【晨读】痛风的最新指南（三）

 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。

Colchicine

In a Cochrane review (2 trials, 124 participants)high and lowdose colchicine reduced the pain of acute gout, but higher doseswere associated with more gastrointestinal adverse effects(diarrhoea 23% v 77%; severe diarrhoea 0 v 19% in one trial). Several guidelines recommend using a low dose regimen ofcolchicine.The British Society of Rheumatology (BSR)guideline suggests a dose of colchicine 0.5 mg two to four timesdaily but recognises that higher doses are often associated withgastrointestinal adverse effects.  In the UK, the licensed doseof colchicine is 1 mg followed by 0.5 mg after 1 hour; after 12hours, treatment can resume with a maximum dose of 0.5 mgevery 8 hours until symptoms are relieved with no more than 6mg per course and at least three days between courses.

秋水仙碱

在一项系统性综述中（2项试验，124名参与者），高剂量和低剂量秋水仙碱均可减轻急性痛风的疼痛，但高剂量秋水仙碱会导致更多的胃肠道不良反应（腹泻23%对77%；严重腹泻0%对19%）。一些指南建议使用低剂量的秋水仙碱方案。英国风湿病学会（BSR）指南建议秋水仙碱的剂量为0.5毫克，每天2到4次，并且指出剂量越大，胃肠道不良反应发生率越高。在英国，秋水仙碱的许可剂量为起始1毫克，1小时后追加0.5毫克；如有必要，12小时后可再服用0.5毫克，最大剂量为每8小时0.5毫克，直至症状缓解。每疗程总量不超过6毫克，两疗程间隔至少3天。

In people with moderate renal impairment, a lower starting doseor longer duration between doses is recommended. In patientswith normal renal or liver function who are taking cytochromeP450 3A4 inhibitors (such as ritonavir, clarithromycin,itraconazole, ketaconazole, and diltiazem) or p-glycoproteininhibitors (such as ciclosporin), the dose of colchicine shouldbe reduced by 50% or 75% depending on the interacting drug.There have been case reports of myopathy and rhabdomyolysisassociated with the use of colchicine in people with renalimpairment who were also taking simvastatin or atorvastatin.

对于中度肾功能损害的患者，建议使用较低的起始剂量或较长的间隔时间。对于肾或肝功能正常，但正在服用细胞色素P450 3A4抑制剂（如利托那韦、克拉霉素、伊曲康唑、氯胺康唑和地尔硫卓）或p-糖蛋白抑制剂（如环孢素）的患者，由于存在药物间的相互作用，秋水仙碱的剂量应减少50%或75%。有病例报告称，在同时服用辛伐他汀或阿托伐他汀的肾功能损害患者中，使用秋水仙碱与肌病和横纹肌溶解症的发生有关。

Corticosteroids

European League Against Rheumatism (EULAR) and BSRguidelines recommend a short course (3–5 days) of an oralcorticosteroid (30–35 mg/day prednisolone) in patients unableto tolerate NSAIDs or colchicine.Although there is noevidence from randomised trials to support the use ofintra-articular corticosteroid injections in acute gout, clinicalexperience and expert opinion suggests that such injections canbe helpful, particularly in for gout affecting a single joint orwhere comorbidity precludes other treatments.In patients where monotherapy is insufficient for treating acuteflares, a combination of NSAIDs with either intra-articularcorticosteroid, oral steroid, or colchicine may be used.

皮质类固醇

欧洲抗风湿病联盟（EULAR）和BSR指南建议不能耐受NSAIDs或秋水仙碱的患者短期（3-5天）口服皮质类固醇（30-35毫克/天强的松龙）。尽管随机试验中没有证据支持关节内注射皮质类固醇治疗急性痛风，但临床经验和专家意见表明，这种注射是有帮助的，特别是对于影响单个关节或由于存在合并症而不适合采用其他治疗方法的痛风患者。在单一疗法不足以治疗急性发作的患者中，可以使用非甾体抗炎药与关节内皮质类固醇、口服类固醇或秋水仙碱的联合治疗。

Interleukin-1

inhibitorsCanakinumab is expensive (£9 928/dose), and effectiveness ismarginal according to a Cochrane review. The National Institute for Health and Care Excellence (NICE) has notpublished guidance on canakinumab’s use. It is notrecommended for use in NHS Scotland or NHS Wales.

白细胞介素-1抑制剂

卡那单抗价格昂贵（9 928英镑/剂），根据一篇系统性综述报道，其有效性微乎其微。英国国家卫生与保健优化研究所（NICE）尚未公布卡那单抗的使用指南。而苏格兰或威尔士的国家医疗体系则不建议使用卡那单抗。