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.

To study the efficacy of losartan on urinary uric acid excretion in thiazide induced hyperuricemic and hypertensive patients

The precise relationship of Hyperuricemia found in hypertensive patients is still obscure; this study is a urinary uric acid lowering intervention with Losartan in hypertensive patients induced by Thiazide diuretics. A number of pharmacological agents like loop diuretics, similarly low doses of aspirin [<3g daily] aggravate Hyperuricemia. The effect of Losartan on urinary uric acid excretion In Hypertensive patients with Thiazide induced Hyperuricemia were investigated in the Department of pharmacology and therapeutics, Basic Medical Sciences Institute Jinnah Postgraduate Medical Centre Karachi. It was randomized, open label, prospective, comparative study. Total 60 hypertensive Hyperuricemic patients were enrolled one by one in this study, selected from medical OPD and wards of Jinnah Postgraduate Medical Centre, Karachi. Patients were divided in three groups. Group-1 patients were treated with Thiazide 50 mg/day, Group-2 with Losartan + Thiazide 50 mg/day, and Group-3 with Losartan 50 mg/day. The effect on urinary uric acid level was measured, after every fortnightly. Treatment with Thiazide + Losartan group and Losartan group showed significantly increase in urinary uric acid excretion. Whereas, Thiazide group decrease in urinary uric acid level. In contrast to Thiazide and Losartan alone Thiazide + Losartan led to a greater increased in urinary uric acid excretion. The average percentage increase in urinary uric acid excretion in Thiazide + Losartan group was -13.27% and the average percentage increased in urinary uric acid excretion was 6.7% in Losartan group. Thus it can be concluded from the present study that urinary uric acid excretion was more increased in combination therapies. Ultimately Losartan decrease serum uric acid level and uricosuric effect of Losartan might be particularly useful in Hyperuricemic patients those on Thiazide diuretic [for hypertension and heart failure]

Recent Progress in the Management of Gouty Arthritis and Hyperuricemia / 대한내과학회지

There is an increasing incidence of gout and hyperuricemia worldwide. It is because the population is getting older, their life style is sedentary, and they take protein-enriched food. Gout is one of the most common but best controllable chronic diseases of adult. There have been recent advances in the understanding of underlying mechanisms and treatment of gout and hyperuricemia. This article is aimed to provide the practical review of the currently recommended practice of care and also to introduce some recently approved drugs. The management concept of hyperuricemia is changing because not only the gout but also the hyperuricemia appear to be independent risk factors for hypertension, renal disease and cardiovascular disease. Gout causes a significant individual and social burden and loss of working force. Still hyperuricemia in the gout patient is often under-treated by the patients themselves and by the physicians also. Once the acute gout attack is controlled, patients should be followed with goal-oriented treatment of hyperuricemia and other risk factors. Allopurinol has remained as a first-line treatment for chronic hyperuricemia, but uricosuric agents may also be considered in some patients. These drugs have provided good control of the disease in most gout patients until now but the elderly patients with gout often carry co-medications, contra-indication to these drugs, and risk of adverse drug reaction. Febuxostat is a nonpurine xanthine-oxidase inhibitor. It is a new agent approved by the US FDA and Korean FDA for the treatment of hyperuricemia in patients with gout which may be used when allopurinol is not tolerated or contraindicated. Pegloticase is the PEGylated urate oxidase which is very potent and so recently approved by the US FDA for the gout refractory to conventional treatment.

Study on extracting process of ethanol extract with hypouricemic effect from rhizoma alismatis / 中国中药杂志

<p><b>OBJECTIVE</b>To optimize the extracting process of ethanol extract with hypouricemic effect from Rhizoma Alismatis.</p><p><b>METHOD</b>Orthogonal design was utilized to optimize the preparing conditions including the concentration of ethanol, amount of ethanol, extraction times and extraction duration per time while alisol B 23-acetate was selected as the evaluation index. Both the alisol B 23-acetate and the serum uric acid levels were measured by HPLC.</p><p><b>RESULT</b>The ethanol extract had hypouricemic action. Only extraction times had significant effect on the content of alisol B 23-acetate in ethanol extract.</p><p><b>CONCLUSION</b>The optimal extraction process is to extract two times using sevenfold 70% ethanol and 1 h per time.</p>

Observation on therapeutic effect of electroacupuncture plus blood-letting puncture and cupping combined with diet intervention for treatment of acute gouty arthritis / 中国针灸

<p><b>OBJECTIVE</b>To explore a more effective therapy for acute gouty arthritis.</p><p><b>METHODS</b>Sixty cases were randomly divided into an observation group and a control group, 30 cases in eachgroup. On the basis of diet intervention, the observation group was treated with electroacupuncture at local points combined with blood-letting puncture and cupping, and the control group with oral administration of Probenecid. Their therapeutic effects were ob served.</p><p><b>RESULTS</b>The effective rate was 96.7% in the observation group which was better than 86.7% in the control group (P < 0.01). After treatment, blood uric acid decreased significantly in the two groups (both P < 0.01), the observed group being lower than the control group (P < 0.01).</p><p><b>CONCLUSION</b>On the basis of diet intervention, electroacupuncture plus blood-letting puncture and cupping is a better therapy for acute gouty arthritis.</p>

Updates in the management of gouty arthritis / 대한내과학회지

Gout is the most common inflammatory arthritis in men over 40 years old and the prevalence is increasing. Asymptomatic hyperuricemia is predisposing condition of gout but the frequency of progression to acute gout is not high enough to need prophylactic treatment. In acute gout flare, first line therapy is non-steroid anti-inflammatory agents (NSAIDs) or corticosteroids, depending on comorbidities. Colchicine is now second line therapy. Urate lowering therapy for gout needs to be initiated when the second attack occurs in a year. Allopurinol, a xanthine oxidase inhibitor, has been the most widely used agent for the treatment of chronic gout. Now, febuxostat has emerged as a new xanthine oxidase inhibitor that is expected to be useful in patients with mildly decreased renal function. Uricosuric agents are alternative therapies for patients with preserved renal function and no history of nephrolithiasis. During urate lowering therapy, the dose should be titrated upward until the serum uric acid level is kept less than 6mg/dL. When initiating urate lowering therapy, concurrent prophylactic therapy with NSAIDs or low dose colchicine for more than six months is recommended for reducing flare-ups. In chronic gout treatment, dietary modification seems to have minimal effect, but alcohol drinking and weight control can be recommended.

