Febuxostat downgraded to second-line medication?

Only for medical professionals to read the reference super detailed! Standardized treatment of gout.
At the 2021 Annual Meeting of Rheumatology and Immunology Physicians of the Chinese Medical Doctor Association, Professor Xu Dong from Peking Union Medical College Hospital brought you "Standardized Treatment of Gout-2020 American College of Rheumatology (ACR) Guidelines Practice and Let us review the important contents of this wonderful report together
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01 Initial uric acid-lowering therapy (ULT) indications ▎Strong recommendation: start ULT for gout patients with any of the following conditions: subcutaneous tophi ≥1 (evidence level: high); there is evidence that there is any imaging caused by gout Damage (level of evidence: medium); or frequent gout (≥2 times/year)
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(Level of Evidence: High) ▎Conditional recommendation: Start ULT for patients who have had >1 seizures but infrequent seizures (<2 times/year)
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(Level of Evidence: Medium) When a gout patient has a gout attack for the first time, they are conditionally opposed to starting ULT immediately
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Except for the following cases: patients with first gout attack combined with moderate to severe chronic kidney disease (CKD) (grade 3 or higher), serum urate (SU) concentration> 9 mg/dl or urinary tract stones, if possible, it is recommended to start ULT
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(Level of Evidence: Medium) Patients with asymptomatic hyperuricemia (SU>6.
8 mg/dl, no gout attacks or subcutaneous tophi), are conditionally opposed to the use of ULT
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(Level of Evidence: High) According to the Guidelines for the Diagnosis and Treatment of Hyperuricemia and Gout in China in 2019, it is recommended that patients with gout with uric acid level ≥480μmol/L, or uric acid ≥420μmol/L and any of the following conditions should be initiated when uric acid-lowering therapy is initiated: The number of gout attacks ≥ 2 times/year, tophi, chronic gouty arthritis, kidney stones, CKD, hypertension, diabetes, dyslipidemia, stroke, ischemic heart disease, heart failure, and age of onset <40 years
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02 The choice of initial uric acid-lowering therapy for gout patients is strongly recommended for all patients, including patients with moderate to severe CKD (grade 3 or higher), with allopurinol as the first-line first-line drug for treatment
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For patients with moderate to severe CKD (grade 3 or higher), allopurinol or febuxostat is better than probenecid
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(Level of Evidence: Medium) It is strongly recommended that allopurinol and febuxostat start at a low dose [allopurinol ≤100 mg/day, (for CKD patients, the dose needs to be lower), febuxostat ≤40 mg/day] After treatment, the dose is titrated until the blood uric acid reaches the target
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(Level of Evidence: Medium) It is strongly recommended that ULT be used concurrently with preventive anti-inflammatory treatments [such as colchicine, non-steroidal anti-inflammatory drugs (NSAIDs), prednisone/prednisolone]
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Specific anti-inflammatory preventive measures should be selected individually according to the patient's condition
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(Level of Evidence: Medium) It is strongly recommended to maintain preventive anti-inflammatory therapy for 3 to 6 months (not less than 3 months), and closely follow-up and evaluate patients.
If there is still an attack of gout, continue preventive anti-inflammatory therapy as appropriate
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(Level of Evidence: Medium) Strongly oppose the selection of Precaxi as a first-line drug
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(Level of Evidence: Medium) Conditionally recommend starting treatment with a low-dose probenecid (500 mg, once or twice a day), and then the dose is titrated until the blood uric acid standard is reached
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(Level of Evidence: Medium) "Guidelines for the Diagnosis and Treatment of Gout in China in 2016" and "Guidelines for the Diagnosis and Treatment of Gout in 2020" point out: In the initial stage of uric acid lowering treatment, preventive use of small doses of colchicine (0.
5 mg, 1 to 2 times per day) for at least 3 ~ 6 months, can reduce the acute attack of gout
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When colchicine is ineffective or useful drugs are contraindicated, consider low-dose non-steroidal anti-inflammatory drugs as preventive treatment
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When the above two drugs are contraindicated or have poor efficacy, small doses of prednisone 5-10 mg/d can also be used to prevent seizures, but the side effects of long-term use of glucocorticoids should be noted
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03 Timing of initial uric acid lowering treatment When the patient is indicated for ULT treatment and is experiencing a gout attack, it is conditionally recommended to start ULT during the gout attack, not after the gout attack is relieved
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(Level of Evidence: Medium) It is strongly recommended that all patients receiving ULT treatment adopt a standard treatment strategy, and perform dose titration and subsequent dose adjustments based on continuous SU monitoring, rather than fixed-dose ULT treatment
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(Level of Evidence: Medium) It is strongly recommended that all patients receiving ULT achieve and maintain SU<6mg/dl
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(Level of Evidence: High) Conditional recommendation: Personnel other than clinicians deliver an authoritative dose adjustment plan to all patients receiving ULT in order to achieve as much as possible treatment strategies, including patient education, shared decision-making and treatment plans
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(Level of Evidence: Medium) 04 The duration of uric acid-lowering treatment is conditionally recommended to continue ULT treatment
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(Level of Evidence: Very low) 05 Recommendations for the use of specific drugs for uric acid-lowering therapy 1) Allopurinol Before starting allopurinol, it is conditionally recommended to perform HLA-B*5801 allele testing for Southeast Asian and African-American patients
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(Level of Evidence: Very Low) Conditionally oppose HLA-B*5801 allele testing before initiating ULT treatment in other patients
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(Level of evidence: very low) For patients who have allergic reactions to allopurinol but cannot be treated with other oral preparations, allopurinol desensitization treatment is recommended
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(Level of evidence: very low) 2) Patients who are taking febuxostat and have a history of cardiovascular disease or new cardiovascular-related events, where possible and without conflict with other recommendations in this guide , It is recommended to choose other ULT preparations instead
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(Level of Evidence: Medium) 3) Treatment with uric acid excretion drugs For patients who are considering or are using uric acid excretion drugs for treatment, it is possible to object to uric acid examination
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(Level of Evidence: Very low) For patients undergoing uric acid excretion therapy, there are conditions to oppose alkalinizing urine therapy
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(Level of Evidence: Very low) China: When using uric acid excretion uric acid-lowering drugs, attention should be paid to alkalinizing urine and maintaining urine pH between 6.
