慢性心力衰竭高尿酸血症和痛风的处理

痛风是由于尿酸结晶沉积在关节引起炎症、疼痛,甚至造成患者活动障碍的一组临床综合征。慢性心力衰竭患者经常伴随高尿酸血症,在这些患者中,痛风的处理是一个特殊的问题。由于心力衰竭患者对容量状态敏感和经常伴有慢性肾功能不全, 因而其痛风的治疗限制了非甾体类抗炎药和皮质类固醇激素的应用;同时,治疗高尿酸血症和痛风的药物与治疗心力衰竭的药物也存在相互影响。因此,现就慢性心力衰竭患者中高尿酸血症和痛风的处理作一综述。     

老年人痛风的临床特点及治疗

痛风的治疗已有基本的常规和策略［１,２］,然而,由于抗痛风药物较高的毒副作用及老年痛风病人常伴有高血压和肾功能不全等特点,治疗上有一定困难［３］。为防止抗痛风药物对老年患者的损害,必须仔细选择抗痛风药并调整其剂量。　　老年人痛风的特点６０岁以后发病的痛风（也称迟发型痛风）病人较少有强烈的关节剧痛,以钝痛的慢性关节炎较多见,易与常见的骨关节炎混淆,有时须经关节腔抽液检出尿酸盐结晶才确诊。在迟发痛风病人,极肥胖者并不常见［３］,但这些老人常有高血压和不同程度肾功能不全,应考虑痛风和这些伴发病治疗上的…     

痛风与心血管疾病

随着生活水平提高,痛风已成为常见病,并呈现年轻化的趋势。痛风被证实与心血管疾病的发生密切相关, 多项研究也表明痛风的心血管疾病共患率可达74%~91%。除了疾病本身,相关治疗药物,包括痛风治疗药物和心血 管治疗药物也对这两类疾病有着交互作用。本文就痛风与心血管风险、痛风治疗药物的心血管获益与风险、心血管 药物对痛风的影响等三方面进行讲述,以期加强临床对痛风的心血管风险的认识,对痛风和心血管疾病共患患者的 诊治有所帮助。     

心血管疾病患者急性痛风的治疗选择

急性痛风患者常合并心血管疾病,现有指南鲜有明确推荐的药物治疗方案.本文主要聚焦心血管疾病和急性痛风共病的患者群体,对心血管疾病患者发生高尿酸血症和(或)急性痛风的危险因素、痛风急性期抗炎镇痛治疗方案进行文献综述,以期减少心血管疾病患者痛风急性发作,并为临床药物治疗决策提供依据.     

老年原发性慢性痛风关节炎3种疗法的对照研究

目的探讨老年原发性慢性痛风关节炎3种不同的治疗方法的疗效、安全性和复发的相关因素。方法将2004-03~2005-04湖州市第三人民医院的87例老年原发性慢性痛风关节炎患者随机分为3组:A组31例采用一般治疗,B组32例在一般治疗的基础上加用羟氯喹维持治疗,C组24例在一般治疗基础上加用秋水仙碱维持治疗;观察期12个月。结果A、B、C3组病人治疗前后比较,痛风急性发作次数及血尿酸浓度明显下降(P<0·05)。B组、C组与A组比较,急性痛风关节炎发作次数更少(P<0·05)。入组前相关危险因素调查,不规范饮食控制、不规范使用激素、降尿酸药物、利尿药物、阿司匹林是老年慢性痛风关节炎急性复发的主要诱因,且多数为医源性。因药物相关的不良事件而终止观察,3组分别为A组4例(12·9%),B组3例(9·4%),C组11例(45·8%)。C组高于A、B组(P<0·05)。结论小剂量秋水仙碱、羟氯喹可减少老年慢性痛风关节炎的急性发作次数及降低血尿酸浓度;羟氯喹作为预防性治疗其耐受性和安全性可能更好;老年痛风关节炎患者须规范使用降尿酸药物,慎用利尿剂、阿司匹林。     

痛风治疗药物新进展

痛风是最为常见的炎症性关节病,已经成为"病中之王",给患者及其家庭和社会造成极大的经济负担。据全球数据预测,2018年急性痛风药物治疗经济负担为3.37亿美元,而降尿酸药物更要高达1.9亿美元~([1])。美国风湿病协会(ACR)和欧洲抗风湿病联盟(EULAR)先后颁布了痛风治疗指南,但是其中的药物治疗并不能覆盖目前所有痛风患者,特别是严重的痛风和对目前药物有使用禁忌证的患者。为     

痛风的诊断与治疗

伴随代谢综合征发病率、老年性肾损害患病率的增加及利尿剂的频繁应用，痛风的发病率增加、发病年龄渐年轻化，不典型及难治性痛风增多。痛风的诊断除依据高尿酸血症和临床表现外，还要对其病因、分期及机体损害的部位做出判断，为治疗提供理论依据。痛风的治疗在控制高尿酸血症同时要注意保护脏器、防止急性发作。本文结合新近文献资料，主要介绍了痛风的诊断和治疗，希望对临床医师提供帮助和参考。     

