Rational use of colchicine, NSAIDs, glucocorticoids in gout

At present, the treatment drugs for acute attacks of gout mainly include colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids
.

Hyperuricemia is often caused
by disturbances in purine metabolism or decreased excretion of uric acid.
Gout is directly related to hyperuricemia caused by purine metabolism disorders or decreased uric acid excretion, and is a crystal-related arthropathy that induces local inflammatory response and tissue destruction due to the continuous increase of blood uric acid levels exceeding its saturation in blood or tissue fluid, causing sodium urate (MSU) crystals to be deposited locally in the joints, which belongs to the category of
rheumatism.

01Treatment of acute attacks of gout

Early treatment of patients with acute attacks of gout can effectively anti-inflammatory and analgesic and improve quality of life, and can achieve better prognosis
.
At present, the treatment drugs for acute attacks of gout mainly include colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids
.

Colchicine and NSAIDs are recommended as first-line medications, and glucocorticoids are recommended as second-line drugs
to prevent glucocorticoid abuse and repeated use to increase the incidence of tophi.
For severe acute gout attacks, polyarthritis or involvement of ≥ 2 large joints, or poor response to one drug, or those with other diseases that limit monotherapy, combination therapy with two or more analgesic drugs is recommended, including colchicine in combination with NSAIDs, colchicine in combination with systemic glucocorticoids, and intra-articular glucocorticoid injections in combination
with any other form.

Interleukin-1 (IL-1) blockers can be used in patients with frequent attacks of gout that do not respond well to colchicine, NSAIDs, and glucocorticoids or have contraindications, as well as patients with
refractory gout with recurrent pain that cannot be controlled by conventional drugs.
Tumor necrosis factor-α (TNF-α) antagonists can be used in patients with
refractory gout with recurrent pain that cannot be controlled by conventional drugs.

(1) Colchicine

Colchicine is the first-line drug for acute attacks of gout, which can be anti-inflammatory and analgesic and relieve swelling
.

Can cause kidney damage, bone marrow suppression, etc
.
eGFR< 10 ml/min or dialysis, myelodysplasia is prohibited
.
Colchicine should be used with caution or reduced in doses of P-glycoprotein or potent CYP3A4 inhibitors (such as erythromycin, clarithromycin, nifedipine, verapamil, diltiazim, cyclosporine A, nafinavir, ritonavir, etc
.
).

（2）NSAIDs

NSAIDs can be analgesic, anti-inflammatory, anti-rheumatism, antipyretic, and anti-swelling, including non-selective NSAIDs (eg, diclofenac, indomethacin, naproxen, ibuprofen, loxoprofen, flurbiprofen ester, ketorolac) and selective COX-2 inhibitors (eg, celecoxib, parecoxib, etoricoxib, etoricoxib, erexib), recommended for early and adequate dose, and are the first-line drugs in the acute phase of gout, such as fast-acting preparations etoricoxib, diclofenac sodium, meloxicam, etc
.

For those at high risk of gastrointestinal reactions, oral NSAIDs are recommended with selective COX-2 inhibitors
.
Those at risk of gastrointestinal bleeding are advised to prioritize selective COX-2 inhibitors
.

There is a risk of gastrointestinal reactions, renal ischemia, renal necrosis, and adverse cardiovascular events
.
Contraindicated in active
peptic ulcer/bleeding, recent gastrointestinal bleeding, myocardial infarction, recent coronary artery bypass grafting, eGFR<30 ml·min-1·(1.
73 m2)-1.

(3) Glucocorticoids

It can be anti-inflammatory, analgesic, reduce swelling, and can better relieve joint movement pain
.

Can cause sodium and water retention, hypertension, potassium loss, peptic ulcer, diabetes, Coshing-like syndrome symptoms, osteoporosis, steroid myopathy, infection, insomnia, etc
.
Patients with active peptic ulcer/bleeding, history of recurrent peptic ulcer/bleeding, liver cirrhosis, renal dysfunction, diabetes, osteoporosis, and hypothyroidism should be used
with caution.
Contraindicated in local or systemic bacterial, viral and fungal infections, those who have suffered or are suffering from serious mental illness, and those with severe osteoporosis
.
Joint injection is recommended to be applied to the same joint no more than 2~3 times a year, and the injection interval should not be shorter than 3~6 months
.

02 Prevention of acute attacks of gout during uric acid lowering therapy

After gout patients start taking urate-lowering drugs, in the early stage of urate-lowering treatment, due to the fluctuation of blood uric acid levels, tophi or urate crystals inside and outside the joint can be dissolved, which is easy to cause repeated attacks
of gouty arthritis.
Prophylactic medications are mainly colchicine, NSAIDs, and glucocorticoids
.

Low-dose colchicine is recommended for the prevention of gout attacks
.
Low-dose NSAIDs are recommended as second-line agents for the prevention of gout attacks
in patients who are intolerant to colchicine.
For those who are intolerant to colchicine and NSAIDs or contraindicated, such as chronic renal insufficiency, low-dose glucocorticoids are recommended as agents to prevent gout
.
NSAIDs and glucocorticoids need to be taken with gastric mucosal protectors
for long-term use.

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