痛風患者高尿酸血癥之治療

1、痛風患者高尿酸血癥之治療（Therapy for hyperuricemia in gout）,主題選取的考量,常見的疾病—高盛行率醫(yī)療花費增加臨床治療標準不一國際已有治療指引,主題選取的考量常見的疾病—高盛行率,資料來源：PubMedKeyword: Hyperuricemia in Taiwan16篇 since 1968 to 2004,主題選取的考量常見的疾病—高盛行率,Chang HY, Pan WH, Ye

2、h WT, Tsai KS. Hyperuricemia and gout in Taiwan: results from the Nutritional and Health Survey in Taiwan (1993-96). J Rheumatol. 2001 Jul;28(7):1640-6. Population: 2754 males and 2953 females aged 4 years and older

3、The prevalence of hyperuricemia in aboriginal males and females：＞50﹪,主題選取的考量常見的疾病—高盛行率,Lai SW, Tan CK, Ng KC. Epidemiology of hyperuricemia in the elderly. Yale J Biol Med. 2001 May-Jun;74(3):151-7. Time： 1998 M

4、ayPopulation：586 (66% Men & 34%Women) mean age was 73.1+/-5.3 years The proportions of hyperuricemia ： (p < .01) 57.3 ﹪in men 40.9 ﹪ in women,主題選取的考量常見的疾病—高盛行率,Liu CS, Li TC, Lin

5、CC. The epidemiology of hyperuricemia in children of Taiwan aborigines.Rheumatol. 2003 Apr;30(4):841-5. Time： from March to May 2001 Place：central Taiwan Population：the Bunun tribe ，Children aged 4-13 A total of 4

6、14 children (mean age, 8.9 +/- 2.1 yrs) were recruited. Hyperuricemia was defined as uric acid > 416.5 micromol/l (7 mg/dl) in boys and > 357 micromol/l (6 mg/dl) in girls Ninety of 224 girls (40.2%) and 56 of 19

7、0 boys (29.5%) were hyperuricemic.,主題選取的考量常見的疾病—高盛行率,CHOU Chungtei 周昌德 Hyperuricemia and gout among Taiwan Aborigines and Taiwanese-prevalence and risk factors Chin Med J 2003;116(7):965-967 The prevalence of hyperur

8、icemia and gout in Atayal Aborigines to be 41.4% and 11.7%, respectively. 27% to 45% of aboriginal boys and 13% to 41% of aboriginal girls had hyperuricemia. Kinmen：the prevalence of hyperuricemia in men was 25.8% (391

9、/1515) through more than 6 years of follow-ups on 223 asymptomatic hyperuricemic patients, the 5-year cumulative incidence of onset of gout was 18.8% (42/223). The incidence increased with three different baseline leve

10、ls of uric acid, from 10.8% (7.0＜ uric acid＜8.0), to 27.7% (8.0＜uric acid <9.0), to 61.6% (uric acid＞9.0).,主題選取的考量國際已有治療指引,資料庫：PubMedKeyword: Hyperuricemia guideline 8篇，since 1996 to 20031: Meyers OL, Cassim B, M

11、ody GM. Hyperuricaemia and gout: clinical guideline 2003. S Afr Med J. 2003 Dec;93(12 Pt 2):961-71.  2: Nakajima H, Matsuzawa Y. [Introduction of the new guideline for the management of hyperuricemia and gout

12、with special reference to its policy] Nippon Rinsho. 2003 Jan;61 Suppl 1:442-9.  3: Tatsuno I, Saito Y. [Hyperuricemia and atherosclerosis] Nippon Rinsho. 2003 Jan;61 Suppl 1:259-65. Review.,主題選取的考量國際已有治療指引,4

13、: Nakajima H. [Definition and determination of serum uric acid level] Nippon Rinsho. 2003 Jan;61 Suppl 1:154-7.  5: Nakajima H. [Management of hyperuricemia in occupational health: with reference to "guid

14、elines for the management of hyperuricemia and gout"] Sangyo Eiseigaku Zasshi. 2003 Jan;45(1):12-9. Review. Japanese. 6: Gorter KJ, Romeijnders AC. [The standard 'hyperuricemia' from the Dutch Family

