What is gout?
Gout is a kind of metabolic arthritis in clinic. The main reason is that uric acid is deposited in the joint cavity, which promotes inflammatory reaction and causes joint pain, swelling or degeneration.
When it doesn't attack, we will forget its existence. Once it happens, it makes people feel worse than death.
This paper introduces three kinds of drugs used to treat gout.
First, analgesic drugs
1. Non-steroidal anti-inflammatory drugs: These drugs are the first choice for gout. Non-steroidal anti-inflammatory drugs can be divided into selective cyclooxygenase -2 inhibitors (such as celecoxib, aricoxi, etoricoxib, meloxicam, etc. ) and nonselective cyclooxygenase -2 inhibitors (such as diclofenac sodium, ibuprofen, nimesulide, loxoprofen sodium, etc. ). Compared with non-selective cyclooxygenase -2 inhibitors, selective cyclooxygenase -2 inhibitors have more adverse reactions to gastrointestinal tract.
How to choose two NSAIDs? If there are no gout patients with basic diseases, usually both drugs can be selected, and the difference is only in the speed of onset and maintenance time. For example, loxoprofen sodium tablets take effect quickly after taking it, 15 minutes or so. Gout patients have gastrointestinal risks, such as history of gastrointestinal diseases, old age, use of anticoagulants, combined use of hormones, etc. If the above situation exists, highly selective cyclooxygenase -2 inhibitor should be used, and gastric mucosal protective agent or proton pump inhibitor can be added to protect the stomach if necessary. Patients with gout with cardiovascular risk should choose non-selective NSAIDs, such as loxoprofen sodium tablets and diclofenac, but short-term use of highly selective cyclooxygenase -2 inhibitors is generally no problem.
Note that for gout patients with abnormal renal function, if there is an acute attack in the process of reducing uric acid, glucocorticoid should be chosen instead of non-steroidal anti-inflammatory drugs to control joint pain symptoms.
2. Colchicine: It is also a first-line drug to treat acute gout. Because the therapeutic window of colchicine is very narrow, it is more prone to toxic reactions when the dose is too large. The curative effect of colchicine on gout is no different from that of high dose colchicine. Therefore, the guidelines at home and abroad now suggest that the use of low dose colchicine can significantly reduce the occurrence of adverse reactions. But the common side effects of colchicine are diarrhea, abdominal pain and nausea. If diarrhea is severe, stop using it. We should also pay attention to possible liver and kidney damage and bone marrow suppression, and regularly monitor liver and kidney function and blood routine.
In order to prevent the acute attack of gout during the drug uric acid reduction treatment, the guidelines suggest that small doses of colchicine can be taken orally for 3-6 months.
3. Glucocorticoid: When non-steroidal anti-inflammatory drugs or colchicine have contraindications or poor therapeutic effects, or patients with acute gouty arthritis with severe systemic symptoms, only consider short-term application of glucocorticoid anti-inflammatory therapy to play its rapid anti-inflammatory and analgesic effects.
Second, uric acid lowering drugs
1, inhibiting uric acid production
Allopurinol and febuxostat are both drugs that inhibit uric acid production. Compared with allopurinol, febuxostat has three advantages: stronger uric acid lowering effect, higher safety and less allergic reaction; It can be excreted through the liver and kidney, so patients with liver and renal insufficiency can also use it. One disadvantage of febuxostat is that the risk of cardiovascular events is high after long-term use, so patients with congestive heart failure need to weigh the advantages and disadvantages. On the contrary, allopurinol can improve endothelial function and regional blood flow in patients with heart failure and hyperuricemia, which indicates that allopurinol can bring additional cardiovascular protection benefits.
Allopurinol and febuxostat have renal protective effects, and allopurinol and febuxostat should be selected instead of benbromarone for renal insufficiency.
2, increase uric acid excretion
Benzbromarone is a uric acid excretion promoting drug, which can promote uric acid excretion and reduce blood uric acid level by inhibiting uric acid reabsorption. Therefore, for patients with poor uric acid excretion, benzbromarone should be chosen. Through research, most patients with hyperuricemia in China belong to the type of poor uric acid excretion, so benzbromarone may be more suitable for China people. The serious adverse reaction of benbromarone is hepatotoxicity, and the incidence of hepatotoxicity increases when it is combined with allopurinol, simvastatin, atorvastatin, leflunomide and other drugs. In 2004, the State Administration of Medical Products warned of the risk of liver damage caused by benbromarone. Benzbromarone can increase the incidence of urinary calculi, but it is forbidden for urinary calculi and moderate renal insufficiency. During the treatment, it is necessary to drink plenty of water to increase urine volume or alkalize urine to avoid the formation of uric acid crystals.
Third, drugs for alkalizing urine.
1. sodium bicarbonate tablet: it is a commonly used drug for alkalizing urine at present. Because this product produces carbon dioxide in the stomach, it can increase the intra-gastric pressure, and long-term large-scale administration can cause alkalemia, and can induce congestive heart failure and edema due to the increase of sodium load. Uric acid in the morning and acetazolamide in the evening can increase the solubility of uric acid and avoid the formation of stones.
2. Potassium sodium citrate granules: alkalized urine. This product cannot be used for patients with acute and chronic renal failure, and it is also prohibited for severe acid-base imbalance (alkali metabolism) or chronic urinary tract urea decomposition bacteria infection.
It should be noted that patients with gout should avoid long-term use of therapeutic drugs that may cause elevated blood uric acid, such as thiazides, loop diuretics, low-dose aspirin, tacrolimus, cyclosporine, pyrazinamide, ethambutol, methotrexate and insulin.
Patients with gout should actively treat metabolic and cardiovascular risk factors related to the increase of serum uric acid, and actively control obesity, type 2 diabetes, hypertension, hyperlipidemia, coronary heart disease or stroke, chronic kidney disease, etc. Metformin, daglizine, atorvastatin, fenofibrate, losartan, etc. All of them have different degrees of uric acid reduction and blood sugar, blood lipid and blood pressure reduction, so they can be the first choice.
refer to
1. Rheumatology Branch of Chinese Medical Association. 20 16 China gout diagnosis and treatment guidelines (j) Chinese Journal of Internal Medicine 2016,55 (1): 892-899.