Xiao Yulan, chief physician of cadre diagnosis and treatment department of PLA General Hospital

During acute arthritis, anti-inflammatory and analgesic measures should be taken in time to control symptoms. Non-steroidal anti-inflammatory drugs (NSAIDS) are commonly used, such as voltarin, fenbid and Mobike. The large number of NSAIDS helps patients to choose more targeted drugs. But individual differences are the main factors that determine the efficacy of drugs. Drugs that are effective and safe for patient A may not be effective and safe for patient B, so we should fully understand the specific situation of each patient and choose effective drugs within the available drugs. The simple and modular application of non-steroidal anti-inflammatory drugs is not helpful for the treatment of patients.

Application of non-steroidal anti-inflammatory drugs

1. Drugs with good curative effect and high safety should be selected. At present, there are many kinds of non-steroidal anti-inflammatory drugs to choose from. Many patients often think that colchicine is the first choice for relieving pain and diminishing inflammation in acute arthritis, but this choice may not be appropriate. Colchicine and aspirin are no longer the first choice for relieving pain and diminishing inflammation in gouty arthritis because of their great side effects.

2. The application of non-steroidal anti-inflammatory drugs is limited to the symptomatic treatment of acute arthritis, and the drug can be stopped after the joint swelling and pain subsides without long-term use.

3. Don't use toxic drugs, such as phenylbutazone.

4. Medication should be highly individualized. According to different situations, we should discuss the characteristics of each patient with patients and apply different kinds and doses of drugs according to the situation. Remember, both new drugs and imported drugs are the most effective drugs. The situation of some patients is just the opposite, but the old medicine that has been used for many years in clinic is the best medicine.

5. Gouty arthritis with cardiovascular or liver and kidney diseases should be used with caution.

(1) the general dosage should be small, and the maintenance dosage should be explored as soon as possible.

② If the acute inflammatory reaction of joints needs to be controlled during the course of disease, but NSAIDS cannot be used due to organ function damage, low-dose corticosteroids can be used for short-term treatment.

③ Patients with hypertension should reduce the dosage of non-steroidal anti-inflammatory drugs. Because NSAIDs often cause water and sodium retention and increase blood volume and blood pressure, patients with hypertension should reduce the dosage of NSAIDs.

6. Avoid using two or more NSAIDS at the same time, otherwise the effects will not be superimposed, but the side effects will be superimposed. If patients have taken aspirin to treat cardiovascular diseases and used other NSAIDS to treat gouty arthritis, aspirin should be stopped at this time. First, it can reduce the adverse reactions caused by the use of two drugs, and second, the efficacy of NSAIDS on cardiovascular diseases is similar to that of aspirin, and it does not affect the treatment of cardiovascular diseases.

7. Pay attention to the side effects of gastrointestinal tract. When receiving non-steroidal anti-inflammatory drugs, it is easy to have more gastrointestinal side effects, and its risk factors include:

⑴ Previous history of ulcers caused by NSAIDS or unknown reasons, especially those with complications.

(2) the elderly, especially those over 75 years old. The gastrointestinal ulcer caused by non-steroidal anti-inflammatory drugs in the elderly has the characteristics of large ulcer area, more bleeding, no pain, more misdiagnosis and high mortality (about 10%). Therefore, the elderly are at greater risk of taking non-steroidal anti-inflammatory drugs.

⑶ Use corticosteroids or anticoagulants at the same time.

(4) excessive use of NSAIDS.

Alkalized urine

Normal body fluids are weakly alkaline. The alkaline environment is conducive to the dissolution and excretion of urate crystals, so patients with gouty arthritis should eat more alkaline food. Foods that produce alkaline substances after metabolism in the body are mainly vegetables and fruits, including sour fruits, while foods rich in protein, fat and sugar, such as fish, poultry, meat and eggs, are acidic although they are not sour in taste.

