Tratamento da Gota na Atenção Primária à Saúde / Treatment of Gout in the Primary Health Care / Tratamiento de la Gota en la Atención Primaria de la Salud

Objetivo: O objetivo desta revisão é fornecer informação atualizada e orientações práticas sobre a abordagem da gota na Atenção Primária à Saúde. Métodos: Foram pesquisadas normas de orientação clínica, revisões sistemáticas, meta-análises e estudos originais publicados entre 1 janeiro de 2011 e 31 dezembro de 2016, nas línguas inglesa, portuguesa e espanhola. Resultados: Os fármacos de primeira linha no tratamento da gota aguda são os anti-inflamatórios não esteroides, a colchicina e os corticoides, em monoterapia ou associação. Na gota crônica são usados hipouricemiantes, sendo a primeira linha o alopurinol. O febuxostate e os uricosúricos são alternativas ao alopurinol em casos de intolerância ou ineficácia. A profilaxia das crises de gota agudas está recomendada quando se inicia o tratamento hipouricemiante durante pelo menos 6 meses. Conclusão: A abordagem correta da gota deve fazer parte das competências de um médico especialista em Atenção Primária à Saúde de modo a prestar cuidados adequados à comunidade.

Objective: The objective of this review is to provide updated information and practical guidelines on the approach of gout in Primary Health Care. Methods: We conducted a survey of clinical guidelines, systematic reviews, meta-analyses and original studies published between January 1, 2011 and December 31, 2016 in the English, Portuguese and Spanish languages. Results: First-line drugs in the treatment of acute gout are non-steroidal anti-inflammatory drugs, colchicine and corticosteroids, in monotherapy or combination. In chronic gout, the first-line of hypouricemic therapy is allopurinol. Febuxostat and uricosurics are alternatives to allopurinol in cases of intolerance or ineffectiveness. The prophylaxis of acute attacks is recommended when starting hypouricemic treatment for at least 6 months. Treatment of asymptomatic hyperuricemia is not recommended. Conclusion: The correct approach to gout should be part of the skills of a Primary Care physician in order to provide adequate care to the community.

Objetivo: El objetivo es proporcionar información actualizada y orientación práctica sobre la terapéutica de la gota en la Atención Primaria de Salud. Métodos: Se estudiaron las guías clínicas, revisiones sistemáticas, meta-análisis y estudios originales publicados entre el 1 de enero de 2011 y el 31 de diciembre de 2016, en el inglés, portugués y español. Resultados: Los fármacos de primera línea en el tratamiento de la gota aguda son anti-inflamatorios no-esteroides, la colchicina y los corticosteroides, solos o en combinación. En la gota crónica son utilizados hipouricemiantes, y el alopurinol es lo fármaco de primera línea. Febuxostat y uricosúricos son alternativas al alopurinol en los casos de intolerancia o ineficacia. Se recomienda la profilaxis de las crisis agudas en el tratamiento hipouricemiante durante al menos 6 meses. No se recomienda el tratamiento de la hiperuricemia asintomática. Conclusión: La terapéutica de la gota debe formar parte de las competencias de un médico especialista en Atención Primaria de Salud a fin de proporcionar la atención adecuada a la comunidad.

Prevention of Comorbidity and Acute Attack of Gout by Uric Acid Lowering Therapy

The object of this study was to evaluate the effect of uric acid lowering therapy in reducing the new development of comorbidities and the frequency of acute attacks in gout patients. We retrospectively reviewed patients who were diagnosed to have gout with at least 3 yr of follow up. They were divided into 2 groups; 53 patients with mean serum uric acid level (sUA) or =6 mg/dL. Comorbidities of gout such as hypertension (HTN), type II diabetes mellitus (DM), chronic kidney disease, cardiovascular disease (CVD) and urolithiasis were compared in each group at baseline and at last follow-up visit. Frequency of acute gout attacks were also compared between the groups. During the mean follow up period of 7.6 yr, the yearly rate of acute attack and the new development of HTN, DM, CVD and urolithiasis was lower in the adequately treated group compared to the inadequately treated group. Tight control of uric acid decreases the incidence of acute gout attacks and comorbidities of gout such as HTN, DM, CVD and urolithiasis.

Diuretics physiology pharmacology and clinical use

Uricosuric diuretics have been developed to counteract renal urate retention accompanying diuretic-induced extracellular volume contraction. Their intrinsic uricosuric activity would prevent diuretic-induced hyperuricemia. Ticrynafen, a prototype uricosuric diuretic, has largely fallen into disuse because of hepatic toxicity. However, one lesson learned during the short period that ticrynafen was available in the US is that the administration of a potent uricosuric agent to a patient previously trated with diuretics can precipitate acute renal failure, possibly as a consequence of uric acid nephropathy. Another novel uricosuric diuretic, indacrinone, is composed of two enantiomorphic isomers exhibiting predominantly either a uricosuric or a natriuretic action. Manipulation of the isomer ratio currently is being attempted with a view toward obtaining a combination that produces little change in the serum urate during chronic diuretic therapy. Uricosuric diuretics have the therapeutic potential to treat hypertension and edematous states without increasing the serum urate. Although current information suggests that chronic asymptomatic hyperuricemia poses very little health hazard, future data could indicate that it may be desirable to maintain the serum urate near the normal range