I. Since 1980s, with the continuous improvement of people’s living standard in China, the prevalence of hyperuricemia (HUA) has been increasing year by year, especially in economically developed cities and coastal areas, the prevalence of HUA reaches 5%-23.5%, which is close to the level of western developed countries. HUA is inseparable from gout and is an independent risk factor for metabolic diseases [diabetes, metabolic syndrome, hyperlipidemia, etc.], chronic kidney disease, cardiovascular disease and stroke.
Second, the new view of gout treatment: gout is a curable and refractory disease (2013 European annual meeting consensus). Since gout can be cured, why do so many people still have recurrent attacks and remain untreated for a long time? There are two reasons.
(a) Some physicians do not recognize the danger of hyperuricemia and do not pay attention to blood uric acid-lowering treatment.
(b), patients lack knowledge related to gout treatment, and treatment is not standardized.
It is often manifested as.
1.Not pay attention to early treatment.
2.Treatment only in the gout attack period.
3, long-term abuse of painkillers and glucocorticoids.
4, too afraid of the side effects of drugs, can not adhere to the standardized treatment of blood uric acid to meet the standard.
5.Excessive control of diet.
6.Lack of attention to non-pharmacological treatment (diet, exercise, review).
The result is recurrent gout attacks, persistent arthritis, kidney stones, gout stones, and even serious irreversible complications such as hypertension, diabetes, renal insufficiency and uremia. Therefore, it is necessary to standardize the treatment of gout, cure it, avoid complications and improve the quality of life.
The latest and best program for gout treatment: drug + non-drug integrated standardized treatment. Adherence to standardized treatment can gradually reduce gout attacks until no more gout attacks, and eventually reverse and cure gout.
Third, comprehensive standardized gout treatment consists of six aspects.
(a) non-pharmacological treatment of gout: control your mouth, open your legs, control your weight and drink more water
The body’s 20% of blood uric acid comes from food, control diet can play a role in lowering uric acid and preventing acute attacks of gout to a certain extent.
1, choose low purine food, avoid high purine food, such as animal offal, thick soup, gravy, seafood. Eat more fresh vegetables and fruits (beans and soy products contain vegetable proteins that are not easily digested and absorbed by the body, so try to eat less).
2, avoid alcoholic beverages (especially to avoid drinking beer).
3, milk, eggs, refined meat, etc. are high-quality protein, to be supplemented in moderation. Purine is easily soluble in water, meat can be boiled and eaten in soup, avoid eating stewed meat or marinated meat.
4, Note: Dietary control must take into account a reasonable balance of high-quality protein, carbohydrates, calories, excessive control of diet is harmful to health. Strictly controlled diet can only reduce 70-90μmol/L blood uric acid, you can not just eat sparse vegetables and fruits, otherwise it will be more likely to attack gout because of hunger and increased lactic acid.
Open your legs: adhere to the appropriate amount of exercise, gout patients are more suitable for aerobic exercise, such as brisk walking, jogging. The amount of exercise should be moderate, control the heart rate of: 170-age (aerobic exercise maximum suitable heart rate). Exercise should be gradual, the first exercise time 15 minutes; keep 2 weeks to increase to 30 minutes; after 2 weeks to increase to 45 minutes, can always maintain. For some reason to suspend exercise to restart exercise to recalculate the exercise time. Exercise more than 5 times a week can be.
Weight control: weight control so that the weight standard can effectively prevent the occurrence of gout. Overweight or obese should reduce weight, weight reduction should be gradual, otherwise it is easy to lead to ketosis or gout acute attacks.
Drink more water: drink 2000-3000ml of water daily to increase uric acid excretion. Water, alkaline mineral water and fruit juice are preferred, and strong tea, coffee and carbonated drinks are not recommended.
(II) Alkalinize urine
When urine pH is below 6.0, alkalinization of urine is needed. Urine pH 6.2~6.9 is good for urate crystals dissolution and discharge from urine, but urine pH>7.0
Calcium oxalate and other types of stones are easily formed. Therefore, urine pH should be checked during alkalinization of urine.
Commonly used drug: sodium bicarbonate. 1 g each time, 3 times a day.
(C) Active treatment of metabolic risk factors associated with elevated blood uric acid
Active control of hyperlipidemia, hypertension, hyperglycemia, obesity and smoking cessation is an important part of gout treatment.
(iv) Avoid the application of drugs that elevate blood uric acid
Some medications can cause elevated blood uric acid and should be avoided. Drugs that commonly cause elevated blood uric acid include: aspirin (>2g/d), diuretics, cyclosporine, tacrolimus, nicotine, alcohol, levodopa, pyrazinamide, ethambutol, etc. For patients who need diuretics and combined with hyperuricemia, avoid thiazide diuretics, while alkalinizing urine and drinking more water to keep daily urine output above 2000ml. 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.
