痛风患者高尿酸血症之治疗

痛风患者高尿酸血症之治疗第1页/共29页主題選取的考量常見的疾病—高盛行率醫療花費增加臨床治療標準不一國際已有治療指引第2页/共29页主題選取的考量

常見的疾病—高盛行率資料來源：PubMedKeyword:HyperuricemiainTaiwan16篇since1968to2004第3页/共29页主題選取的考量

常見的疾病—高盛行率ChangHY,PanWH,YehWT,TsaiKS.HyperuricemiaandgoutinTaiwan:resultsfromtheNutritionalandHealthSurveyinTaiwan(1993-96).JRheumatol.2001Jul;28(7):1640-6.Population:2754malesand2953femalesaged4yearsandolderTheprevalenceofhyperuricemiainaboriginalmalesandfemales：＞50﹪

尿酸值年齡男性＞7.7mg/dl女性＞6.6mg/dl≧19y/o26﹪17﹪≧45y/o22﹪23﹪第4页/共29页主題選取的考量

常見的疾病—高盛行率LaiSW,TanCK,NgKC.Epidemiologyofhyperuricemiaintheelderly.YaleJBiolMed.2001May-Jun;74(3):151-7.Time：1998MayPopulation：586(66%Men&34%Women)meanagewas73.1+/-5.3yearsTheproportionsofhyperuricemia：(p<.01)

57.3﹪inmen40.9﹪inwomen第5页/共29页主題選取的考量

常見的疾病—高盛行率LiuCS,LiTC,LinCC.TheepidemiologyofhyperuricemiainchildrenofTaiwanaborigines.Rheumatol.2003Apr;30(4):841-5.

Time：fromMarchtoMay2001Place：centralTaiwanPopulation：theBununtribe，Childrenaged4-13Atotalof414children(meanage,8.9+/-2.1yrs)wererecruited.Hyperuricemiawasdefinedasuricacid>416.5micromol/l(7mg/dl)inboysand>357micromol/l(6mg/dl)ingirlsNinetyof224girls(40.2%)and56of190boys(29.5%)werehyperuricemic.第6页/共29页主題選取的考量

常見的疾病—高盛行率CHOUChungtei周昌德

HyperuricemiaandgoutamongTaiwanAboriginesandTaiwanese-prevalenceandriskfactorsChinMedJ2003;116(7):965-967

TheprevalenceofhyperuricemiaandgoutinAtayalAboriginestobe41.4%and11.7%,respectively.27%to45%ofaboriginalboysand13%to41%ofaboriginalgirlshadhyperuricemia.

Kinmen：theprevalenceofhyperuricemiainmenwas25.8%(391/1515)

throughmorethan6yearsoffollow-upson223asymptomatichyperuricemicpatients,the5-yearcumulativeincidenceofonsetofgoutwas18.8%(42/223).Theincidenceincreasedwiththreedifferentbaselinelevelsofuricacid,from10.8%(7.0＜uricacid＜8.0),to27.7%(8.0＜uricacid<9.0),to61.6%(uricacid＞9.0).

第7页/共29页主題選取的考量

國際已有治療指引資料庫：PubMedKeyword:Hyperuricemiaguideline8篇，since1996to20031:MeyersOL,CassimB,ModyGM.Hyperuricaemiaandgout:clinicalguideline2003.SAfrMedJ.2003Dec;93(12Pt2):961-71.

2:NakajimaH,MatsuzawaY.[Introductionofthenewguidelineforthemanagementofhyperuricemiaandgoutwithspecialreferencetoitspolicy]NipponRinsho.2003Jan;61Suppl1:442-9.

3:TatsunoI,SaitoY.[Hyperuricemiaandatherosclerosis]NipponRinsho.2003Jan;61Suppl1:259-65.Review.第8页/共29页主題選取的考量

國際已有治療指引4:NakajimaH.[Definitionanddeterminationofserumuricacidlevel]NipponRinsho.2003Jan;61Suppl1:154-7.

5:NakajimaH.[Managementofhyperuricemiainoccupationalhealth:withreferenceto"guidelinesforthemanagementofhyperuricemiaandgout"]

SangyoEiseigakuZasshi.2003Jan;45(1):12-9.Review.Japanese.

6:GorterKJ,RomeijndersAC.[Thestandard'hyperuricemia'fromtheDutchFamilyPhysician;reactionfromrheumatologyandgeneralmedicine]NedTijdschrGeneeskd.2002May4;146(18):872;authorreply872-3.Dutch.

