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*For medical professionals only
It's really full of dry goods~
hyperuricemia (HUA) due to disturbance of purine metabolism and/or decreased uric acid excretion.
As early as the 5th century BC, Hippocrates recorded the clinical manifestations of gout
.
The word gout is derived from the Latin Guta (a drop), which means a drop of harmful liquid that causes joint damage, and the pain is like a gust of wind, coming and going quickly, hence the name gout
.
Gout can be complicated by renal lesions, and in severe cases, joint destruction and renal function damage may occur, often accompanied by hyperlipidemia, hypertension, diabetes, arteriosclerosis and coronary heart disease
.
The huge number of sick people and the trend of younger diseases have caused a heavy burden
on families and society.
The "Medical Rheumatology and Immunology Channel" invited Professor Zhu Xiaoxia from the Department of Rheumatology and Immunology of Huashan Hospital affiliated to Fudan University to share with us those things
about gout.
Gout "son preference"? It's true!
5% and 3.
6%, respectively, especially the prevalence of young men aged 18 to 29 years was close to 33%, such a significant difference was mainly caused by the following aspects:
Men consume more: Men's daily diet intake of high-purine foods such as seafood, animal offal, and red meat is significantly higher
than that of women.
Male metabolism is higher than female metabolism: 80% of uric acid in the human body comes from its own endogenous metabolism, and only 20% is exogenously ingested
.
Male muscles are much more developed than women, and muscle cell metabolism can produce a lot of uric acid, so men's blood uric acid will be higher
than women's.
Outpatient clinics will also find that the blood uric acid levels of some male fitness fanatics are significantly higher than others, which is also reasonable
.
Protective effect of female estrogen: estrogen is a protective endogenous hormone that can promote the excretion of uric acid by the kidneys, so the blood uric acid level of women of childbearing age is relatively low, especially around 20
years old.
However, after menopause, a woman's blood uric acid level gradually increases
.
.
3 major auxiliary examinations, each with its own advantages and disadvantages
We know that at present, in addition to routine laboratory tests, blood uric acid determination, uric acid determination, imaging examination is also very important, and there are three commonly used imaging tests in clinical practice: 1, X-rays: X-ray film can be seen that the subchondral bone destruction caused by MSU crystal deposition is manifested as eccentric round or oval cystic changes, and even insect-like and piercing defects, and the edge of the bone defect can be "hanging edge sign".
In the late stage, the joint space may be significantly narrowed or even disappeared, forming fibrotonic rigidity, joint subluxation or dislocation, and even pathological fractures
.
X-rays of patients with early gout showing soft tissue edema or local inflammation have limited
diagnostic value.
When bone destruction occurs in middle or late gout, it is often irreversible
.
2.
Dual-energy CT: Dual-energy CT is different from ordinary CT, dual-energy CT can accurately distinguish different tissue components in joint anatomy, display different colors, and can display MSU deposition
in three-dimensional and three-dimensional MAG.
Dual-energy CT examination is rapid and non-invasive, can detect early MSU deposition without clinical symptoms, and has strong objectivity, which is very helpful for diagnosis
.
At the same time, joint bone destruction or other damaging lesions
can also be evaluated.
The disadvantage is that the price is more expensive, there is a certain amount of radiation, and many hospitals do not currently carry out this examination, which causes certain inconvenience
to patients.
3.
Joint ultrasound: synovial hyperplasia, joint inflammation, and bone and cartilage morphology and other joint and surrounding tissue lesions can be evaluated
by ultrasound examination.
Ultrasound features such as tophi, double-track sign, aggregate, and snowstorm sign are specific manifestations
of musculoskeletal ultrasound for the diagnosis of gouty arthritis.
In addition, ultrasound can clearly show the surface of the bone cortex to observe whether there is bone erosion; Ultrasound synovial inflammation and hyperplasia of the joint cavity has a high value in evaluating the severity of inflammation, and the blood flow signal is observed by energy Doppler to determine the severity
of inflammation.
In addition, it has the advantages
of economy, convenience and no radiation.
However, the disadvantage is that it cannot detect small bone destruction, and because ultrasound is a human-evaluated examination operation, the detection results depend on the level of the operator, there may be certain errors, and the operator cannot detect the part that the probe cannot reach during the operation, so it is difficult to make a comprehensive assessment
.