2 and 6.
9.
Patients with gout with normal heart and kidney function are advised to drink more water and maintain a urine volume of more than 2000ml It can increase the amount of uric acid dissolved and prevent the deposition of urate crystals in the kidney or the formation of stones
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06 When to change the uric acid-lowering treatment strategy For patients who received xanthine oxidase inhibitor (XOI) monotherapy at the maximum tolerated dose or according to the FDA instructions for the first time, SU was still not up to standard, and/or frequent gout attacks (> 2 times/year) or the subcutaneous tophus remains undissolved.
If possible, it is recommended to change to another XOI instead of combined uric acid excretion drugs
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(Level of Evidence: Very low) It is strongly recommended for patients who have failed to meet the SU target with XOI treatment, uric acid excretion drug treatment, and other interventions, and have persistent gout attacks (≥2 attacks/year) or subcutaneous tophus undissolved Switch to Precish treatment instead of maintaining the current ULT treatment plan
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(Level of Evidence: Medium) For patients who have failed to reach the SU target after XOI treatment, uric acid excretion drug treatment and other interventions, but have infrequent gout attacks (<2 times/year) and no tophi, it is strongly recommended to continue the current ULT Plan instead of converting to Precish
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(Level of Evidence: Medium) 07 Colchicine, non-steroidal anti-inflammatory drugs or glucocorticoids (oral, intra-articular or intramuscular) are strongly recommended as first-line drugs for the treatment of acute gout attacks
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(Level of Evidence: High) When colchicine is the drug of choice, low-dose colchicine is strongly recommended instead of high-dose colchicine due to similar efficacy and lower risk of adverse reactions
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(Level of Evidence: High) For patients with gout attacks, it is possible to recommend the use of topical ice as an adjuvant treatment
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(Level of Evidence: Low) For patients with gout attacks, if the above anti-inflammatory therapies are ineffective, poorly tolerated, or contraindicated, IL-1 inhibitors are recommended (except for support and analgesia)
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(Level of Evidence: Medium) For patients who cannot receive oral medications, intramuscular, intravenous or intraarticular injections of glucocorticoids are strongly recommended instead of IL-1 inhibitors or corticotropin
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(Level of Evidence: High) 08 Life>
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(Level of Evidence: Very Low) For patients with gout, regardless of their disease status, they are conditionally opposed to vitamin C supplementation
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(Level of Evidence: Low) "2016 Chinese Gout Guidelines": Limit alcohol; reduce high-purine food intake; prevent strenuous exercise or sudden cold; reduce intake of fructose-rich beverages; drink plenty of water (more than 2000ml per day); control weight ; Increase intake of fresh vegetables; regular diet and work and rest; regular exercise; smoking ban
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09 Combined medication management For patients with gout, regardless of their disease state: It is conditionally recommended that patients with gout switch hydrochlorothiazide to another antihypertensive drug when feasible
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(Level of Evidence: Very Low) It is conditionally recommended that Losartan should be preferred as a hypotensive drug when feasible
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(Level of Evidence: Very low) There is a conditional objection to discontinuation of low-dose aspirin (when the patient needs to be treated with aspirin due to relevant indications)
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(Level of Evidence: Very low) Conditionally oppose the addition or adjustment to fenofibrate, even if it has a certain uric acid-lowering effect
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(Level of Evidence: Very Low) In short, there are many highlights and updates in the 2020 ACR Gout Management Guidelines, as well as shortcomings
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Different countries and regions have different guidelines and recommendations for gout, a common disease.
We need to combine clinical research on the actual situation in China to provide the best treatment strategy and plan for the treatment of gout
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Source of this article: Medical Rheumatism Channel Author of this article: Jenny Responsible Editor: Xiao Dangdang Annual Survey of Clinical Pharmacy Channel of Medical World! Your opinion is very important to us! More good articles on clinical medication, follow the clinical pharmacy channel, and check the medical community strives to be accurate and reliable when the content is reviewed, but it is not about the timeliness of the published content, and the accuracy and completeness of the cited information (if any), etc.
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