In the process of medication, it is necessary to understand the acid-base situation in the body and measure the pH value of urine to guide the application of alkaline drugs. When the pH value of urine is 7, the solubility of uric acid is 6.6 ~ 9 times that of urine pH value is 5. It is not difficult to see the importance of alkaline urine in the treatment of gouty arthritis. The commonly used drug is sodium bicarbonate, 0.5g each time, three times a day, after meals. In the process of treatment, the pH value of urine is generally maintained at around 6.5, and cannot exceed 7.0, otherwise it will easily lead to the formation of calcium oxalate or other stones.

Prohibit uric acid lowering drugs

In acute arthritis, NSAIDS are mainly used to relieve inflammation and pain, while uric acid-lowering drugs have no analgesic effect. Many patients bring their own uric acid lowering drugs for a long time and take them themselves whenever acute arthritis attacks, which is unscientific. Therefore, it is hoped that patients should not blindly take uric acid-lowering drugs themselves, but should take them under the guidance of a doctor.

Taking uric acid-lowering drugs during acute arthritis can not only relieve pain, but also aggravate joint inflammation. The reason for this is the following：

After the application of uric acid-lowering drugs, the serum uric acid drops sharply, which dissolves urate in joints and releases insoluble needle-like crystals. When the lens is swallowed by white blood cells, it releases inflammatory factors, such as chemokine complement C3a and leukotriene B4, which attract more white blood cells to degranulate and release lysosomal enzymes, thus inducing joint inflammation. In addition, crystallization also stimulates macrophages and fibroblasts to produce prostaglandin, which is an important component in inducing joint inflammation.

Especially those with renal insufficiency, such as taking probenecid or gout elixir during acute arthritis, can increase the accumulation of uric acid in the body. Compared with patients without renal insufficiency, patients with renal insufficiency have more acute arthritis.

nip in the bud

Wang Yuming, deputy chief physician, Department of Rheumatology, Beijing Hospital of Traditional Chinese Medicine.

Family Medicine, 2003,No. 1.

Although gout is closely related to heredity, some acquired factors play an important role in the occurrence of gout. Once attention is paid to prevention, gout will enter seamlessly.

First of all, diet is closely related to gout. Many people regard eating and drinking as a kind of enjoyment and enjoy it. As we all know, most delicious foods are high purine foods. Excessive intake of high purine food is an important cause of hyperuricemia and the chief culprit of gout. Therefore, people should control their mouths, adjust their diet structure and choose their diet reasonably.

According to the level of purine content, people generally divide the diet into three categories: high purine, medium purine and low purine.

High purine food, that is,100g food contains150 ~ 500mg purine. These foods mainly include: animal offal, seafood, sardines, anchovies, hairtail, clams, chicken soup and broth. Gout patients try to fast these foods.

Purine food, that is, 100g food contains 50 ~ 150mg purine. These foods mainly include: poultry and livestock meat, fish, shrimp, crab, eel, white fish, flat fish, silver carp, various beans, peanuts and sesame. Gout patients should try to eat less of this kind of food. In addition, some vegetables also contain high purine, such as leeks, cauliflower, bean sprouts, pea seedlings, lentils, cauliflower, laver, fungi and so on. So it's best not to eat or eat less.

Low-purine food, that is, 100g food contains less than 50mg of purine. These foods mainly include eggs, duck eggs, milk, cheese and so on. These foods are edible. Fruits and vegetables, such as radishes, carrots, tomatoes, cabbages, potatoes and so on. The content of purine is extremely low, which is the recommended food for gout patients. Studies have shown that the concentration of uric acid in blood can be reduced by about 65438 0.2 mg/L after eating a purine-free diet for 7 days.

The staple food of gout patients should be mainly flour and rice, such as pasta made of refined flour and refined rice, and coarse grains should not be eaten because the purine content in flour and rice products is less than that in coarse grains. Avoid drinking. Alcohol in wine increases lactic acid in the body, which will affect the excretion of uric acid by the kidneys and easily lead to urinary calculi. Ethanol can also increase purine synthesis in the body, especially beer, which will produce a lot of purine during fermentation, which is very unfavorable to gout patients.