3 tips to control acute attacks of gout
The treatment of gout has always been a topic of concern for everyone, and the current first-line drugs for the treatment of acute attacks of gout are colchicine, NSAIDs and glucocorticoids, and Professor Zhu Xiaoxia explained in detail some of the problemsthat need to be paid attention to in the process of medication.
1.
Colchicine
It can inhibit neutrophil chemotaxis to the joint, and early use of colchicine is recommended, especially before 36 hours, preferably within
12 hours.
Because after 36 hours, the inflammation has reached its peak and neutrophils have chemoted to the joints, then the effect of colchicine will not be able to exert its extreme
.
The instructions will also deceive: at present, the instructions for colchicine are still the usual amount for adults to take 0.
5~1mg orally every 1~2 hours, until the joint symptoms are relieved, or diarrhea or vomiting occurs, and the therapeutic amount is generally 3-5mg, and it should not exceed 6mg
within 24 hours.
Studies have shown that there is no significant difference between small doses and toxic doses of colchicine in the treatment of gout, and high-dose application of colchicine may have bone marrow suppression, liver and kidney insufficiency in addition to gastrointestinal adverse reactions such as diarrhea and vomiting
.
Why hasn't the manual been amended in this case? It is because the indications for modifying the instructions must be supported by RCT studies, but there are no RCT studies yet, so the instructions have not been modified, so patients will still use according to the instructions, which is currently a more contradictory point
.
Colchicine correct opening method: it is recommended to add 0.
5mg after 1 hour, change to 0.
5mg after 12h, 1-3 times a day, depending on the condition and liver and kidney function
.
If the effect is not good, and then switch to other drugs, it is not recommended to increase the dose of colchicine, so the use of colchicine still needs to be cautious
.
Renal insufficiency: In patients with renal insufficiency, it is necessary to reduce the dose as appropriate, and calculate the dose
according to the renal function index.
eGFRshould be reduced at 30~50ml/min, and eGFR should be disabled when < 30ml/min<b30>.
2.
Non-steroidal anti-inflammatory drugs (NSAIDs)
to use.
The general principle is to use rapid-acting formulations as early as possible and in full doses.
However, it should be used
with caution in patients with old age, liver and kidney insufficiency, hypertension, previous peptic ulcer, bleeding, and perforation.
3.
Glucocorticoids
.
Because the study found that the analgesic effect of glucocorticoids in the acute attack of gout is similar to that of NSAIDs, but for patients with abnormal liver and kidney function, the use of the above two drugs is limited
.
Although there are also certain adverse reactions, such as hyperglycemia, hypertension, infection, etc.
, for patients with chronic renal insufficiency, the safety of using hormones is better
.
Kidney damage + gout, medication should be vigilant
Renal impairment is the second most common comorbid condition of hyperuricemia and gout, what should patients with gout and kidney disease pay attention to when undergoing uric acid-lowering therapy? Professor Zhu Xiaoxia emphasized that because renal insufficiency can cause a decrease in blood uric acid excretion, resulting in an increasein blood uric acid.
Conversely, if blood uric acid is elevated for a long time, it can also cause acute or chronic renal impairment
.
Therefore, when renal insufficiency and gout are found, it is first necessary to judge the causal relationship, clarify the cause of renal function damage as soon as possible, and then reverse or restore kidney function as much as possible, which is the most basic principle
.
On top of this principle, we choose uric acid-lowering drugs
.
Allopurinol and febuxostat: in patients with renal insufficiency, drugs that inhibit uric acid production are allopurinol or febuxostat.
It should be noted that in addition to monitoring routine adverse reactions, the occurrence of allopurinol hypersensitivity reaction is significantly correlated with HLA-B*5801 positivity, and the frequency of carrying this genotype in Han people is 10%~20%, so domestic and foreign guidelines are on HLA-B*5801 Allopurinol is not recommended in positive patients, and HLA-B*5801 is best tested before taking allopurinol for the first time in areas where conditions permit.
In patients with renal insufficiency, the dose
of allopurinol can be adjusted according to eGFR.
When the eGFR is 15~60ml/min (equivalent to CKD stage 3~4), the amount of allopurinol should be reduced; When eGFR < 15 ml/min (equivalent to CKD stage 5), allopurinol should be disabled<b22>.
In patients with moderate to severe renal insufficiency, it is recommended to start with a small dose and adjust the start, increment, and maximum dose
according to renal function.
- Benzbromarone: Benzbromarone inhibits tubular reabsorption of uric acid by inhibiting the renal proximal tubular MSU transporter 1 (URAT-1) to promote uric acid excretion, and patients with mild to moderate renal impairment or eGFR> 60 ml/min do not need to adjust the dose The usual dose is 50mg/d, and the maximum dose is 100mg/d
.
