【晨读】痛风的最新指南（四）

 英语晨读 ·

山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。

本次文献选自Drug and Therapeutics Bulletin. Latest guidance on the management of gout. BMJ. 2018 Jul 18;362:k2893. 本次学习由阎芳副研究员主讲。

Reducing the risk of recurrence

When should urate lowering therapy (ULT) beused?

The effectiveness of ULT in preventing gout flares and longterm complications is much debated. The updated EULAR andBSR guidelines advise that ULT should be considered anddiscussed with every patient from the first presentation. ULTis recommended for patients with recurrent attacks (two or morea year), tophi, urate arthropathy, or renal impairment. Theguidelines also suggest that ULT should be initiated close tothe time of first diagnosis in patients who are young (<40 yearsold), have a high serum uric acid level (≥480 μmol/L), are usingdiuretics, or have comorbidities (such as renal impairment,hypertension, ischaemic heart disease, or heart failure).Therecommendation to initiate ULT earlier was based on expertopinion and influenced by epidemiological data that gout wasassociated with increased mortality from coronary heart diseaseand renal disease. However, randomised evidence of benefit islacking.

降低复发风险

什么时候应该使用降尿酸疗法？

ULT在预防痛风发作和长期并发症方面的有效性存在很大争议。最新的EULAR和BSR指南建议，从第一次痛风发作时起，就应与患者探讨ULT的相关事项。对于反复发作（一年两次或两次以上）、痛风石、尿酸性关节病或肾功能损害的患者，建议使用ULT。该指南还建议，对于年轻（<40岁）、血清尿酸水平高（≥480μmol/L）、正在使用利尿剂或有合并症（如肾功能损害、高血压、缺血性心脏病或心力衰竭）的患者，应在首次诊断痛风时开始进行ULT。基于专家意见，以及流行病学数据显示痛风与冠心病和肾病死亡率增加相关，建议早期启动ULT。然而，早期启动ULT的获益缺乏随机研究的证据。

In contrast, the American College of Physicians guidelineadvises against initiating long term ULT in most patients aftera first gout attack or in patients with infrequent attacks. Onlymoderate quality observational evidence has shown that patientswith lower serum uric acid levels had fewer flares than thosewith higher levels.

相比之下，美国医师学会的指南建议大多数痛风首次发作或不常发作的患者不要开始长期的ULT。只有中等质量的观察证据表明，血清尿酸水平较低的患者比血清尿酸水平较高的患者发作较少。

The target level for serum uric acid differs between guidelines.The BSR recommends an initial target of 300 μmol/L. A highertarget of 360 μmol/L is advocated when tophi have resolvedand the patient remains free of symptoms. EULAR suggests aninitial target of 360 μmol/L. Many treated patients do notachieve target serum uric acid reductions. There is currently insufficient evidence to recommend ULT forasymptomatic people with raised serum uric acid levels.

不同指南所制定的的血尿酸目标水平不同。BSR建议初始目标值300μmol/L。当痛风石消失且患者无症状时，建议可以提高目标值至360μmol/L。EULAR建议初始目标为360μmol/L。许多接受治疗的患者没有达到血清尿酸降低的目标值。目前没有足够的证据建议对血清尿酸水平升高的无症状人群进行ULT治疗。

Which drugs are recommmended?

The main classes of urate lowering drugs are the xanthineoxidase inhibitors, which decrease production of uric acid (suchas allopurinol and febuxostat), and uricosuric agents, whichincrease renal excretion of uric acid (such as sulfinpyrazoneand benzbromarone, which is not licensed in the UK). In theUK, uricosuric drugs have a limited role and are usually initiatedonly by a rheumatologist.

推荐哪些药物？

降低尿酸盐的药物主要有黄嘌呤氧化酶抑制剂，可减少尿酸的产生（如别嘌呤醇和非布司他），以及排尿酸药，可增加尿酸的肾排泄（如磺吡酮和苯溴马隆，在英国没有许可证）。在英国，排尿酸药的作用有限，通常只有风湿病学家才使用。

AllopurinolAllopurinol is recommended as first line therapy when renalfunction allows. A Cochrane review (11 studies, 4531participants)found moderate quality evidence that, comparedwith placebo, allopurinol (100–300 mg daily) probably doesnot reduce the number of acute gout attacks but does increasethe proportion of people achieving target serum uric acid levelswithout increasing withdrawals due to adverse effects or seriousadverse event rates.

别嘌呤醇

当肾功能允许时，别嘌呤醇推荐作为一线治疗。一项系统性综述（11项研究，4531名参与者）发现，与安慰剂相比，中等质量的证据表明，别嘌呤醇（每日100-300毫克）可能不会减少急性痛风发作的次数，但确实会增加达到目标血尿酸水平的人数比例，而不会因不良反应或严重不良事件率而停药。