Secondly, ensure adequate water intake and drink about 2000 ml of boiled water every day, excluding liquid foods such as milk, soup and porridge. Because about 70% of uric acid in the human body is excreted from the kidneys, the daily urine output should reach about 1800 ml. Sweating and drinking water will increase in summer.

Third, pay attention to the rules of life, work and rest on time, eat regularly, and be full at seven points. Maintain an ideal weight. Avoid fatigue and mental stimulation. Exercise properly, but not vigorously, such as playing football, running fast, skating, swimming, climbing, etc. , will make the body produce too much lactic acid, inhibit the function of kidney excretion of uric acid, increase blood uric acid, and cause gouty arthritis.

In addition, we should have regular physical examination, strive for early detection of hyperuricemia and take timely measures to prevent gout.

● About the author:

Wang Yuming, 1983, graduated from the Department of Traditional Chinese Medicine of Beijing College of Traditional Chinese Medicine, and has been engaged in clinical and scientific research work on rheumatism. Zeng studied under Professor Wang, a famous rheumatologist in China, and achieved good results in treating various rheumatism and intractable diseases with integrated traditional Chinese and western medicine. Won the third prize of Beijing Science and Technology Progress Award. Published more than 20 papers in professional magazines.

Controlling gout from "blowing"

Liu Gang, Chief Physician, Department of Rheumatology and Immunology, West China Hospital

Family Medicine, 2003,No. 1.

The common manifestation of gout is acute arthritis. Colchicine is commonly used in acute gout attack, with a dose of 0.5 mg each time. Take orally 1 day for 3 times, twice on the second and third days, and 1 time every day on the fourth day and thereafter until the joint symptoms disappear.

In the initial stage of gout treatment, patients often have recurrent acute arthritis. At this time, the cycle of oral colchicine 1 time can be appropriately extended to prevent the recurrence of acute gouty arthritis. Taking colchicine at the beginning of symptoms can achieve the best effect. If there is obvious inflammation before taking the medicine, the dosage of the required medicine should be increased within the allowable dosage range and the course of treatment should be prolonged.

In addition, non-steroidal anti-inflammatory drugs, such as Voltalin, Mobike, Lifen, Naproxen, etc. , can also be used for the attack of acute arthritis, one of which can be taken orally. If colchicine combined with NSAID is used to relieve pain, the anti-inflammatory effect is better than that of single NSAID.

After the symptoms of acute arthritis subside, drugs to reduce serum uric acid concentration should be used. According to the mechanism of action, drugs for lowering blood uric acid can be divided into two categories, one is to interfere with the production of uric acid, and the other is to promote the excretion of uric acid by the kidney. If the patient's renal function is normal, drugs that promote renal excretion of uric acid, such as benzbromarone, can be selected; Or drugs that reduce uric acid production, such as allopurinol; You can also use both. If the renal function is abnormal, allopurinol can only be used to prevent the increase of uric acid excretion in the kidney, increase the burden on the kidney and cause renal function damage. Allopurinol is also excreted through the kidney, so it should be adjusted according to renal dysfunction. In addition, alkaline medicine baking soda can be added to increase the ph value of urine, improve the solubility of uric acid, and prevent its crystal deposition and kidney damage.

If gout is not treated in time, uric acid crystals will be deposited in large quantities, and tophi will appear around the auricle and joints of patients, and acute intermittent arthritis will also evolve into chronic arthritis with tophi. The course of this kind of arthritis is often prolonged for a long time, and the characteristics of intermittent attacks are not obvious. At this time, the treatment measures are different from acute arthritis, mainly drugs to reduce serum uric acid, supplemented by non-steroidal anti-inflammatory drugs and low-dose colchicine.

When a small number of patients go to the hospital, their renal function has been obviously damaged. Allopurinol should be used to reduce serum uric acid at this time. However, allopurinol should be reduced. In addition, drugs to improve renal function should be used to prevent further decline of renal function. If the patient's renal function has entered uremia stage, corresponding treatment is needed.

