痛风患者高尿酸血症之治疗Therapyforhyperuricemiaingout.ppt

痛風患者高尿酸血症之治療痛風患者高尿酸血症之治療（Therapy for hyperuricemia in goutTherapy for hyperuricemia in gout）主題選取的考量主題選取的考量常見的疾病常見的疾病高盛行率高盛行率醫療花費增加醫療花費增加臨床治療標準不一臨床治療標準不一國際已有治療指引國際已有治療指引主題選取的考量主題選取的考量常見的疾病常見的疾病高盛行率高盛行率資料來源：資料來源：PubMedPubMedKeyword:Hyperuricemia in TaiwanKeyword:Hyperuricemia in Taiwan1616篇篇 since 1968 to 2004since 1968 to 2004主題選取的考量主題選取的考量常見的疾病常見的疾病高盛行率高盛行率Chang HY,Pan WH,Yeh WT,Tsai KS.Chang HY,Pan WH,Yeh WT,Tsai KS.Hyperuricemia and gout in Taiwan:results from the Hyperuricemia and gout in Taiwan:results from the Nutritional and Health Survey in Taiwan(1993-96).Nutritional and Health Survey in Taiwan(1993-96).J Rheumatol.2001 Jul;28(7):1640-6.J Rheumatol.2001 Jul;28(7):1640-6.Population:2754 males and 2953 females aged 4 Population:2754 males and 2953 females aged 4 years and older years and older The prevalence of hyperuricemia in aboriginal The prevalence of hyperuricemia in aboriginal males and femalesmales and females：5050 尿酸值尿酸值 年齡年齡男性男性 7.7 mg/dl 女性女性 6.6 mg/dl 19y/o26 17 45y/o22 23 主題選取的考量主題選取的考量常見的疾病常見的疾病高盛行率高盛行率Lai SW,Tan CK,Ng KC.Lai SW,Tan CK,Ng KC.Epidemiology of hyperuricemia in the elderly.Epidemiology of hyperuricemia in the elderly.Yale J Biol Med.2001 May-Jun;74(3):151-7.Yale J Biol Med.2001 May-Jun;74(3):151-7.TimeTime：1998 May1998 MayPopulationPopulation：586(66%Men&34%Women)586(66%Men&34%Women)mean age was 73.1+/-5.3 mean age was 73.1+/-5.3 years years The proportions of hyperuricemia The proportions of hyperuricemia：(p .01)(p 416.5 Hyperuricemia was defined as uric acid 416.5 micromol/l(7 mg/dl)in boys and 357 micromol/l(6 micromol/l(7 mg/dl)in boys and 357 micromol/l(6 mg/dl)in girls mg/dl)in girls Ninety of 224 girls(40.2%)and 56 of 190 boys Ninety of 224 girls(40.2%)and 56 of 190 boys(29.5%)were hyperuricemic.(29.5%)were hyperuricemic.主題選取的考量主題選取的考量常見的疾病常見的疾病高盛行率高盛行率CHOU Chungtei CHOU Chungtei 周昌德周昌德 Hyperuricemia and gout among Taiwan Aborigines and Hyperuricemia and gout among Taiwan Aborigines and Taiwanese-prevalence and risk factors Taiwanese-prevalence and risk factors Chin Med J 2003;116(7):965-967 Chin Med J 2003;116(7):965-967 The prevalence of hyperuricemia and gout in The prevalence of hyperuricemia and gout in Atayal Aborigines to be 41.4%and 11.7%,Atayal Aborigines to be 41.4%and 11.7%,respectively.respectively.27%to 45%of aboriginal boys and 13%to 41%of 27%to 45%of aboriginal boys and 13%to 41%of aboriginal girls had hyperuricemia.aboriginal girls had hyperuricemia.KinmenKinmen：the prevalence of hyperuricemia in men the prevalence of hyperuricemia in men was 25.8%(391/1515)was 25.8%(391/1515)through more than 6 years of follow-ups on 223 through more than 6 years of follow-ups on 223 asymptomatic hyperuricemic patients,the 5-year asymptomatic hyperuricemic patients,the 5-year cumulative incidence of onset of gout was 18.8%cumulative incidence of onset of gout was 18.8%(42/223).The incidence increased with three(42/223).The incidence increased with three different baseline levels of uric acid,from different baseline levels of uric acid,from 10.8%(7.010.8%(7.0 uric aciduric acid8.0),to 27.7%(8.08.0),to 27.7%(8.0uric uric acid 9.0),to 61.6%(uric acidacid 9.0),to 61.6%(uric acid9.0).9.0).主題選取的考量主題選取的考量國際已有治療指引國際已有治療指引資料庫：資料庫：PubMedPubMedKeyword:Hyperuricemia guideline Keyword:Hyperuricemia guideline 8 8篇，篇，since 1996 to 2003since 1996 to 20031:Meyers OL,Cassim B,Mody GM.Hyperuricaemia 1:Meyers OL,Cassim B,Mody GM.Hyperuricaemia and gout:clinical guideline 2003.S Afr Med J.and gout:clinical guideline 2003.S Afr Med J.2003 Dec;93(12 Pt 2):961-71.2003 Dec;93(12 Pt 2):961-71.2:Nakajima H,Matsuzawa Y.Introduction of the 2:Nakajima H,Matsuzawa Y.Introduction of the new guideline for the management of hyperuricemia new guideline for the management of hyperuricemia and gout with special reference to its policy and gout with special reference to its policy Nippon Rinsho.2003 Jan;61 Suppl 1:442-9.Nippon Rinsho.2003 Jan;61 Suppl 1:442-9.3:Tatsuno I,Saito Y.Hyperuricemia and 3:Tatsuno I,Saito Y.Hyperuricemia and atherosclerosis Nippon Rinsho.2003 Jan;61 Suppl atherosclerosis Nippon Rinsho.2003 Jan;61 Suppl 1:259-65.Review.1:259-65.Review.