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▎WuXi AppTec content team editor
Gout is an inflammatory disease caused by monosodium urate deposition and is characterized
by acute and chronic arthritis.
If the patient is left untreated, gout symptoms can last for days or even weeks
.
In addition, with the exception of the asymptomatic "non-acute interval", the frequency and severity of gout attacks will gradually increase
over time.
Approximately 15% of patients with gout progress to advanced gout, which is characterized by the precipitation of tophi into subcutaneous nodules and carries a risk of persistent joint inflammation and potential joint erosion/deformity
.
It is worth noting that in recent decades, the incidence of gout has been increasing globally and has now become an important disease
that threatens people's health and quality of life.
The latest epidemiological survey shows that nearly 3.
9% of adults (> 20 years old) in the United States have been diagnosed with gout, and the incidence of gout in Chinese adults in the past 10 years is as high as 0.
86%~2.
20%.
Recently, the world's top medical journal "New England Journal of Medicine (NEJM) published a blockbuster review, focusing on the epidemiology, risk factors, interventions, treatment methods and future exploration directions of gout
.
Screenshot source: NEJM
These factors are associated with gout attacks!
Hyperuricemia is a necessary and insufficient condition for gout attacks, that is, patients with gout attacks must have hyperuricemia (ie, blood uric acid > 420 μmol/L), and patients with hyperuricemia may not necessarily have gout attacks, and the prevalence of hyperuricemia can be 3~5 times
the prevalence of gout.
Hyperuricemia and gout are influenced by genetic factors, specifically heritability up to 60%.
In addition, other risk factors for hyperuricemia and gout include: male sex, older age, dietary factors (excessive alcohol consumption, especially beer; excessive intake of high-purine foods such as meat, seafood, and animal offal; Low daily water intake; Intake of high fructose sweeteners, etc.
), lifestyle factors (low levels of physical activity, etc.
), obesity, kidney damage, use of drugs that cause elevated uric acid levels (such as diuretics).
It is worth noting that although epidemiological studies have confirmed that dietary factors, obesity, etc.
are associated with the risk of gout, the effectiveness of dietary and lifestyle interventions in gout management has been limited
.
A 2019 systematic review of data from 18 clinical trials of dietary interventions (e.
g.
, low-calorie diet, low-purine diet) showed that uric acid reductions from these interventions were generally small (<60 μmol/L).
Treatment of gout
First-line treatment for gout management and prevention: the goal of gout treatment is to rapidly relieve pain and restore joint function
.
First-line treatment for patients with gout should be individualized based on factors such as comorbid disease, and colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), and glucocorticoids
are currently recommended.
It should be pointed out that based on the key role played by NLRP3 inflammasomes in gout-related inflammation (such as activating and releasing interleukin-1), colchicine is currently used in the clinical treatment of gout to block NLRP3 oligomerization
.
In addition, parenteral corticosteroid therapy provides the most rapid pain relief
in patients with gout among recommended first-line regimens.
First-line urate-lowering therapy: Allopurinol is a xanthine oxidase inhibitor that has been the first-line drug for urate-lowering therapy since it was launched in the 60s of the 20th century
.
Other urate-lowering drugs include febuxostat (xanthine oxidase inhibitor), probenecid (a urate-prostatic drug), benzbromarone (a urate-producing drug), and pegolonase
.
At present, the goal of gout treatment is still controversial, and some guidelines believe that the treatment goal of patients with gout should be a target value of blood uric acid level (eg< 360 μmol/L</b10>); In addition, there are guidelines that the goal of gout treatment is to achieve resolution of patient-related symptoms (eg, long-term use of colchicine, NSAIDs, or glucocorticoids in the absence of urate-lowering therapy).
In addition, rapid decrease in uric acid levels may cause gout attacks, so the dose of the drug can be gradually increased during urate-lowering therapy, or prophylactic anti-inflammatory therapy can be used during the initiation and adjustment phase of urate-lowering therapy.
The review highlights that despite the existence of cost-effective treatments for gout, there is still significant room for improvement in the care of people with gout: although gout is a lifelong disease, more than half of people with gout stop urate-lowering therapy within 1 year of initiation of treatment, and this low adherence to treatment may improve with patient education and close follow-up
.
Image source: 123RF
Exploring directions in gout treatment
There are still many questions to be explored in the management of gout, including: what is the appropriate blood uric acid threshold for patients with advanced ventilation; whether long-term, substantial reduction of uric acid therapy (e.
g.
, blood uric acid <180 μmol/L)</b11>