● About the author:

Liu Gang, born in 1954, studied in the postgraduate class of 1979 to 1982, and obtained a master's degree in medicine. After graduation, he has been engaged in clinical work of internal medicine for a long time, and 1997 began to systematically engage in the prevention and treatment of rheumatism. He studied under Professor Zhang Naizheng, the founder of rheumatology in China, and famous rheumatologists such as Jasmine Yi Dong, Tang Fulin, Zhang Fengchun and Zeng Xiaofeng. As the first author, he has published more than 30 papers in academic journals such as Chinese Journal of Rheumatology, Chinese Journal of Hematology, Journal of Immunology and Foreign Medical Blood Transfusion and Hematology. 1999, as the first person in charge to undertake the key scientific and technological projects of Sichuan Science and Technology Commission/kloc-0; As the deputy editor, he wrote the Handbook of Diagnosis and Treatment of Rheumatism published by People's Health Publishing House.

Gout, modern wealth disease

Professor Liu Wei, Director of Rheumatology Department, First Affiliated Hospital of Tianjin College of Traditional Chinese Medicine

Family Medicine, 2003,No. 1.

Our ward once treated a patient surnamed Zhang, 42 years old, of medium build. He is a generous, warm and friendly person, who likes to drink and chat with friends at ordinary times. Perhaps it is for this reason that his figure is obviously overweight. One day, he and his friends drank to their heart's content and went home to sleep with a strong sense of drunkenness. When I was sleeping soundly in the middle of the night, I was suddenly awakened by the severe pain in my right big toe. I saw that my big toe was swollen and I couldn't touch it. Persuaded by his family, he came to our hospital for treatment. By the time he was admitted to our hospital, he could no longer walk and dared not wear shoes on his right foot. After laboratory examination, it was diagnosed as acute attack of gout.

What disease is gout?

There is a substance in our body called purine, which is decomposed and metabolized to form a product-uric acid. Under normal circumstances, uric acid can be excreted through the kidney and large intestine.

If the human body ingests too much purine-containing substances, or purine metabolism is disordered, or uric acid excretion is reduced, uric acid in serum and body fluids will increase abnormally, resulting in hyperuricemia. If uric acid is not discharged in time, further accumulation will form crystals. These crystals are deposited in joints and their surrounding tissues, subcutaneous tissues, renal tissues and so on. , thus causing gouty arthritis, tophi, gouty nephropathy, etc. It can be seen that gout is a group of metabolic disorders, and hyperuricemia is its prelude and the main basis for gout diagnosis.

Gout can be divided into two categories: primary gout and secondary gout. About 10% ~ 25% of patients with primary gout have a positive family history of gout; About 1% ~ 2% patients have congenital enzyme defects, which hinder purine synthesis and catabolism; Other reasons are not clear. Secondary gout is caused by hyperuricemia caused by certain diseases, such as kidney disease, leukemia and tumor, or by certain drugs, such as diuretics and chemotherapy drugs, or by obesity and hunger therapy.

Gout is common in 30 ~ 50 years old. Early clinical manifestations are often recurrent acute arthritis. The typical manifestations of acute gouty arthritis are very serious, most of them start suddenly, and most of them wake up suddenly in the middle of the night because of foot pain. The joints are red, swollen, hot and painful, and the pain is beyond touch; The pain peaked within 48 ~ 72 hours. The attack was "knife-shaped", "bite-shaped" or "burning pain", which was unbearable for most patients, and some patients had no choice but to "hug their feet and cry". More than 70% patients take metatarsophalangeal joint as the first joint, followed by ankle joint, knee joint, finger, wrist joint and elbow joint. The time of each acute attack is about 1 week, and then it naturally relieves.

"upgraded version" of gout

Most patients with acute gouty arthritis can relieve themselves or after treatment. You won't feel any symptoms after remission, but don't think everything is normal. If it is not treated and controlled in time and systematically, it will be upgraded like a computer-it will enter the chronic stage of gout.