主題選取的考量主題選取的考量國際已有治療指引國際已有治療指引4:Nakajima H.Definition and determination of 4:Nakajima H.Definition and determination of serum uric acid level Nippon Rinsho.2003 Jan;61 serum uric acid level Nippon Rinsho.2003 Jan;61 Suppl 1:154-7.Suppl 1:154-7.5:Nakajima H.Management of hyperuricemia in 5:Nakajima H.Management of hyperuricemia in occupational health:with reference to guidelines occupational health:with reference to guidelines for the management of hyperuricemia and gout for the management of hyperuricemia and gout Sangyo Eiseigaku Zasshi.2003 Jan;45(1):12-9.Sangyo Eiseigaku Zasshi.2003 Jan;45(1):12-9.Review.Japanese.Review.Japanese.6:Gorter KJ,Romeijnders AC.The standard 6:Gorter KJ,Romeijnders AC.The standard hyperuricemia from the Dutch Family Physician;hyperuricemia from the Dutch Family Physician;reaction from rheumatology and general medicine reaction from rheumatology and general medicine Ned Tijdschr Geneeskd.2002 May 4;146(18):872;Ned Tijdschr Geneeskd.2002 May 4;146(18):872;author reply 872-3.Dutch.author reply 872-3.Dutch.7:Chalmers J.Role of diuretics in the 7:Chalmers J.Role of diuretics in the treatment of hypertension:from large controlled treatment of hypertension:from large controlled trials to international guidelines Arch Mal trials to international guidelines Arch Mal Coeur Vaiss.1996 Sep;89 Spec No 4:39-43.Review.Coeur Vaiss.1996 Sep;89 Spec No 4:39-43.Review.French.French.8:Cummins D,Sekar M,Halil O,Banner N.8:Cummins D,Sekar M,Halil O,Banner N.Myelosuppression associated with azathioprine-Myelosuppression associated with azathioprine-allopurinol interaction after heart and lung allopurinol interaction after heart and lung transplantation.Transplantation.1996 Jun transplantation.Transplantation.1996 Jun 15;61(11):1661-2.15;61(11):1661-2.目前製作目前製作guidelineguideline之目的之目的台灣地區高尿酸血症的盛行率驚人，尤其施行成人健康體檢台灣地區高尿酸血症的盛行率驚人，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症該如何處理。而後，門診診療中常遇到病人詢問高尿酸血症該如何處理。而目前因無統一的目前因無統一的guidelineguideline可供依循，治療標準不一，常造可供依循，治療標準不一，常造成醫師及患者的困擾。期待檢視文獻後，能提供有用的資訊，成醫師及患者的困擾。期待檢視文獻後，能提供有用的資訊，建立使用降尿酸藥物之臨床底線，以為臨床診療之準則。建立使用降尿酸藥物之臨床底線，以為臨床診療之準則。臨床問題臨床問題1 1：無症狀之高尿酸血症需不需要治療？無症狀之高尿酸血症需不需要治療？資料來源：資料來源：PubMedPubMedKeyword:Asymtomatic hyperuricemia and treatment and Keyword:Asymtomatic hyperuricemia and treatment and review review 2323篇，篇，since 1977 to 2003since 1977 to 2003臨床問題臨床問題1 1：無症狀之高尿酸血症需不需要治療？無症狀之高尿酸血症需不需要治療？Dincer HE,Dincer AP,Levinson DJ.Asymptomatic Dincer HE,Dincer AP,Levinson DJ.Asymptomatic hyperuricemia:to treat or not to treat.Cleve hyperuricemia:to treat or not to treat.Cleve Clin J Med.2002 Aug;69(8):594,597,600-2 passim.Clin J Med.2002 Aug;69(8):594,597,600-2 passim.Publication Types:Publication Types:ReviewReviewTreatment of asymptomatic hyperuricemia is not Treatment of asymptomatic hyperuricemia is not necessary in most patients,unless perhaps they have necessary in most patients,unless perhaps they have very high levels of uric acid or are otherwise at very high levels of uric acid or are otherwise at risk of complications,such as those with a personal risk of complications,such as those with a personal or strong family history of gout,urolithiasis,or or strong family history of gout,urolithiasis,or uric acid nephropathy.uric acid nephropathy.臨床問題臨床問題1 1：無症狀之高尿酸血症需不需要治療？無症狀之高尿酸血症需不需要治療？