重视痛风疾病的诊治

痛风是一种炎症性关节炎。痛风有几个敏感性特异性高的临床诊断标准,而关节腔穿刺找到尿酸盐晶体仍是 诊断金标准,双能CT 和关节超声检查都对诊断痛风有帮助。急性痛风发作的治疗包括激素、非甾体类抗炎药、低剂 量秋水仙碱。对于发作频繁的痛风患者建议开始降尿酸治疗,药物包括别嘌醇和非布司他。     

痛风的诊治现状及展望

痛风的发病率和患病率逐年上升,我们对于痛风的诊断及相应的治疗也随之变化。患者的饮食、生活方式、 治疗目标及合并症的管理已成为诊疗核心。一些新的药物不断涌现,为诊治提供了新的手段。我们需要重新明确 新老药物的适应证,同时原有的治疗策略也进行新的补充和更新。     

痛风及其药物治疗的策略

痛风及其药物治疗的策略施桂英痛风系由嘌呤代谢的终未产物──尿酸单钠或尿酸结晶从超饱和的细胞外液沉积于组织引起的一组临床综合征。该综合征包括：①反复发作的特殊类型的急性炎性关节炎；②器官或组织中破坏性结晶的聚集，即痛风石；③尿酸性泌尿系结石；及少见的④...     

Difficult gout and new approaches for control of hyperuricemia in the allopurinol-allergic patient

A major obstacle to the treatment of hyperuricemia in patients allergic to allopurinol is the limited availability of suitable, equally effective, alternative, urate-lowering drugs. Conventional uricosuric drugs, including probenecid and sulfinpyrazone, are recommended for allopurinolintolerant patients with gout and “underexcretion” hyperuricemia who have normal renal function and no history of nephrolithiasis. Therapeutic options in those in whom traditional uricosuric drugs are contraindicated, ineffective, or poorly tolerated include slow oral desensitization to allopurinol and cautious administration of oxipurinol. Allopurinol desensitization is useful particularly in those who have failed other treatment modalities. If available (as in Europe, South Africa, and Japan), benzbromarone may be tried in patients with gout and mild-to-moderate renal insufficiency. Recombinant urate oxidase can be used in the short-term prophylaxis and treatment of chemotherapy-associated hyperuricemia in patients with lymphoproliferative and myeloproliferative disorders. Hyperuricemia and gout occur with increased frequency in cyclosporine-treated allograft transplant recipients. The management of gout in these patients is complicated by two main factors: cyclosporine-induced renal impairment, and interactions with medications used to preserve the allograft.     

Effectiveness of interventions for the treatment of acute and prevention of recurrent gout--a systematic review

OBJECTIVE: To determine the evidence for the effectiveness of treatments for acute gout and the prevention of recurrent gout. METHOD: Seven electronic databases were searched for randomized controlled trials of treatments for gout from their inception to the end of 2004. No language restrictions were applied. All randomized controlled trials of treatments routinely available for the treatment of gout were included. Trials of the prevention of recurrence were included only if patients who had had gout and had at least 6 months of follow-up were studied. RESULTS: We found 13 randomized controlled trials of treatment for acute gout, two of which were placebo controlled. Colchicine was found to be effective in one study; however, the entire colchicine group developed toxicity. The only robust conclusion from studies of non-steroidal anti-inflammatory drugs is that pain relief from indometacin and etoricoxib are equivalent. We found one randomized controlled trial, reported only as a conference abstract, of recurrent gout prevention. CONCLUSION: The shortage of robust data to inform the management of a common problem such as gout is surprising. All of the drugs used to treat gout can have serious side effects. The incidence of gout is highest in the elderly population. It is in this group, who are at a high risk of serious adverse events, that we are using drugs of known toxicity. The balance of risks and benefits for the drug treatment of gout needs to be reassessed.     

New Agents for the Treatment of Gout and Hyperuricemia: Febuxostat,Puricase, and Beyond

The rising prevalence of gout has led the pharmaceutical industry to rediscover what it had considered a forgotten disease. In April 2009, the Food and Drug Administration (FDA) approved febuxostat (Takeda Pharmaceuticals; Deerfield, IL), the first new urate-lowering gout drug in more than 40 years. In August 2009, the FDA approved colchicine for the treatment of acute gout. Several other pharmaceutical companies are also conducting clinical trials to test new drugs for acute and chronic gout. This article reviews new drugs and drugs in development in the management of acute and chronic gout.     