In the process of chronic diseases, tophi can be formed. The typical part of tophi occurs in auricle, and it is also common in the bend of thumb, finger, wrist, knee and elbow. The deposition of tophi in joints gradually increases, and the more frequent gout attacks, the more joints are involved, and even lead to bone erosion, defects and fibrosis of surrounding tissues. Nodules from soft to hard, from less to more, resulting in stiff joints. Therefore, joints are easy to wear and form fistulas. White paste is discharged from the fistula, and urate crystals can be detected. The tissue around the fistula is chronic inflammatory granuloma, which is not easy to heal.

In addition, about 30% gout patients can have kidney damage. The main manifestations are gouty nephropathy and urinary calculi.

Gouty nephropathy, the early manifestations are mild edema, low back pain, moderate increase in blood pressure, intermittent or persistent proteinuria, which is caused by urate deposition in the kidney, thus affecting renal function. If the nephropathy gets worse, the creatinine clearance rate will decrease and urea nitrogen will increase, which will lead to uremia and eventually die of renal failure.

Urinary calculi, because the patient's urine is acidic, lead to the increase of uric acid concentration in urine, resulting in urinary acid stones. Smaller stones can be excreted with urine without discomfort. Larger stones can block the ureter, causing renal colic, hematuria and even acute renal failure. Secondary infection can also become pyelonephritis. Huge stones can cause deformation of renal pelvis and calyx and hydronephrosis.

Gout is no stranger.

Here, there must be readers who want to ask: Since gout is so serious, why have you rarely heard of it before?

In fact, gout has existed since ancient times, but the incidence of gout in China was low. But it is more common in western countries, so many people think that gout is only a common disease in western countries, but it is rare in eastern countries.

In recent years, with the improvement of people's material living standards and the unscientific diet structure and habits in China, people's intake of purine-containing foods has increased, and the incidence of gout has increased year by year. According to a large sample survey, about 5% people in China suffer from hyperuricemia, and about 10% ~ 20% of them will suffer from or have suffered from gout. The onset of gout has been proved to be related to eating high purine diet, and is closely related to economic development and changes in diet structure. Therefore, it is not unreasonable for people to call gout a modern "rich disease".

● About the author:

Liu Wei, female, Manchu, was born in 1962. 1985 Tianjin college of traditional Chinese medicine stayed in school to teach after graduation. 1990 graduated from Tianjin college of traditional Chinese medicine with a master's degree in medicine. He is a close disciple of Wang Yunhe, a late famous old Chinese medicine practitioner in Kinmen. He used to diagnose and treat a variety of intractable diseases in internal medicine with his teacher, which is quite true. He has high attainments in the diagnosis and treatment of gout, rheumatoid arthritis, systemic lupus erythematosus and ankylosing spondylitis.

Gout (puzzle)

Family Medicine, 2003,No. 1.

Q: What tests do gout patients need to do?

Professor Liu Wei: Patients with gout should regularly check their blood uric acid levels and uric acid excretion. For patients with acute gout combined attack, white blood cell count and erythrocyte sedimentation rate should also be detected. In severe cases, the synovial fluid should be taken from the joint cavity for examination, and needle-like urate crystals can be found. For patients who can't be diagnosed for a while, it is feasible to use colchicine for experimental treatment, and most patients get better after taking the medicine.

Patients with chronic gout should also have X-ray examination of the affected joints to understand the degree of destruction of bones and joints; Imaging examination of the kidney to determine whether there are renal and ureteral stones. Elderly people with a course of disease should also have a renal function examination. In addition, tophi biopsy can confirm the existence of urate crystals.

Q: What are the toxic effects of taking colchicine for a long time?

Chief physician Liu Gang: Colchicine is a cytotoxic drug, which can inhibit the function of microtubules in cytoplasm. In the acute attack of gout, it can inhibit the chemotaxis of neutrophils and alleviate local inflammatory reaction. Therefore, it is a very effective drug to treat acute gout attack. However, the therapeutic dose is quite close to the toxic dose, so patients often have symptoms such as nausea, vomiting and diarrhea after taking the medicine according to the doctor's advice, which is caused by the toxic effect of colchicine on gastrointestinal epithelial cells. In addition, it can inhibit the hematopoietic function of bone marrow and lead to leukopenia; It can also cause hair loss; It also has certain toxic effects on liver, kidney, nervous system function and spermatogenesis. So don't use colchicine in large doses for a long time. For patients with renal insufficiency, colchicine should be used in small doses, because it is excreted by the kidney very slowly at this time, which is easy to lead to accumulation poisoning.