Effect of Fenofibrate in Combination with Urate Lowering Agents in Patients with Gout

BACKGROUND: To assess the efficacy of fenofibrate treatment in combination with urate lowering agents in patients with gout. METHODS: Fourteen male patients with chronic tophaceous or recurrent acute attacks of gout were evaluated in an open-label pilot study of the hypolipidemic agent, fenofibrate (Lipidil Supra(R) 160 mg/d). Patients were stable on urate lowering agents (allopurinol or benzbromarone) for > or =three months without acute attack for the most recent one month before participating. All patients were being treated with established doses of urate lowering agents without modification throughout the study. Clinical and biochemical assessments including serum uric acid, creatinine, liver function test and fasting serum lipid were measured at (1) baseline (2) after two months of fenofibrate treatment and (3) two months after fenofibrate was withdrawn. RESULTS: Serum uric acid was lowered by 23% after two months of fenofibrate treatment (6.93+/-2.16 vs. 5.22+/-1.16 mg/dL; p=0.016). Triglyceride levels were also reduced after fenofibrate treatment (p=0.001). However, this effect was reversed after the withdrawal (p=0.002) of the drug. Alkaline phosphatase was reduced after fenofibrate treatment (p=0.006), but increased 21% after the withdrawal of the drug (p=0.002). By contrast, serum levels of high density lipoprotein and creatinine were increased 9% (p=0.018) and 12% (p=0.006), respectively; however, both levels were significantly decreased to the baseline levels upon withdrawal of fenofibrate. CONCLUSIONS: Fenofibrate can effectively reduce uric acid levels in addition to its known hypolipidemic effect. Fenofibrate may be used as a potential urate lowering agent in patients with gout, especially in those with coexisting hyperlipidemia.

The efficacy of combined low dose of Allopurinol and benzbromarone compared to standard dose of Allopurinol in hyperuricemia.

OBJECTIVE: To compare the efficacy of combined low dose of hypouricemic drugs (Allopurinol 100 mg and benzbromarone 20 mg; Allomaron) and standard dose 300 mg of allopurinol in hyperuricemia. MATERIAL AND METHOD: A prospective, open study of 94 hyperuricemic patients was done at King Chulalongkorn Memorial Hospital. Each group of 47 patients was given a combined low dose of hypouricemic drugs (Allopurinol 100 mg and benzbromarone 20 mg; Allomaron) and a standard dose 300 mg of allopurinol. Serum uric acid was measured before and 4 weeks after receiving the drugs. The efficacy was measured from the difference of the level of serum uric acid before and after receiving the drugs. RESULTS: The patients receiving the combined low dose of hypouricemic drugs and standard dose of allopurinol showed a mean reduction of serum uric acid of 2.5+/-3.4 mg/dl and 4.1+/-2.7 mg/dl consecutively. There was a statistically significant difference between the 2 groups (P = 0.010). CONCLUSION: This study demonstrates that the efficacy of standard dose 300 mg of allopurinol is superior to a combined low dose of allopurinol and benzbromarone in lowering the level of serum uric acid level.

Efficacy of benzbromarone compared to allopurinol in lowering serum uric acid level in hyperuricemic patients.

This study was aimed to evaluate the efficacy of benzbromarone compared to allopurinol in lowering serum uric acid level in hyperuricemic patients with normal renal function (serum creatinine < or = 1.5). The authors conducted a crossover study consisting of two four-week treatment periods of allopurinol 300 mg/day and benzbromarone 100 mg/day separated by a four-week washout period. Fourteen patients with mean age and duration of hyperuricemia of 60.78 +/- 8.62 and 6.93 +/- 3.69 years, respectively, were recruited and all completed our study protocol. This study was a crossover design consisting of two four-week treatments of allopurinol and benzbromarone separated by a four-week washout period. The serum uric acid level was reduced from 9.89 +/- 1.43 mg/dl to 5.52 +/- 0.83 mg/dl and from 9.53 +/- 1.48 to 4.05 +/- 0.87 mg/dl by allopurinol and benzbromarone, respectively. The efficacy of benzbromarone in lowering serum uric acid level was significantly superior to allopurinol (p=0.005). No patient reported clinical side effects during treatment with either drug. In conclusion, the authors have shown that benzbromarone is more effective than allopurinol in the reduction of serum uric acid levels in hyperuricemic patients with normal renal function.

Gota: opciones terapéuticas y profilaxis

Es indispensable posponer el tratamiento de la hiperuricemia subyacente hasta que el ataque agudo de gota haya sido resuelto

Antiinflamatorios nao esteroides (AINEs) / Nonsteroidal antiinflammatory drugs

Os antiinflamatorios nao esteroides sao farmacos usados em varias situacoes clinicas - patologias reumaticas, dor, febre e gota. Abordamos os aspectos fundamentais: mecanismos de acao, efeitos adversos e interacoes medicamentosas. Tem propriedades farmacologicas semelhantes, mas ha diferencas na eficacia, dependendo do tipo de patologia

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