《2010年中国痛风临床诊治指南》解读

《2010年中国痛风临床诊治指南》指出,在诊断痛风时要特别注意痛风患者的病程阶段:即无症状高尿酸血症、急性痛风性关节炎或慢性痛风,强调关注患者是否为无症状高尿酸血症或痛风合并其它情况(糖尿病、高血压病,或心脑血管的危险因素)。除了合理应用非甾类抗炎药或糖皮质激素积极治疗急性关节炎急性发作外,痛风患者的综合管理尤为重要,包括对所有患者去除引起高尿酸血症的诱因及给予非药物干预(生活方式和饮食调整、减轻体重、适度饮酒,停用引起尿酸升高的药物等),有效控制合并症。对反复发作的、间歇期或慢性痛风患者给予降尿酸药物治疗以维持血尿酸水平低于327μmol/L,以及为严重的慢性痛风石患者寻找可能的手术治疗机会。     

Gota y corticosteroides: luces y sombras

Gout is usually treated with colquicine and non steroidal antiinflammatory drugs. However occasionally these drugs are contraindicated. Corticosteroids and ACTH hormone may be an attractive alternative in the treatment of acute gout.In the present paper we reviewed the role of corticosteroids and ACTH hormone in the treatment of acute gout.     

The effect of control and self-medication of chronic gout in a developing country. Outcome after 10 years

OBJECTIVE: We describe a 10 year observation of the effect of control of hyperuricemia compared with self-medication alone in patients with chronic gout. METHODS: We studied 299 consecutively self-referred Malayo-Polynesian men with chronic gout, mean age 35 +/- 14.3 SD years. Subjects comprised 228 cases with chronic gout without tophi or urolithiasis (Group 1) and 71 with those complications (Group 2). Attacks of acute gouty arthritis were treated with nonsteroidal antiinflammatory drugs (NSAID) and/or corticosteroids. After acute arthritis had settled, urate-lowering drugs were instituted in both groups combined with low dose colchicine and/or low dose NSAID for at least 0.5-2 years. Urate levels were maintained longterm at a mean of < 5 mg/dl. After 10 years, the dropouts were traced and evaluated for comparison with baseline and those who remained in the study. In Group 2 the urate-lowering drugs were continued. RESULTS: Control of gout and hyperuricemia was achieved in all patients who remained under control: 91.6% of the 299 patients for at least 2 years (short-term), up to 5 years in 87.5% (medium term), and up to 10 years in 79.6% (longterm). In Group 1 (chronic gout without complication) only 36.8% had no attacks during 8 years, after they had tapered urate-lowering drug after the first 2 years of the study. In the 61 dropouts the intermittent symptomatic treatment and/or self-medication without longterm control of hyperuricemia resulted after 1 decade in chronic gout with more complications and associated conditions leading to increased morbidity, disability, and comorbidity, and 3 early mortalities. CONCLUSION: By controlling hyperuricemia, improvement of the prognosis of chronic gout, comorbidity, and early death was achieved compared with self-medication alone. Self-medication in a developing country if continued unchecked may become a public health problem in a population with a high prevalence rate of gout.     

REVIEW: Management of gout: beyond allopurinol

The basic concepts of the pathogenesis and management of gout have not altered for many years. Monosodium urate monohydrate crystals drive the disease and identification of these crystals is required for certain diagnosis. In contrast, our understanding of the mediators of gouty inflammation, the appropriate target serum urate concentration during treatment, the drugs available and the best ways to use those drugs have all advanced in recent years and will be the focus of this review.     

Control of crystal-induced arthropathies

Present approaches to the treatment to crystal-induced arthropathies and indications for their use are reviewed. Successes and limitations of such therapy are discussed and potential new approaches to treatment are discussed. Treatment of gout hyperuricemia is generally effective if appropriately applied and is likely to be improved principally by better application of presently available drugs. New approaches to treatment may improve care for those patients in whom present approaches to management remain unsatisfactory.     

New and Pipeline Drugs for Gout

Gout is the most common inflammatory arthropathy in the western world. Affecting millions and accounting for lost wages, increased health care costs, and significant disability, it remains a burden for those afflicted, their families, and the health care system. Despite the availability of a number of effective therapies, gout is often inadequately treated, and its impact on the patients overall health and well-being is underestimated by physicians and patients alike. For many decades, controlling acute flares was the priority in the management of gout. More recently, however, a deeper understanding of gout pathophysiology has resulted in a new appreciation that gout impacts the patient with consequences well beyond the episodes of acute inflammatory arthritis. Reflecting the chronic nature of the disease, gout treatment needs to be chronic as well, and aimed at reducing the underlying cause of gout—hyperuricemia—as well as the symptom of acute attacks. Therapy therefore requires both urate lowering and anti-inflammatory strategies. Unfortunately, the most commonly used urate lowering and anti-inflammatory treatments may be problematic in some gout patients, who often have multiple comorbidities that establish relative contraindications. Novel urate lowering therapies, and new medications to treat and prevent acute gouty flares, can not only improve care of the individual; they can also lead to a better discourse for the edification of those who manage and are managed for this underestimated disease. In this paper, we discuss new and pipeline drugs for acute gout, prophylactic anti-inflammatory therapies as well as urate lowering therapies.