7:ChalmersJ.[Roleofdiureticsinthetreatmentofhypertension:fromlargecontrolledtrialstointernationalguidelines]ArchMalCoeurVaiss.1996Sep;89SpecNo4:39-43.Review.French.8:CumminsD,SekarM,HalilO,BannerN.Myelosuppressionassociatedwithazathioprine-allopurinolinteractionafterheartandlungtransplantation.Transplantation.1996Jun15;61(11):1661-2.第9页/共29页目前製作guideline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guideline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，建立使用降尿酸藥物之臨床底線，以為臨床診療之準則。第10页/共29页臨床問題1：

無症狀之高尿酸血症需不需要治療？資料來源：PubMedKeyword:Asymtomatichyperuricemiaandtreatmentandreview

23篇，since1977to2003第11页/共29页臨床問題1：

無症狀之高尿酸血症需不需要治療？DincerHE,DincerAP,LevinsonDJ.Asymptomatichyperuricemia:totreatornottotreat.CleveClinJMed.2002Aug;69(8):594,597,600-2passim.PublicationTypes:·

ReviewTreatmentofasymptomatichyperuricemiaisnotnecessaryinmostpatients,unlessperhapstheyhaveveryhighlevelsofuricacidorareotherwiseatriskofcomplications,suchasthosewithapersonalorstrongfamilyhistoryofgout,urolithiasis,oruricacidnephropathy.

第12页/共29页臨床問題1：

無症狀之高尿酸血症需不需要治療？UhligT.[Goutandhyperuricaemia--shouldbothbetreated?]TidsskrNorLaegeforen.2003Oct23;123(20):2878-80PublicationTypes:·

ReviewPatientswithincreasedlevelsofuricacidwillusuallybetreatedwithdrugsifsymptomsofacutearthritisorkidneystonesoccur.Thereisstillnoconsensusonthetreatmentofindividualswithasymptomatichyperuricaemia.

第13页/共29页臨床問題1：

無症狀之高尿酸血症需不需要治療？HarrisMD,SiegelLB,AllowayJA.Goutandhyperuricemia.AmFamPhysician.1999Feb15;59(4):925-34.

PublicationTypes:·

ReviewPatientswithasymptomatichyperuricemiadonotrequiretreatment,buteffortsshouldbemadetolowertheiruratelevelsbyencouragingthemtomakechangesindietorlifestyle.第14页/共29页臨床問題1：

無症狀之高尿酸血症需不需要治療？PollmannG,KullichW,KleinG.[Therapyofhyperuricemiaandgout]WienMedWochenschr.1997;147(16):382-7

PublicationTypes:·

ReviewDietaryregimenareintheforefrontintreatmentofasymptomatichyperuricemia.Uricacidloweringdrugscanonlybesupportedinrepeatedserum-measuresfrom9mg/dlup.第15页/共29页臨床問題2：

痛風患者高尿酸血症之治療Keyword:HyperuricemiaandGoutandtreatment資料來源：PubMedBandolierGoogle

第16页/共29页臨床問題2：

痛風患者高尿酸血症之治療UhligT.[Goutandhyperuricaemia--shouldbothbetreated?]TidsskrNorLaegeforen.2003Oct23;123(20):2878-80PublicationTypes:·

ReviewDrugsforthetreatmentofacutearthritisattacksincludenon-steroidalanti-inflammatorydrugs(NSAIDs),glucocorticoidssystematicallyorinjectedintothejoint,andcolchicine.Asprophylacticlong-termtreatmentofrecurringattacks,allopurinol,probenicideandcolchicinearetherapeuticalternatives.第17页/共29页臨床問題2：

痛風患者高尿酸血症之治療PittmanJR.etalDiagnosisandmanagementofgout.AmFamPhysician1999Apr1;59(7):1799-806,1810Treatmentgoals(ofgout)includeterminationoftheacuteattack,preventionofrecurrentattacksandpreventionofcomplicationsassociatedwiththedepositionofuratecrystalsintissues.Pharmacologicmanagementremainsthemainstayoftreatment.Acuteattacksmaybeterminatedwiththeuseofnonsteroidalanti-inflammatoryagents,colchicineorintra-articularinjectionsofcorticosteroids.Probenecid,sulfinpyrazoneandallopurinolcanbeusedtopreventrecurrentattacks.Obesity,alcoholintakeandcertainfoodsandmedicationscancontributetohyperuricemia.Thesepotentiallyexacerbatingfactorsshouldbeidentifiedandmodified第18页/共29页臨床問題2：

痛風患者高尿酸血症之治療PollmannG,KullichW,KleinG.[Therapyofhyperuricemiaandgout]WienMedWochenschr.1997;147(16):382-7

