People often call colds “colds” and cerebrovascular diseases “strokes”. But the word gout is not known to many people. The prevalence of gout is increasing year by year in China, and this disease is associated with elevated blood uric acid. Do you know that the incidence of hyperuricemia in some areas of China has reached 13.3%, which is comparable to 2% to 18% in western countries, and the incidence of gout has increased from 0.34% in 1998 to 1.33% in 2003. Gout has gradually become a serious threat to people’s health as a common disease.
There is another problem that we should pay attention to: most patients with elevated blood uric acid have no symptoms, which we call asymptomatic hyperuricemia; some patients can see subcutaneous nodules around the auricle and joints, which we call gout stones; a small number of patients can also develop kidney problems, including uric acid kidney stones or renal insufficiency. Gout has a long history and is characterized by the sudden onset of redness and swelling in a joint, like the above-mentioned Mr. Dai, and the pain is so intense that the ancients described it as a drop of fluid running through the body, and the pain is unbearable wherever it runs. Some people also explain gout in this way, that is, the joint pain is so severe that the patient’s joints cannot even tolerate the wind blowing next to them.
In recent years, since hyperuricemia and gout often coexist with hypertension, diabetes, hyperlipidemia, obesity and various cardiovascular diseases, which aggravate the damage to kidneys and important organs such as cardiovascular and cerebrovascular, it is necessary to let people understand the characteristics of hyperuricemia and gout, how to diagnose and treat them.
I. Epidemic trend of hyperuricemia and gout: preference for men over women
One morning before 8:00 a.m., a 66-year-old female patient came to the outpatient clinic, mainly because of sudden and severe back pain at night and hematuria, and after examination, it was clear that it was caused by kidney stones. We know that most of the kidney stones are composed of calcium, but this old man was found to have uric acid and high blood uric acid after laboratory tests. The old man and his family were puzzled: “How can I have high blood uric acid and uric acid stones? This disease should be acquired by men!” Their doubts are justified. Previously, it was thought that the majority of patients were men, but it was not known that the prevalence of women increased significantly with age. The incidence of gout in postmenopausal women is significantly higher, and the incidence of gout in elderly patients over 75 years of age is 7% for men and 4% for women, while gout in women of childbearing age is very rare. From the above data we believe that older women should also be aware of the problem of elevated blood uric acid and gout.
Many people are still confused about the relationship between hyperuricemia and gout, and it is important to clarify here. Just as high blood sugar is likely to be diabetes and high blood lipids are prone to atherosclerosis, people with high blood uric acid are prone to gout, and the higher the blood uric acid, the higher the incidence of gout. Also the higher the blood uric acid, the younger the age of onset of gout. The incidence of kidney stones in gout patients is 10% to 25%, which is higher than the general population.
It is important to note that most people with hyperuricemia are asymptomatic for life, with elevated blood uric acid found only on physical examination. The majority of the few patients who develop symptoms develop arthritis at the earliest and very quickly, which we call acute gouty arthritis. 90% or more of this arthritis is manifested as swelling and pain in a single joint, with the big toe being the most common.
In patients with hyperuricemia, if left untreated, gout stones can appear in 12% of cases after 5 years and 55% after 20 years. Gout stones are small stones that appear around a joint or in the auricle and are painful on pressure. Gout stones may appear earlier in patients with comorbid osteoarthritis, in patients with renal insufficiency, in heart failure patients treated with diuretics, and in organ transplant patients treated with cyclosporine. Other risk factors for the development of gout stones include alcohol abuse, high blood uric acid levels, and ineffective drug therapy.
Acute gouty arthritis: it comes and goes in a hurry
I believe many patients with gouty arthritis have had a similar experience as Mr. Dai, that is, a dinner party with friends, beer and seafood, a meal, but after a full meal, wash and sleep, but woke up at night by the sudden onset of severe foot pain, so much so that the red, swollen and painful toes do not dare to touch, not to mention walking on the ground. This is typical of acute gouty arthritis, which is the result of tossing and turning until dawn and going to the hospital for emergency treatment.