15、 Physician; reaction from rheumatology and general medicine] Ned Tijdschr Geneeskd. 2002 May 4;146(18):872; author reply 872-3. Dutch.  7: Chalmers J. [Role of diuretics in the treatment of hypertension: from la

16、rge controlled trials to international guidelines] Arch Mal Coeur Vaiss. 1996 Sep;89 Spec No 4:39-43. Review. French. 8: Cummins D, Sekar M, Halil O, Banner N. Myelosuppression associated with azathioprine-allopurino

17、l interaction after heart and lung transplantation. Transplantation. 1996 Jun 15;61(11):1661-2.,目前製作guideline之目的,臺灣地區(qū)高尿酸血癥的盛行率驚人，尤其施行成人健康體檢後，門診診療中常遇到病人詢問高尿酸血癥該如何處理。而目前因無統(tǒng)一的guideline可供依循，治療標準不一，常造成醫(yī)師及患者的困擾。期待檢視文獻後，能提供有用的

18、資訊，建立使用降尿酸藥物之臨床底線，以為臨床診療之準則。,臨床問題1：無癥狀之高尿酸血癥需不需要治療？,資料來源：PubMedKeyword: Asymtomatic hyperuricemia and treatment and review 23篇，since 1977 to 2003,臨床問題1：無癥狀之高尿酸血癥需不需要治療？,Dincer HE, Dincer AP, Levinson DJ. Asymptomat

19、ic hyperuricemia: to treat or not to treat. Cleve Clin J Med. 2002 Aug;69(8):594, 597, 600-2 passim. Publication Types: ·         ReviewTreatment of asymptomatic hype

20、ruricemia is not necessary in most patients, unless perhaps they have very high levels of uric acid or are otherwise at risk of complications, such as those with a personal or strong family history of gout, urolithiasis,

21、 or uric acid nephropathy.,臨床問題1：無癥狀之高尿酸血癥需不需要治療？,Uhlig T. [Gout and hyperuricaemia--should both be treated?] Tidsskr Nor Laegeforen. 2003 Oct 23;123(20):2878-80 Publication Types: ·    &

22、#160;    ReviewPatients with increased levels of uric acid will usually be treated with drugs if symptoms of acute arthritis or kidney stones occur. There is still no consensus on the treatment of indivi

23、duals with asymptomatic hyperuricaemia.,臨床問題1：無癥狀之高尿酸血癥需不需要治療？,Harris MD, Siegel LB, Alloway JA. Gout and hyperuricemia. Am Fam Physician. 1999 Feb 15;59(4):925-34. Publication Types: ·    &

24、#160;    Review Patients with asymptomatic hyperuricemia do not require treatment, but efforts should be made to lower their urate levels by encouraging them to make changes in diet or lifestyle.,臨床問題1：

25、無癥狀之高尿酸血癥需不需要治療？,Pollmann G, Kullich W, Klein G. [Therapy of hyperuricemia and gout] Wien Med Wochenschr. 1997;147(16):382-7 Publication Types: ·         Review Dietary

26、regimen are in the forefront in treatment of asymptomatic hyperuricemia. Uric acid lowering drugs can only be supported in repeated serum-measures from 9 mg/dl up.,臨床問題2：痛風患者高尿酸血癥之治療,Keyword: Hyperuricemia and Gout and

27、 treatment資料來源：PubMed Bandolier Google,臨床問題2：痛風患者高尿酸血癥之治療,Uhlig T. [Gout and hyperuricaemia--should both be treated?] Tidsskr Nor Laegeforen. 2003 Oct 23;123(20):2878-80 Publication Types

28、: ·         ReviewDrugs for the treatment of acute arthritis attacks include non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids systematically or injected into t

29、he joint, and colchicine. As prophylactic long-term treatment of recurring attacks, allopurinol, probenicide and colchicine are therapeutic alternatives.,臨床問題2：痛風患者高尿酸血癥之治療,Pittman JR. et al Diagnosis and management o

