介紹
使用降尿酸藥物治療的前3-6個月, 痛風個案的急性痛風發作機率可能會上升.
1. colchicine 0.5 mg~1mg qd 服用 3 ~ 6 months
2. feburic acid 40 mg qd x 2 weeks, check uric acid 2 weeks later
UA target < 6
3. 若 CCR < 50, 秋水仙素劑量減半
4. 何時可停用秋水仙素: 尿酸達標, 無痛風症狀 3-6 months
5. 痛風合併高血壓
-- 首選降血壓藥物 losartan = Cozaar
-- 儘量不要使用 thiazide 類利尿劑, 利尿劑會增加痛風發作機率。
6. 痛風合併高血脂，首選 fenofibrate， 降血脂同時也會降低血尿酸濃度。
第八節 痛風的預防
痛風的預防，首要的是生活型態的調整及使用降尿酸藥物，生活型態的調整包括：肥胖者 減輕體重，減少酒精攝取 (尤其是啤酒及烈酒)，減少動物性高嘌呤食物攝取，另外需維持血 尿酸值在 <6.0 mg/dL，然而對某些嚴重痛風石患者，將血尿酸值控制在 <5.0 mg/dL，可加速 結石的溶解速度。
使用降尿酸藥物的初期，因血尿酸值急速降低，有可能誘發痛風之發作。
故 宜合併使用預防痛風發作之藥物【圖八】。
預防痛風發作藥物之首選為低劑量秋水仙素。
秋水仙素預防痛風之建議劑量為每天 0.5-1 mg，使用期間需至少三個月，相較於安慰劑，可有效預防痛風復發，但另一個研究指出，每 日 0.5 mg 秋水仙素，使用六個月，可以有效預防痛風復發，且無明顯副作用。
秋水仙素在腎功能不佳的病患 (CCr <50 mL/min) 劑量宜減半。
若血尿酸值已達治療目標，且無痛風症狀至少 3 至 6 個月，則可考慮停止預防痛風發 作藥物。
痛風病人若合併高血壓，則首選降血壓藥物為 losartan，儘量不要使用 thiazide 類利尿 劑。因為利尿劑會增加痛風發作機率。
若病人合併高血脂，則首選降血脂藥物為 fenofibrate， 可同時降低血尿酸濃度。
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Prophylaxis for acute gout flares after initiation of
urate-lowering therapy
Augustin
Latourte, Thomas
Bardin, Pascal
Richette
Rheumatology, Volume 53, Issue 11, November 2014, Pages 1920–1926, https://academic.oup.com/rheumatology/article/53/11/1920/1792549
當開始降尿酸藥物治療之後, 如何預防痛風急性發作
有兩種第一線治療, 可以使用六個月
1. 低劑量秋水仙素 colchicine 0.5 mg qd or BID
2. 低劑量消炎止痛藥物 NSAID naproxen 250 mg bid. 如果因任何原因無法使用上述兩種藥物治療. 可考慮低劑量類固醇
prednisone 或 prednisolone.
近期還有其他研究, 在服用 allopurinol 期間, 使用介白素抑制劑 IL-1 inhibitor 輔助治療
canakinumab
rilonacept
Abstract
This review summarizes evidence relating to prophylaxis for gout flares after
the initiation of urate-lowering therapy (ULT). We searched MEDLINE via
PubMed for articles published in English from 1963 to 2013 using MEsH terms
covering all aspects of prophylaxis for flares. Dispersion of monosodium
urate crystals during the initial phase of deposit dissolution with ULT
exposes the patient to an increased rate of acute flares that could
contribute to poor treatment adherence. Slow titration of ULT might decrease
the risk of flares. According to the most recent international
recommendation, the two first-line options for prophylaxis are low-dose
colchicine (0.5 mg once or twice a day) or low-dose NSAIDs such as naproxen
250 mg orally twice a day. They can be given for up to 6 months. If these
drugs are contraindicated, not tolerated or ineffective, low-dose
corticosteroids (prednisone or prednisolone) might be used. Recently, reports
for four trials described the efficacy of canakinumab and rilonacept, two
IL-1 inhibitors, for preventing flares during the initiation of allopurinol
therapy. Prophylaxis for flares induced by ULT is an important consideration
in gout management. Low-dose colchicine and low-dose NSAIDs are the
recommended first-line therapies. Although no IL-1 blockers are approved as
prophylactic treatment, this class of drug could become an interesting option
for patients with gout with intolerance or contraindication to colchicine,
NSAIDs or corticosteroids.
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