Gout is more common in men, usually between the ages of 40 and 60, and 85% to 90% of patients have their first episode as a single joint involvement, the most common site being the first metatarsophalangeal joint (big toe). The other joints are, in order, the dorsum of the foot, ankle, heel, knee, wrist, fingers, and elbow. Most patients have a sudden onset of the first attack, often waking up at night after a deep sleep. Within a few hours, the affected joints become red, swollen, warm and have significant pressure pain. Mild attacks may resolve within a few hours or last only 1 to 2 days, while severe attacks may last for days or weeks. After remission, the patient’s symptoms disappear completely.
There are many triggers for acute gouty arthritis attacks, including trauma, alcohol consumption, surgery, over-eating, bleeding, allogeneic protein therapy, infection, and use of radiographic contrast agents. Diuretic therapy is a very important trigger for the development of gouty arthritis in the elderly.
The period between two gout attacks is called the interval. Although some patients never have a second gout attack again, most patients have a second attack within 6 months to 2 years.
Third, the comprehensive treatment of gout: pay attention to the disease from the mouth
Diet and lifestyle changes are an important part of the prevention and treatment of hyperuricemia and gout. Weight loss and controlling the intake of high-purine foods are necessary. The so-called high-purine foods include beer, white wine, certain seafood, animal offal and broth. Strictly limiting the intake of purine-containing foods can reduce the blood uric acid level by 10% to 15% and effectively control gout attacks. Patients with gout attacks and uric acid stones should be encouraged to drink more water, more than 2 liters per day is recommended.
In addition, in terms of self-protection, cold compresses are an effective aid to control acute symptoms, and joint trauma and strenuous exercise should be avoided, the latter often being the trigger for acute gouty arthritis attacks. Patients with hyperuricemia and gout should strictly limit their alcohol intake, especially avoiding beer. In addition, studies have shown that there is no significant correlation between wine and high uric acid and that moderate wine consumption does not increase the risk of gout.
The patient should be warned that diet alone cannot bring blood uric acid to the desired level and that additional uric acid-lowering medications are necessary. Currently, there are two types of uric acid-lowering drugs, one is allopurinol, which inhibits uric acid synthesis, and the other is benzbromarone, which promotes uric acid excretion. Only under the comprehensive treatment of life conditioning, diet control and reasonable medication, the patient’s blood uric acid can be maintained at the ideal level for a long time, so as to achieve no or as little disease as possible.
Fourth, the standardized treatment of acute gouty arthritis
Many patients have a misconception that drugs that can lower uric acid can treat acute attacks of gouty arthritis, this concept is wrong. Acute gouty arthritis attacks first need to rest, drink more water, and take anti-inflammatory painkillers rather than uric acid-lowering drugs as soon as possible. On the contrary, applying uric acid-lowering drugs during the acute phase can aggravate arthritis symptoms and prolong the duration of gouty arthritis attacks. The following points are principles of treatment for acute gouty arthritis.
1.After the diagnosis of acute gouty arthritis, anti-inflammatory and pain-relieving treatment should be given immediately, and the drugs include non-steroidal anti-inflammatory drugs, colchicine and glucocorticoids, while the affected joints should be applied cold and activities should be avoided, and the above treatment process usually lasts about 1~2 weeks.
2, strictly grasp the timing of application of uric acid-lowering drugs, uric acid-lowering drugs are generally applied gradually after the symptoms of arthritis disappear. Patients with gout stones, patients with combined renal insufficiency, patients with uric acid stones, patients with recurrent gout attacks and patients who must continue to apply diuretics should be given uric acid-lowering drugs, and blood uric acid should be maintained at ≤360mmol/L.
3. Pay attention to the principles of uric acid-lowering drugs: Regarding the choice of uric acid-lowering drugs, it is generally believed that allopurinol therapy is preferred for patients without comorbidities, and the starting dose of this drug should be low (e.g. 50-100mg/d) and can be increased by 50-100mg every 2-4 weeks until the blood uric acid is reduced to the ideal level. Benzbromarone can be used in patients with mild to moderate renal insufficiency, in patients with impaired uric acid excretion, and in patients who cannot tolerate allopurinol or for whom allopurinol is not effective.