PublicationTypes:·

ReviewThetherapyofanacuteattackofgoutprimarilyisdonewithnon-steroidalantiinflammatorydrugs,inrarecaseswithcolchicineorcorticoids.Goutyarthritisinintermission,independentoftheextentofhyperuricemia,aswellaschronicgoutareindicationsforanuricacidloweringpharmacotherapy,usuallyforlife.第19页/共29页臨床問題2：

痛風患者高尿酸血症之治療RottKT,AgudeloCA:Gout.JAMA.2003;289(21):2857-60.Ashort,practical,up-to-datereviewarticletargetedatthenon-rheumatologistclinician.AgudeloCA,WiseCM:Crystal-associatedarthritisintheelderly.RheumDisClinNorthAm.2000;26(3):527-46.Acomprehensivereviewbytwooftheleadingauthoritiesongoutandothercrystal-inducedarthropathies.EmmersonBT:Themanagementofgout.NEnglJMed.1996;334(7):445-51.Adatedbutinsightfulclassicreviewarticle.PRODIGYGuidance--Gout.April2002.digy.nhs.uk/ApracticalUKguidelinethatmaybeparticularlyusefulforUSclinicians,especiallyuntilastandardevidence-basedUSclinicalguidelineisavailable.第20页/共29页臨床問題2：

痛風患者高尿酸血症之治療Bandolier：Allopurinol,oxipurinol,benzbromaroneandprobenecidforloweringuricacidHEPaulusetal.Prophylacticcolchicinetherapyofintercriticalgout.Aplacebo-controlledstudyofprobenecid-treatedpatients.ArthritisandRheumatism197417:609-614.HRArntzetal.Serumuricacidloweringeffectofallopurinolandbenzbromaroneinlowdosage.FortschrMed197919:1-3.GWSchepersetal.Benzbromaronetherapyinhyperuricaemia:comparisonwithallopurinolandprobenecid.JIntMedRes19819:511-515.PWBull&JTScott.Intermittentcontrolofhyperuricaemiainthetreatmentofgout.JRheumatol198916:1246-1248.HBerg.Effectivenessandtoleranceoflong-termuricosurictreatment.ZGestamteInnMed199045:719-20.IWalter-Sacketal.Uricacidloweringeffectsofoxipurinolsodiuminhyperuricaemicpatients-therapeuticequivalencetoallopurinol.JRheumatol199623:498-501.

第21页/共29页ReferenceDesignIncludedpatientsoutcomesResultsHEPaulusetal,1974Randomised,doubleblindcomparisonofprobenecid500mgthreetimesadayplusplaceboversusprobenecidpluscolchicineforuptosixmonths53menwithgoutandserumuricacidabove7.5mg/dLUricacidResultsreportedonlyformenwithsignificantandsustainedfallsinuricacid(38/52),whenmeanreductionwasto6.3mg/dLfromabout8.8mg/dL.Acuteattacks0.5/monthwithprobenecidalone,and0.2/monthwithprobenecidpluscolchicine.Pretreatmentattacksaveraged3-4/12months.Table1:Allopurinol,benzbromaroneandprobenecidingout第22页/共29页ReferenceDesignIncludedpatientsoutcomesResultsArntzetal,1979Randomcomparisonof100mgallopurinol,20mgbenzbromaroneandthecombinationinacrossovertrialwithfourweektreatmentperiodsTwelvepatientswithhyperuricaemiaandtypeIVhyperlipidaemiaUricacidSignificantfallsforalltreatments,butmoresoforthecombination.Table1:Allopurinol,benzbromaroneandprobenecidingout第23页/共29页ReferenceDesignIncludedpatientsoutcomesResultsSchepers,1981Non-randomcrossoverofprobenecid1000mg,allopurinol300mgdaily,benzbromarone100mgdailyinsixpatients.Oneweekoftreatmentwithtwoweekwashout.Serumuricacidof450µmol/Lormore.UricacidClaimsbenzbromaronesuperiortoothertwotreatmentsTable1:Allopurinol,benzbromaroneandprobenecidingout第24页/共29页ReferenceDesignIncludedpatientsoutcomesResultsBull&Scott,1989Random(lastdigitofhospitalnumber)tocontinuousdailyallopurinol300mg(10)orallopurinol300mg(10)fortwomonthseveryyear.Aimofcontinuoustreatmentwasuricacidbelow6mg/100mL.Duration2-4years.Atleastthreeattacksofclassicalgoutyarthritiswithhyperuricaemia.Patientsnewtoallopurinol.Acuteattacks20attacksversus26attacks(continuous/intermittent)infirsttwoyears.Noattacksper166patientmonthsthereafterforcontinuous,versus10/140monthsforintermittent.Table1:Allopurinol,benzbromaroneandprobenecidingout第25页/共29页ReferenceDesignIncludedpatientsoutcomesResultsBerg,1990Randomisedcomparisonof