痛风诊断与管理的多国证据推荐意见

临床医师

导语：由欧洲、南美洲和大洋洲14个国家78个风湿免疫科专家组成的推荐制订小组，按照“3e”方案（证据、专业、交流）并基于目前最重要的临床问题，就痛风的诊断和管理提出了10个问题，经查阅Medline等数据库后，对所有问题进行了系统资料综述，经多轮讨论和投票后，形成了最终的推荐意见。研究发表于《风湿病年鉴》。

       标签：痛风  诊断  管理

       由欧洲、南美洲和大洋洲14个国家78个风湿免疫科专家组成的推荐制订小组，按照“3e”方案（证据、专业、交流）并基于目前最重要的临床问题，就痛风的诊断和管理提出了10个问题，经查阅Medline等数据库后，对所有问题进行了系统资料综述，经多轮讨论和投票后，形成了最终的推荐意见。研究发表于《风湿病年鉴》。
　　痛风诊断与管理十条推荐建议：
　　1.为确定诊断痛风，应对尿酸钠结晶进行鉴别；当无法鉴别时，若患者存在典型临床表现（如足痛风、痛风石、对秋水仙碱治疗反应快）和（或）特征性影像学发现时，也可支待痛风的诊断
　　2.对于痛风和（或）高尿酸血症患者，推荐检测其肾功能和评估其心血管危险因素
　　3.根据合并症情况及不良反应风险，使用低剂量秋水仙碱（最大剂量为2mg/d）、非类固醇类抗炎药（NSAID）和（或）糖皮质激素（关节内、口服或肌注）治疗急性痛风
　　4. 建议患者采取健康的生活方式，包括减肥、规律锻炼、戒烟、避免大量饮酒和含糖饮料
　　5. 别嘌醇应为一线降尿酸治疗药物；当无法使用别嘌醇时的替代方案有促尿酸排泄药物（如苯溴马隆、丙磺舒）或非布司他；仅当患者存在严重痛风且其他药物治疗失败或存在使用禁忌时，可考虑使用尿酸酶单药治疗。降尿酸治疗（尿酸酶除外）应从低剂量开始并逐渐加量，以达到血清尿酸靶目标。
　　6.在使用降尿酸药物治疗时，须对患者进行有关痛风复发风险和管理的教育；可考虑使用秋水仙碱（最大剂量为1.2mg/d）预防复发，若存在使用禁忌或不耐受，可考虑使用NSAID或低剂量糖皮质激素。预防治疗时长根据患者个人情况而定。
　　7.对存在轻中度肾损伤的患者，可在严密监测下使用别嘌醇，以低剂量（50~100mg）起始逐渐增加剂量，以使血清尿酸达到靶目标；非布司他和苯溴马隆可作为替代治疗药物且无须剂量调整。
　　8.治疗的靶目标是血清尿酸低于0.36mmol/lL（6mg/L）、无痛风发作和痛风石溶解；监测血清尿酸水平、痛风发作次数和痛风石大小。
　　9.应通过持续降低血清尿酸水平[最好低于0.30mmol/L（5mg/L）]治疗痛风石；仅在特定病例中（如神经受压、感染等）科施行手术治疗。
　　10.对无症状高尿酸血症，不推荐进行药物治疗以预防痛风关节炎、肾病或心血管事件。

原文阅读：

Multinational evidence-based recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion of a broad panel of rheumatologists in the 3e initiative
　　Abstract
　　We aimed to develop evidence-based multinational recommendations for the diagnosis and management of gout. Using a formal voting process, a panel of 78 international rheumatologists developed 10 key clinical questions pertinent to the diagnosis and management of gout. Each question was investigated with a systematic literature review. Medline, Embase, Cochrane CENTRAL and abstracts from 2010–2011 European League Against Rheumatism and American College of Rheumatology meetings were searched in each review. Relevant studies were independently reviewed by two individuals for data extraction and synthesis and risk of bias assessment. Using this evidence, rheumatologists from 14 countries （Europe, South America and Australasia） developed national recommendations. After rounds of discussion and voting, multinational recommendations were formulated. Each recommendation was graded according to the level of evidence. Agreement and potential impact on clinical practice were assessed. Combining evidence and clinical expertise, 10 recommendations were produced. One recommendation referred to the diagnosis of gout, two referred to cardiovascular and renal comorbidities, six focused on different aspects of the management of gout （including drug treatment and monitoring）， and the last recommendation referred to the management of asymptomatic hyperuricaemia. The level of agreement with the recommendations ranged from 8.1 to 9.2 （mean 8.7） on a 1–10 scale, with 10 representing full agreement. Ten recommendations on the diagnosis and management of gout were established. They are evidence-based and supported by a large panel of rheumatologists from 14 countries, enhancing their utility in clinical practice.