30、f gout. Am Fam Physician 1999 Apr 1;59(7):1799-806, 1810 Treatment goals (of gout) include termination of the acute attack, prevention of recurrent attacks and prevention of complications associated with the deposition

31、of urate crystals in tissues. Pharmacologic management remains the mainstay of treatment.Acute attacks may be terminated with the use of nonsteroidal anti-inflammatory agents, colchicine or intra-articular injections o

32、f corticosteroids. Probenecid, sulfinpyrazone and allopurinol can be used to prevent recurrent attacks. Obesity, alcohol intake and certain foods and medications can contribute to hyperuricemia. These potentially exace

33、rbating factors should be identified and modified,臨床問題2：痛風患者高尿酸血癥之治療,Pollmann G, Kullich W, Klein G. [Therapy of hyperuricemia and gout] Wien Med Wochenschr. 1997;147(16):382-7 Publication Types: ·  &

34、#160;      Review The therapy of an acute attack of gout primarily is done with non-steroidal antiinflammatory drugs, in rare cases with colchicine or corticoids. Gouty arthritis in intermissio

35、n, independent of the extent of hyperuricemia, as well as chronic gout are indications for an uric acid lowering pharmacotherapy, usually for life.,臨床問題2：痛風患者高尿酸血癥之治療,Rott KT, Agudelo CA: Gout. JAMA. 2003;289(21):2857-6

36、0. A short, practical, up-to-date review article targeted at the non-rheumatologist clinician. Agudelo CA, Wise CM: Crystal-associated arthritis in the elderly. Rheum Dis Clin North Am. 2000;26(3):527-46. A comprehen

37、sive review by two of the leading authorities on gout and other crystal-induced arthropathies. Emmerson BT: The management of gout. N Engl J Med. 1996;334(7):445-51.A dated but insightful classic review article. PRO

38、DIGY Guidance -- Gout. April 2002. www.prodigy.nhs.uk/A practical UK guideline that may be particularly useful for US clinicians, especially until a standard evidence-based US clinical guideline is available.,臨床問題2：痛風患

39、者高尿酸血癥之治療,Bandolier：Allopurinol, oxipurinol, benzbromarone and probenecid for lowering uric acidHE Paulus et al. Prophylactic colchicine therapy of intercritical gout. A placebo-controlled study of probenecid-treated pa

40、tients. Arthritis and Rheumatism 1974 17: 609-614.HR Arntz et al. Serum uric acid lowering effect of allopurinol and benzbromarone in low dosage. Fortschr Med 1979 19: 1-3.GW Schepers et al. Benzbromarone therapy in hy

41、peruricaemia: comparison with allopurinol and probenecid. J Int Med Res 1981 9: 511-515.PW Bull & JT Scott. Intermittent control of hyperuricaemia in the treatment of gout. J Rheumatol 1989 16: 1246-1248.H Berg. Ef

42、fectiveness and tolerance of long-term uricosuric treatment. Z Gestamte Inn Med 1990 45: 719-20.I Walter-Sack et al. Uric acid lowering effects of oxipurinol sodium in hyperuricaemic patients - therapeutic equivalence t

43、o allopurinol. J Rheumatol 1996 23: 498-501.,Table 1: Allopurinol, benzbromarone and probenecid in gout,Table 1: Allopurinol, benzbromarone and probenecid in gout,Table 1: Allopurinol, benzbromarone and probenecid in gou

44、t,Table 1: Allopurinol, benzbromarone and probenecid in gout,Table 1: Allopurinol, benzbromarone and probenecid in gout,Table 1: Allopurinol, benzbromarone and probenecid in gout,臨床問題2：痛風患者高尿酸血癥之治療,Bandolier：Allopurinol

45、, oxipurinol, benzbromarone and probenecid for lowering uric acidComment：Not exactly a wealth of information yet. The longer duration study by Bull & Scott implies that maintaining a serum uric acid level below 6 mg

46、/100 mL (350 µmol/L) eventually depletes body stores and gives good relief from acute attacks. The Paulus probenecid study did not appear to show any reduction in attacks without addition of prophylactic colchicine.