of gout is important because once diagnosed, lifelong uric acid-lowering therapy is usually recommended.
2. Patients with gout and/or hyperuricemia
In patients with gout and/or hyperuricemia, renal function tests should be performed and assessment of cardiovascular risk factors is recommended.
3. Patients with acute gouty arthritis
In patients with acute gouty arthritis, treatment should be based on the patient’s coexisting disease and the risk of adverse drug reactions, including low-dose colchicine (maximum dose of 2 mg per day), NSAIDs and/or glucocorticoids (intra-articular injection, oral or intramuscular). The strength of evidence for oral and intramuscular hormones was much stronger than for intra-articular injections of hormones; the difference in efficacy between selective cyclooxygenase (cox)-2 inhibitors and non-selective non-steroidal anti-inflammatory drugs (NSAIDs) was not statistically significant.
4. Healthy lifestyle
Patients are advised to lead a healthy lifestyle, including body mass reduction, regular exercise, smoking cessation, and avoidance of excessive alcohol and sugary drinks. Experts recommend that gout patients avoid beer and spirits as much as possible, and wine can be considered in small amounts.
5. Choose allopurinol as the first-line drug for uric acid-lowering treatment
Allopurinol should be chosen as the first-line drug for uric acid-lowering therapy, and the next drugs that can be considered include pro-uric acid excretory drugs (e.g., benzbromarone, probenecid) or febuxostat. Uric acidase monotherapy should only be used in those cases of severe gouty arthritis where all other treatments have been ineffective or where treatment is contraindicated. The use of uric acid-lowering drugs (except uricase) should be started at a low dose and then gradually increased to bring the blood uric acid down to the target value.
6.Initial uric acid-lowering treatment
When starting uric acid-lowering therapy, patients should be informed of the risk of acute arthritis attacks and how to deal with them. The use of low-dose colchicine (maximum 1.2 mg/d), NSAIDs or low-dose glucocorticoids can be considered to prevent acute arthritis attacks, with low-dose colchicine having the highest level of evidence (level 1b) and recommendation (level B). The timing of preventive medication should vary from person to person.
7. Impact of coexisting diseases on drug selection
Allopurinol can be used in patients with mild to moderate renal impairment, but should be closely monitored for possible adverse effects. Allopurinol should be started at a lower dose (50-100 mg/d) and gradually increased to achieve target blood uric acid values. Febuxostat and benzbromarone are also available and do not require dose adjustment.
8.Treatment target
The treatment goals are blood uric acid <0.36 mmol/L (60 mg/L), eventual absence of gout attacks, and gout stone dissolution. For patients who have developed gout stones, lower blood uric acid levels facilitate gout stone dissolution and delay gout recurrence. Clinicians need to monitor the patient's blood uric acid level, the frequency of gout attacks and the size of gout stones.
9. Treatment of gout stones
The patient’s blood uric acid should be kept at a consistently low level, preferably <0.30 mmol/L (50 mg/L). There is no significant difference in the efficacy of various uric acid-lowering drugs. Surgical procedures are only used in certain patients who present with nerve compression, mechanical injury or infection.
10. Patients with simple asymptomatic hyperuricemia
In patients with pure asymptomatic hyperuricemia, the use of drugs to prevent gouty arthritis, renal disease and cardiovascular events is not recommended. However, in view of the risks associated with hyperuricemia, a healthy lifestyle is recommended.
The 10 recommendations for the diagnosis and treatment of gout are derived from evidence-based medical evidence and expert consensus, are highly credible and authoritative, provide answers and guidance to common and important questions in clinical work, and are widely accepted by rheumatologists worldwide.
Compared with the previous guidelines for the treatment of gout proposed by the American College of Rheumatology, this guideline not only includes the treatment of benzbromarone, but also gives the corresponding levels of evidence and strength of recommendation for different drugs, so it is also a more comprehensive and practical recommendation. It is hoped that this latest recommendation for the diagnosis and treatment of gout will provide some guidance to rheumatologists and physicians in related fields in China.