Rheumatology Associates of Long Island, Melville, NY 11747, USA.
Postgrad Med. 2011 Nov;123(6 Suppl 1):3-36. doi: 10.3810/pgm.2011.11.2511.
Gout is a major health problem in the United States; it affects 8.3 million people, which is approximately 4% of the adult population. Gout is most often diagnosed and managed in primary care physician practices. Primary care physicians have a significant opportunity to diagnose and manage patients with gout and improve patient outcomes. Following publication of the 2006 European League Against Rheumatism (EULAR) gout guidelines, significant evidence on gout has accumulated and new treatments for patients with gout have become available. It is the objective of these 2011 recommendations for the diagnosis and management of gout and hyperuricemia to update the 2006 EULAR guidelines, paying special attention to the needs of primary care physicians, who manage most patients with gout. The revised 2011 recommendations are based on the Grading of Recommendations Assessment, Development, and Evaluation approach as an evidence-based strategy for rating quality of evidence and grading strength of recommendation in clinical practice. A total of 26 key recommendations for diagnosis (n = 10) and management (n = 16) were evaluated. Presence of tophus (proven or suspected) and response to colchicine had the highest clinical diagnostic value (likelihood ratio [LR], 15.56 [95% CI, 2.11-114.71] and LR, 4.33 [95% CI, 1.16-16.16], respectively). The key aspect of effective management of an acute gout attack is initiation of treatment within hours of onset of first symptoms. Low-dose colchicine is better tolerated than and is as effective as high-dose colchicine (number needed to treat [NNT], 5 [95% CI, 3-13] and NNT, 6 [95% CI, 3-72], respectively). For urate-lowering therapy, allopurinol in combination with probenecid was shown to be more effective than either agent alone (effect size [ES], 5.51 for combination; ES, 4.46 for probenecid; and ES, 2.80 for allopurinol). Febuxostat, also a xanthine oxidase inhibitor, has a slightly different mechanism of action and can be prescribed at unchanged doses for patients with mild-to-moderate renal or hepatic impairment. Febuxostat 40 mg versus 80 mg (NNT, 6 [95% CI, 4-11]) and 120 mg (NNT, 6 [95% CI, 3-26]) both demonstrated long-term efficacy. The target of urate-lowering therapy should be a serum uric acid level of ≤ 6 mg/dL. For patients with refractory and tophaceous gout, intravenous pegloticase is a new treatment option.
痛风是美国的一个主要健康问题；它影响了 830 万人，约占成年人口的 4%。痛风最常被诊断和管理在初级保健医生的实践中。初级保健医生有很大的机会诊断和管理痛风患者，并改善患者的预后。在 2006 年欧洲抗风湿病联盟（EULAR）痛风指南发布后，大量关于痛风的证据积累起来，并且有了新的痛风患者治疗方法。这些 2011 年痛风和高尿酸血症诊断和管理建议的目的是更新 2006 年 EULAR 指南，特别关注管理大多数痛风患者的初级保健医生的需求。经过修订的 2011 年建议是基于建议评估、制定和评估方法的分级，这是一种基于证据的策略，用于评估临床实践中证据质量和推荐强度的分级。共评估了 26 项诊断（n=10）和管理（n=16）的关键建议。痛风石的存在（已证实或疑似）和秋水仙碱的反应具有最高的临床诊断价值（似然比[LR]，15.56[95%可信区间，2.11-114.71]和 LR，4.33[95%可信区间，1.16-16.16]）。有效管理急性痛风发作的关键方面是在首次症状出现后的数小时内开始治疗。小剂量秋水仙碱的耐受性优于大剂量秋水仙碱，且疗效相当（需要治疗的人数[NNT]，5[95%可信区间，3-13]和 NNT，6[95%可信区间，3-72]）。对于尿酸降低治疗，别嘌呤醇联合丙磺舒的疗效优于单独使用任何一种药物（联合用药的效应量[ES]为 5.51；丙磺舒的 ES 为 4.46；别嘌呤醇的 ES 为 2.80）。黄嘌呤氧化酶抑制剂非布司他也具有不同的作用机制，可在轻中度肾功能或肝功能损害的患者中以不变剂量处方。非布司他 40 毫克与 80 毫克（NNT，6[95%可信区间，4-11]）和 120 毫克（NNT，6[95%可信区间，3-26]）均显示出长期疗效。尿酸降低治疗的目标应为血清尿酸水平≤6mg/dL。对于难治性痛风石痛风患者，静脉注射培戈洛酶是一种新的治疗选择。