(E) Use appropriate drugs to control blood uric acid to the target value
1.Treatment principles with drugs
One 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 joint fluid during the attack.
2. Precautions for medication
The medication should be used with caution, observation should be paid attention to after the medication is used, abnormalities are found and the medication should be stopped in time, and active treatment should be given to avoid adverse drug reactions. Gout attacks should not start uric acid-lowering treatment, but should be given anti-inflammatory and analgesic treatment until 1-2 weeks of relief before uric acid-lowering treatment. At the beginning of uric acid-lowering treatment, acute attacks of gout may be induced by a rapid decrease in blood uric acid concentration, at which time there is no need to stop the medication, and non-steroidal anti-inflammatory drugs or colchicine can be added. Once on uric acid-lowering therapy, it is recommended not to stop. Most patients can 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.
3. Blood uric acid control goal
Blood uric acid is controlled below the saturated serum concentration, rather than just reaching normal values, blood uric acid
The blood uric acid can be controlled below the saturated serum concentration instead of reaching the normal value, blood uric acid >400μmol/L only slows down the progress but cannot reverse the disease. According to 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.
4.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 the metabolism of hypoxanthine and xanthine to uric acid, thus reducing the production of uric acid. Indicated in patients with excessive uric acid production (urinary uric acid ≥ 1000 mg/24h), impaired renal function, and history of urinary stones.
Allopurinol.
Oral, adult dosage: initial dose of 50mg once, 1-2 times a day, can be increased by 50-100mg per week to 200-300mg per day, divided into 2-3 doses, blood and uric acid levels are tested every 2 weeks, if the control target has been reached, then no further increase, if still high can be increased again. However, the maximum amount should not be more than 600mg a day.
Febuxostat.
Administered orally at a starting dose of 40 mg once daily. If the blood uric acid level is still not lower than 360 μmol/L after 2 weeks, the recommended dose is increased to 80 mg once a day.
(2) Pro-uric acid excretory agents (recommended benzbromarone).
It inhibits the reabsorption of urate in the proximal renal tubule, suitable for those with good renal function, and cannot be used when the endogenous creatinine clearance rate is less than 20ml/min. Drink plenty of water during the dosing period, keep urine volume at 2000ml/d, and take 3-6g/d of sodium bicarbonate.
The starting dose for adults is 25mg once daily after breakfast, and the dose is adjusted to 50-100mg daily after 1-3 weeks according to the blood uric acid level, and the recommended dose for renal insufficiency (Ccr<60ml/min) is 50mg once daily.
5. Long-term maintenance treatment after blood uric acid reaches the standard.
After blood uric acid reaches the standard and gout symptoms (signs) disappear, all treatments should be continued to ensure long-term maintenance of blood uric acid in the target value range. After the blood uric acid reaches the standard, try to reduce the dosage, and if the blood uric acid is still within the target value range, try to reduce the dosage again until you find the minimum maintenance dose that suits you.
(VI) 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 the quality of life.
1.Self-management
…… Understand the pathogenesis, process and treatment aspects of gout.
…… Understand your comprehensive treatment plan, measures, goals and prognosis. Prevent and monitor possible adverse drug reactions and various acute and chronic complications. Relaxation and integration of psychological adjustment into daily life.
…… Many people who have gout complain 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 and adherence to standardized treatment can avoid the harm and complications caused by high blood uric acid.
…… Reasonable adjustment of diet structure.
…… What to eat? How much to eat? It is a big problem faced by the patients. The quality, origin, maturity and moisture content of food can affect the purine content of food, and some foods do not have data on purine content measurement. Various factors such as the age, work intensity, height and weight of the patients determine that the diet structure of the patients cannot be uniform.
…… 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 body’s nutritional needs, but also to control the blood uric acid standard, but also to minimize the amount of maintenance drugs? There is a relatively simple method to share with you.
…… ①Prioritize foods with low purine content.
…… ② Do not eat foods with high purine content such as animal offal, beer, gravy, and thick soups.
…… ③ Eat as little or as much as possible of mushrooms, beans and soy products.
…… ④Purines are easily soluble in water, cook meat first before eating.
…… ⑤ Adjust the amount of food according to your needs to ensure adequate nutrition.
……⑥Use the minimum dose of medication to control to make the blood uric acid reach the standard.
……⑦Check the blood uric acid regularly, and use the examination results to infer whether the diet structure and medication are reasonable, and have a suitable recipe for yourself after the control is stable.
2.Regular review
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 the patient’s compliance with treatment drugs. The items to be reviewed regularly are: blood routine, urine routine, kidney function, and the items to be reviewed once every 3-6 months: liver function, blood sugar, blood pressure, ultrasound of digestive system and ultrasound of urinary system.