Q: What is the best method of treating gout by Chinese medicine?

Professor Liu Wei: The most fundamental treatment of TCM is syndrome differentiation and treatment, highlighting the individualized characteristics of treatment. We believe that gout attacks are mostly related to dampness, turbidity and blood stasis in the body. Generally speaking, the methods of clearing away heat and toxic materials, promoting blood circulation and dredging collaterals, inducing diuresis and removing turbidity are often used in the acute phase. In the stable period, on the basis of removing blood stasis and dredging collaterals, drugs for clearing heat, promoting diuresis and resolving turbidity are added. We often use Tongfeng decoction to treat acute attack. Tongfeng decoction controls hyperuricemia and Huayu Tongmai decoction has satisfactory clinical effect.

Q: What medicine should gout patients take?

Wang Yuming, Deputy Chief Physician: Patients with gout should pay attention to the fact that some drugs should not be used or used with caution. These drugs include penicillin, tetracycline, diuretics, compound antihypertensive drugs containing diuretics, vitamin B 1, B2, aspirin, nicotinic acid, warfarin, rifampicin, remifentanil and other drugs. Because some drugs affect the excretion of uric acid, the concentration of uric acid in the body increases after taking them, which can induce acute gouty arthritis or aggravate the symptoms of gouty arthritis. In addition, vitamin C and vitamin D should also be used with caution, because they can promote the formation of urinary calculi and accelerate the renal damage of gout patients.

Q: Are children prone to gout?

Deputy Chief Physician Wang Yuming: Children are not easy to suffer from primary gout. This is because the uric acid level of newborns begins to rise within 24 hours after birth, reaches a stable level after about 3 days, and continues until adolescence. After puberty, the serum uric acid value rises rapidly, and then maintains a peak state. After middle age, the blood uric acid value gradually rises, and it is easy to suffer from gout at this time. Therefore, gout in children is rare. However, some diseases, such as abnormal renal function, leukemia after chemotherapy and congenital metabolic disorder, can cause secondary gout. Children with these diseases should prevent gout.

Q: What is the difference between gout and rheumatoid arthritis?

Chief physician Liu Gang: Gout and rheumatoid arthritis are two completely different diseases:

Gout is a group of metabolic disorders, and rheumatoid arthritis belongs to the category of diffuse connective tissue disease. The former is more common in men, while the latter is more common in women. The former is often acute, and the most common part is the metatarsophalangeal joint of the first toe. At the time of attack, local redness, swelling, heat and pain were unbearable. The latter is a chronic attack, which usually occurs in the wrist, metacarpophalangeal joint and proximal interphalangeal joint of the hand, and the pain is generally tolerable. The former attack is intermittent, and there may be no joint symptoms in remission, but repeated attacks for a long time may eventually lead to joint destruction and deformity, and those with renal damage may progress to uremia; The latter can cause joint deformity and dislocation in the later stage.

When gout is located in the finger joint, it is similar to the finger joint disease of rheumatoid arthritis, and both of them can cause finger joint swelling. However, it can still be found that the swelling of finger joints in gout patients is nodular and lobulated, and sometimes white tophi deposits can be seen on the skin surface. "Limestone"-like uric acid crystals can flow out after local skin ulceration in some patients. Examination of rheumatoid arthritis showed that the proximal interphalangeal joint was spindle-shaped swelling in the early stage, and the focus was symmetrical. The number of joints involved is more than gout, and rheumatoid nodules are sometimes seen around the joints. X-ray examination showed osteoporosis and swelling of soft tissues around joints. In the late stage, the joint space is narrow and the articular surface is insect-like destruction. High concentrations of rheumatoid factor are often found in serum.

Because the pathogenesis of these two diseases is completely different, the treatment methods are also different.