Data from the National Health and Nutrition Survey (NHANES) show that the prevalence of gout among Americans rose from 2.64% between 1988 and 1994 to 3.76% between 2007 and 2010. In order to standardize the treatment of gout and hyperuricemia, the American Rheumatism Association (ACR) formed and published the “ACR Gout Diagnosis and Treatment Guidelines” in 2012 on the basis of evidence-based research, literature analysis and expert discussion.
Compared with other gout guidelines, ACR guidelines describe in more detail the selection, dosage and precautions of gout uric acid-lowering drugs. Next, we will list this part of the ACR guide for your reference.
1.Xanthine oxidase inhibitor allopurinol and non-ibusine are the preferred uric acid-lowering drugs. Benzbromarone is not recommended. This is because there has been serious liver failure caused by benzbromarone in the United States. The drug has been ordered to withdraw from the market by the FDA. However, in other countries, there has been no such serious adverse reaction, which may be related to specific races.
The initial dose of allopurinol should not exceed 100 mg per day. Patients with moderate to severe chronic kidney disease should start with a smaller dose (50 mg per day), then gradually increase the dose until an appropriate maintenance dose is found. Maintenance dose can exceed the recommended standard dose of allopurinol (300 mg per day), even in patients with chronic kidney disease. For patients taking more than 300 mg per day, attention should be paid to itching, rash and elevated liver enzymes, so that side effects of allopurinol can be detected as soon as possible (i.e. severe drug eruptions).
For a specific population, such as Korean descendants, with chronic kidney disease of more than three grades at the same time; all Chinese Han and Thai descendants, because of the high positive rate of HLA-B*5801 (HLA-B*5801 is a high-risk gene for severe drug eruption induced by allopurinol), have an increased risk of severe allergic drug eruption associated with allopurinol, they should first carry out the rapid HLA-B*5801 gene before using allopurinol. PCR test, positive people are not recommended to take.
2.If a single xanthine oxidase inhibitor does not reach the treatment target (blood uric acid reaches the standard) after increasing to an appropriate dose, a drug that promotes uric acid excretion can be used in combination. These drugs include probenecid, fenofibrate and losartan available on the US market, but exclude benzbromarone and benzosulfonazole.
3.For severe gout patients, if they are resistant to or intolerant of traditional hypouric acid therapy, uric acid oxidase (such as Prekashi) can be used to treat them. However, there is no consensus on how long the medication cycle is appropriate. In gout patients, those who take low-dose aspirin (which may raise blood acid levels) to prevent cardiovascular disease do not need to stop taking it.
4.For patients with grade 2 to 5 nephropathy or end-stage nephropathy, if they have gout attacks and have hyperuricemia at present, they should be treated with hypouricemia; for the assessment of renal insufficiency, Ccr (endogenous creatinine clearance rate) is more important than serum creatinine; because there is no non-budesonide information on the safety of medication for patients with grade 4 or above chronic nephropathy, propionate can be used. Sulfonazole is a first-line drug; for those whose Ccr is less than 50 ml per minute, it is not recommended to use probenecid alone as a first-line drug.
5.In ACR guidelines, there are many choices of preventive medication in the process of reducing uric acid, and the course of treatment is also clear. Oral low-dose colchicine and non-steroidal anti-inflammatory drugs are the first-line drugs to prevent gout attacks. Colchicine 0.5 mg once a day or twice a day, or low-dose naproxen 250 mg twice a day, combined with proton pump inhibitors, is the first choice for the treatment of hyaluronic acid. When these drugs are ineffective, small doses of glucocorticoids can be used, such as Gunisone not exceeding 10 mg per day.
For those with signs of gout activity, prophylactic medication should last for 6 months. Signs of gout activity include: A, gout stone found in physical examination; B, recent acute gout attack; C, chronic gouty arthritis and/or blood uric acid failed to meet the standard. Or for patients treated with hypouric acid, continue to use until 3 months (no gout stone) or 6 months (gout stone).
Summary: There are differences in body weight and physique between Chinese and Americans, so there are also some differences in drug recommendation (drug type and dosage). Generally speaking, any medication for gout prevention and treatment needs to be comprehensively weighed in terms of its own condition, drug tolerance, economic situation, and so on. Moreover, any medication has its advantages and disadvantages. The most suitable medication is expensive medicine, which embodies the principle of individualized and precise medication.