Uhlig T.Gout and hyperuricaemia-should both be Uhlig T.Gout and hyperuricaemia-should both be treated?Tidsskr Nor Laegeforen.2003 Oct treated?Tidsskr Nor Laegeforen.2003 Oct 23;123(20):2878-80 23;123(20):2878-80 Publication Types:Publication Types:ReviewReviewPatients with increased levels of uric acid will Patients with increased levels of uric acid will usually be treated with drugs if symptoms of acute usually be treated with drugs if symptoms of acute arthritis or kidney stones occur.arthritis or kidney stones occur.There is still no consensus on the treatment of There is still no consensus on the treatment of individuals with asymptomatic hyperuricaemia.individuals with asymptomatic hyperuricaemia.臨床問題臨床問題1 1：無症狀之高尿酸血症需不需要治療？無症狀之高尿酸血症需不需要治療？Harris MD,Siegel LB,Alloway JA.Gout and Harris MD,Siegel LB,Alloway JA.Gout and hyperuricemia.Am Fam Physician.1999 Feb hyperuricemia.Am Fam Physician.1999 Feb 15;59(4):925-34.15;59(4):925-34.Publication Types:Publication Types:Review Review Patients with asymptomatic hyperuricemia do not Patients with asymptomatic hyperuricemia do not require treatment,but efforts should be made to require treatment,but efforts should be made to lower their urate levels by encouraging them to make lower their urate levels by encouraging them to make changes in diet or lifestyle.changes in diet or lifestyle.臨床問題臨床問題1 1：無症狀之高尿酸血症需不需要治療？無症狀之高尿酸血症需不需要治療？Pollmann G,Kullich W,Klein G.Therapy of Pollmann G,Kullich W,Klein G.Therapy of hyperuricemia and gout Wien Med Wochenschr.hyperuricemia and gout Wien Med Wochenschr.1997;147(16):382-7 1997;147(16):382-7 Publication Types:Publication Types:Review Review Dietary regimen are in the forefront in treatment of Dietary regimen are in the forefront in treatment of asymptomatic hyperuricemia.asymptomatic hyperuricemia.Uric acid lowering drugs can only be supported in Uric acid lowering drugs can only be supported in repeated serum-measures from 9 mg/dl up.repeated serum-measures from 9 mg/dl up.臨床問題臨床問題2 2：痛風患者高尿酸血症之治療痛風患者高尿酸血症之治療Keyword:Hyperuricemia and Gout and treatmentKeyword:Hyperuricemia and Gout and treatment資料來源：資料來源：PubMedPubMed Bandolier Bandolier Google Google 臨床問題臨床問題2 2：痛風患者高尿酸血症之治療痛風患者高尿酸血症之治療Uhlig T.Gout and hyperuricaemia-should both be Uhlig T.Gout and hyperuricaemia-should both be treated?Tidsskr Nor Laegeforen.2003 Oct treated?Tidsskr Nor Laegeforen.2003 Oct 23;123(20):2878-80 23;123(20):2878-80 Publication Types:Publication Types:ReviewReviewDrugs for the treatment of acute arthritis attacks Drugs for the treatment of acute arthritis attacks include non-steroidal anti-inflammatory drugs include non-steroidal anti-inflammatory drugs(NSAIDs),glucocorticoids systematically or injected(NSAIDs),glucocorticoids systematically or injected into the joint,and colchicine.into the joint,and colchicine.As prophylactic long-term treatment of recurring As prophylactic long-term treatment of recurring attacks,allopurinol,probenicide and colchicine are attacks,allopurinol,probenicide and colchicine are therapeutic alternatives.therapeutic alternatives.臨床問題臨床問題2 2：痛風患者高尿酸血症之治療痛風患者高尿酸血症之治療Pittman JR.et al Diagnosis and management of Pittman JR.et al Diagnosis and management of gout.Am Fam Physician 1999 Apr 1;59(7):1799-806,gout.Am Fam Physician 1999 Apr 1;59(7):1799-806,1810 1810 Treatment goals(of gout)include termination of Treatment goals(of gout)include termination of the acute attack,prevention of recurrent attacks the acute attack,prevention of recurrent attacks and prevention of complications associated with and prevention of complications associated with the deposition of urate crystals in tissues.the deposition of urate crystals in tissues.Pharmacologic management remains the mainstay of Pharmacologic management remains the mainstay of treatment.treatment.Acute attacks may be