It is not recommended for patients with eGFR<30ml/min</b17>
The treatment effect is not good, what is the difficulty?
There is also some refractory gout, which is a focus of clinical attention, and there is currently no clear definitionof refractory gout in the world.
The difficulty is mainly reflected in two aspects, the symptoms of arthritis are difficult to control and uric acid cannot be
reduced under standard treatment.
If the patient does not respond well to the three acute anti-inflammatory drugs, and the joint still repeatedly swells and pains, a combination of the two anti-inflammatory drugs can be considered at this time:
of the digestive tract.
Lowering blood uric acid: urate-lowering treatment needs to meet the standard for a long time, but for a urate-lowering drug titrated to the maximum dose, still can not meet the standard, considering that the patient may not be sensitive to the drug, we first consider to change the drug, if the change of the drug can not meet the standard (4~5 weeks later), then consider the combination of drugs: advocate inhibition of uric acid production drugs combined with drugs
to promote uric acid excretion.
Start with your daily diet: keep your mouth shut
The diet of gout patients has always been a hot topic, the purpose of dietary control is not only to reduce blood uric acid levels and reduce acute attacks of gout, but more importantly, to promote and maintain an ideal health state, prevent and properly manage complications of gout patients, gout patients need to pay attention to the following problemsin terms of diet.
Professor Zhu Xiaoxia emphasized that if patients strictly follow the above standards, it will seriously affect their own quality of life, and it is recommended that patients try not to eat "avoidance" and "restricted intake" foods in the acute phase, and when the control of blood uric acid is relatively stable in the intermittent period, it can be eaten appropriately to achieve a balanced
diet.
Sport is king
In the non-acute attack of gouty arthritis, it is necessary to adhere to reasonable exercise.
Exercise helps to prevent gout attacks, but also to strengthen the body, the current recommended exercise methods are: 1, hyperuricemia patients are recommended to exercise
regularly.
2.
The exercise of gout patients should start from low intensity and gradually transition to medium intensity to avoid strenuous exercise
.
Strenuous exercise can increase sweating, reduce blood volume, renal blood flow, reduce uric acid excretion, and even induce gout attacks
.
In addition, excessive movement of common joints is also easy to induce recurrence of gout
.
In the acute phase of gout, rest is the main thing, interrupting exercise, which is conducive to the resolution of inflammation
.
3.
The number of exercise should be 4-5 times per week, 0.
5-1h
each time.
Aerobic exercises such as jogging, tai chi, swimming, etc
.
can be used.
4.
During or after exercise, drink an appropriate amount of water to promote uric acid excretion
.
Avoid drinking large amounts of water quickly to avoid burdening
your body.
Because low temperature is easy to induce acute attack of gout, cold baths
should be avoided after exercise.
5.
For patients with cardiovascular and pulmonary underlying diseases, exercise intensity and exercise time
should be moderately reduced.
Expert profile
: Zhu Xiaoxia Deputy Chief Physician
, Department of Rheumatology and Immunology, Huashan Hospital Affiliated to Fudan University
Member of Rheumatology Branch of Shanghai Medical Association
Member and Secretary of the Youth Committee of the Rheumatology Branch of the Chinese Medical Association
Member and Secretary of Gout Group of Rheumatology and Immunology Branch of Chinese Medical Doctor Association
Vice Chairman of the Youth Committee of the Immunotherapy Engineering Branch of the Chinese Society of Biomedical Engineering
Member and Secretary of the Gout Group of the Rheumatology and Immunology Professional Committee of the Cross-Strait Medical and Health Exchange Association
Member and Secretary of the Expert Committee on Hyperuric Acid and Gout of the Chinese Geriatrics Committee
From October 2009 to April 2011, he studied abroad at Harvard Medical School
Main achievements: He has presided over a number of international, provincial and ministerial projects such as the National Natural Science Foundation of China, the special scientific research fund for doctoral disciplines in colleges and universities of the Ministry of Education, the promotion of appropriate technology of Shanghai Shenkang Development Center, and published a number of SCI and core journal publications
Where to see more rheumatology clinical knowledge? Come to the "doctor station" and take a look 👇
at the source of this articleMedical Rheumatology and Immunology ChannelSkin Shrimp This article reviewZhu Xiaoxia Deputy chief physician responsible editorCassette
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