A new perspective on gout treatment, gout is a refractory disease that can be cured (2013 European Annual Meeting Consensus). If gout can be cured, why do so many people still have recurrent attacks that go on for so long? There are two reasons.
First, some physicians do not recognize the danger of hyperuricemia and do not pay attention to blood uric acid-lowering treatment.
Second, patients lack knowledge related to gout treatment, and treatment is not standardized. It is often manifested as
Not paying attention to early treatment.
Treatment only during the gout attack.
Long-term abuse of painkillers and glucocorticoids.
Excessive fear of side effects of drugs, unable to adhere to the standardized treatment of blood uric acid to meet the standard.
Excessive control of diet.
Not paying attention to non-medication 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 mellitus, renal insufficiency and uremia. Therefore, it is necessary to standardize the treatment of gout, cure it, avoid complications and improve the quality of life.
Early gout treatment guidelines emphasized only the treatment of the acute phase; recent gout treatment guidelines not only emphasize the treatment of the acute phase, but also begin to focus on uric acid-lowering treatment in remission, especially stratified uric acid-lowering treatment. The newest and best plan for gout treatment: drug + non-drug comprehensive standardized treatment. Adherence to standardized treatment can gradually reduce gout attacks until no more gout attacks occur, and eventually reverse and cure gout. Comprehensive standardized gout treatment consists of six aspects.
I. Non-pharmacological treatment of gout: control your mouth, open your legs, control your weight and drink more water
(a) Control your mouth: 20% of the blood uric acid in the body comes from food, control the diet can play a role in lowering uric acid and preventing acute attacks of gout to a certain extent.
Choose low purine foods and avoid high purine foods such as animal offal, thick soup, gravy and 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 of them).
Avoid alcoholic beverages (especially avoid drinking beer).
Milk, eggs and refined meat are high-quality proteins and should be supplemented in moderation. Purines are easily soluble in water, meat can be boiled and eaten in soup, avoid stewed or marinated meat.
Note: Dietary control must take into account a reasonable balance of high quality protein, carbohydrates and calories, excessive control of diet is harmful to health. Strictly controlled diet can only reduce 70-90μmol/L blood uric acid, you can’t just eat sparse vegetables and fruits, otherwise you will be more prone to gout attacks due to hunger and increased lactic acid.
(b) 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: 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 5 times a week or more.
(C) weight control: weight control to make weight standards 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.
(d) Drink more water: drink 2000-3000ml of water daily to increase uric acid excretion. Water, alkaline mineral water, fruit juice, etc. are preferred, and strong tea, coffee and carbonated drinks are not recommended.
II. Alkalinize urine
Alkalinization of urine can dissolve uric acid stones. When urine pH < 5.5, uric acid is supersaturated and less uric acid is dissolved; when pH > 6.5, most uric acid exists in the form of anionic urate and uric acid stones are most easily dissolved and excreted with urine. Therefore, it is most appropriate to maintain urine pH at about 6.5.
The most commonly used drug to alkalize urine is sodium bicarbonate. Sodium bicarbonate is more irritating to the stomach and can be taken intermittently, but it is not recommended to take it continuously for a long time.
Active treatment of metabolic risk factors associated with elevated blood uric acid
In 2006, the European League Against Rheumatism (EULAR) recommendations on gout prevention and treatment emphasized that active control of hyperlipidemia, hypertension, hyperglycemia, obesity and smoking cessation are important components of gout treatment.
Fourth, avoid applying drugs that raise blood uric acid
Some drugs can cause elevated blood uric acid and should be avoided. Common drugs that can increase 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 the daily urine volume 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.
V. Use appropriate drugs to control blood uric acid to the target value
(A) Principles of drug treatment
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 the joint fluid during the attack
(II) Precautions for medication
The medication should be used with caution, and observation should be made after the medication is administered, and the medication should be discontinued in time when abnormalities are detected, and active treatment should be given to avoid adverse drug reactions.
Gout attacks should not start uric acid-lowering treatment, but should be treated with anti-inflammatory and analgesic treatment until 1-2 weeks of remission 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 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.
(iii) Blood uric acid control goal
Blood uric acid is controlled below saturated serum concentrations, 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 reduce the size of 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.
For patients with excessive uric acid production (uric acid ≥ 1000mg/24h), impaired renal function, history of urinary stones, and ineffective uric acid detoxification drugs.
Dosage.
Allopurinol: oral, adult dosage: initial dose of 50mg once, 1-2 times a day, may be increased by 50-100mg per week to 200-300mg per day, divided into 2-3 doses, blood and urine uric acid levels tested every 2 weeks, 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, and 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 a day after breakfast, after 1-3 weeks the dose is adjusted to 50-100mg per day according to the blood uric acid level, in case of renal insufficiency (Ccr<60ml/min) the recommended dose is 50mg once a day.
3.For more detailed information about uric acid reduction drugs, please add the WeChat public number: TF8999 and reply to the number 8.
(E) Long-term maintenance treatment after reaching the blood uric acid standard
After the blood uric acid reaches the standard and the gout symptoms (signs) disappear, all treatments should be continued to ensure that the blood uric acid is maintained in the target range for a long time.
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) New drug information (febuxostat, uricase, oxypurinol)
Febuxostat: a new type of xanthine oxidase inhibitor with better efficacy than allopurinol and fewer side effects, the domestic generic version has entered phase 4 clinical trials, and all the febuxostat currently in circulation originates from informal routes.
Uricase: It can cause rapid oxidation of uric acid into allantoic acid, which is no longer absorbed by the renal tubules and excreted. It is effective in nodular gout, urinary calculi and hyperuricemia due to nephropathy failure.
Oxypurinol: active metabolite of allopurinol, indicated for patients who are allopurinol intolerant and the drug can be cleared by hemodialysis.
Acetate: A new broad-spectrum polymeric adsorbent that adsorbs creatinine, non-protein nitrogen and uric acid in the intestinal tract. (See: Zuo Xiaoxia, Luo Hui, You Yunhui. Clinical study on the treatment of gout and hyperuricemia with Acetate. Chinese Journal of Modern Medicine. 2003, 13(22):117-118.)
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.
(I) Self-management
Understand the pathogenesis, process and treatment 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 regulation 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 hazards and complications brought about by high blood uric acid.
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 can 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 to meet the standard and minimizing the amount of maintenance medication? There is a relatively simple method to share with you.
①Prioritize foods with low purine content.
Do not eat foods with high purine content such as animal offal, beer, gravy and thick soup.
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.
Retain and manage disease files.
Keep all kinds of examination reports and records for future diagnosis.
(II) 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 patients’ compliance with treatment drugs.
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 effectiveness of treatment.
Items to be reviewed once every 3-6 months: blood count, urine count, kidney function.
Items to be reviewed once in 6-12 months: liver function, blood sugar, blood pressure, ultrasound of digestive system, ultrasound of urinary system.
Blood pressure and blood sugar need to be monitored daily if they are abnormal.