terminated with the use of Acute attacks may be terminated with the use of nonsteroidal anti-inflammatory agents,colchicine nonsteroidal anti-inflammatory agents,colchicine or intra-articular injections of corticosteroids.or intra-articular injections of corticosteroids.Probenecid,sulfinpyrazone and allopurinol can be Probenecid,sulfinpyrazone and allopurinol can be used to prevent recurrent attacks.used to prevent recurrent attacks.Obesity,alcohol intake and certain foods and Obesity,alcohol intake and certain foods and medications can contribute to hyperuricemia.medications can contribute to hyperuricemia.These potentially exacerbating factors should be These potentially exacerbating factors should be identified and modifiedidentified and modified臨床問題臨床問題2 2：痛風患者高尿酸血症之治療痛風患者高尿酸血症之治療Pollmann G,Kullich W,Klein G.Therapy of Pollmann G,Kullich W,Klein G.Therapy of hyperuricemia and gout Wien Med Wochenschr.hyperuricemia and gout Wien Med Wochenschr.1997;147(16):382-7 1997;147(16):382-7 Publication Types:Publication Types:Review Review The therapy of an acute attack of gout primarily is The therapy of an acute attack of gout primarily is done with non-steroidal antiinflammatory drugs,in done with non-steroidal antiinflammatory drugs,in rare cases with colchicine or corticoids.rare cases with colchicine or corticoids.Gouty arthritis in intermission,independent of the Gouty arthritis in intermission,independent of the extent of hyperuricemia,as well as chronic gout are extent of hyperuricemia,as well as chronic gout are indications for an uric acid lowering indications for an uric acid lowering pharmacotherapy,usually for life.pharmacotherapy,usually for life.臨床問題臨床問題2 2：痛風患者高尿酸血症之治療痛風患者高尿酸血症之治療Rott KT,Agudelo CA:Gout.JAMA.2003;289(21):2857-Rott KT,Agudelo CA:Gout.JAMA.2003;289(21):2857-60.60.A short,practical,up-to-date review article A short,practical,up-to-date review article targeted at the non-rheumatologist clinician.targeted at the non-rheumatologist clinician.Agudelo CA,Wise CM:Crystal-associated arthritis in Agudelo CA,Wise CM:Crystal-associated arthritis in the elderly.Rheum Dis Clin North Am.the elderly.Rheum Dis Clin North Am.2000;26(3):527-46.2000;26(3):527-46.A comprehensive review by two of the leading A comprehensive review by two of the leading authorities on gout and other crystal-induced authorities on gout and other crystal-induced arthropathies.arthropathies.Emmerson BT:The management of gout.N Engl J Med.Emmerson BT:The management of gout.N Engl J Med.1996;334(7):445-51.1996;334(7):445-51.A dated but insightful classic review article.A dated but insightful classic review article.PRODIGY Guidance-Gout.April 2002.PRODIGY Guidance-Gout.April 2002.www.prodigy.nhs.uk/www.prodigy.nhs.uk/A practical UK guideline that may be particularly A practical UK guideline that may be particularly useful for US clinicians,especially until a useful for US clinicians,especially until a standard evidence-based US clinical guideline is standard evidence-based US clinical guideline is available.available.臨床問題臨床問題2 2：痛風患者高尿酸血症之治療痛風患者高尿酸血症之治療BandolierBandolier：Allopurinol,oxipurinol,benzbromarone Allopurinol,oxipurinol,benzbromarone and probenecid for lowering uric acidand probenecid for lowering uric acid1.1.HE Paulus et al.Prophylactic colchicine therapy HE Paulus et al.Prophylactic colchicine therapy of intercritical gout.A placebo-controlled of intercritical gout.A placebo-controlled study of probenecid-treated patients.Arthritis study of probenecid-treated patients.Arthritis and Rheumatism 1974 17:609-614.and Rheumatism 1974 17:609-614.2.2.HR Arntz et al.Serum uric acid lowering effect HR Arntz et al.Serum uric acid lowering effect of allopurinol and benzbromarone in low dosage.of allopurinol and benzbroma