急性痛風發作治療-from uptodate

2023-10-18 11:07AM 資料來自 uptodate.
uptodate 裡面建議的秋水仙素劑量. 是 2011年NEJM 建議.
第一天馬上吃兩顆秋水仙素(1.2mg). 一小時之後吃一顆秋水仙素(0.6mg). 第一天療程結束.
第二天開始. 每天早晚各吃一顆秋水仙素(0.6mg).

SUMMARY AND RECOMMENDATIONS
●Pretreatment considerations – Early treatment of a gout flare leads to more rapid and complete resolution of the flare.
However, gout and septic arthritis may present similarly. Glucocorticoids should be avoided until septic arthritis can be reasonably excluded.
●Treatment of gout flare – For patients with a first or infrequent recurrent gout flare affecting one to two joints, we suggest intraarticular glucocorticoids if this treatment can be delivered in a timely manner (Grade 2C). When using intraarticular glucocorticoids, we use triamcinolone acetate (40 mg for a large joint; 20 mg for a medium joint). Such treatment is highly effective with a single dose and avoids complications associated with systemic therapy.
For all other patients (including when intraarticular glucocorticoids are not available), systemic nonsteroidal antiinflammatory drugs (NSAIDs), colchicine, or glucocorticoids are alternatives to intraarticular therapy. Patient factors, prior experience, and availability should guide the choice of therapy.

Guidance for dosing and administration include:
•Glucocorticoids – We use prednisone 40 mg daily until the flare resolves. Intravenous methylprednisolone 20 mg twice daily or intramuscular triamcinolone acetate 40 to 60 mg every two days are alternatives for patients who cannot take oral medications. Both should be continued until flare resolution.
•Colchicine – On the first day of therapy, 1.2 mg of oral colchicine is followed one hour later by 0.6 mg. On subsequent days, colchicine 0.6 mg twice daily should be administered until 48 hours following the flare. Colchicine is contraindicated in the presence of any degree of kidney or hepatic impairment in patients receiving a P-glycoprotein (P-gp) inhibitor (table 2) or an agent that strongly reduces availability of the cytochrome P450 system component CYP3A4.
Colchicine most commonly causes gastrointestinal symptoms but also may be associated with neuropathy, cytopenia, myopathy, liver failure, and rash.
Colchicine may need to be adjusted or avoided in patients with impaired liver or kidney function and in patients taking drugs that impact the cytochrome P450 system. (See 'Colchicine' above.)
•NSAIDs – We use naproxen 500 mg twice daily or indomethacin 50 mg three times daily until a few days after the flare has resolved. NSAIDs should be avoided in older patients and others who are at higher risk of the kidney, cardiovascular, and gastrointestinal side effects of NSAIDs
●Special considerations
•Patients on anticoagulation – In patients taking anticoagulation, we use colchicine or oral glucocorticoids to avoid increasing the risk of bleeding that may occur with NSAIDs. An experienced provider may also be able to safely inject one or two joints with intraarticular glucocorticoids.
•Older adults – For older adults, we typically use oral glucocorticoids to manage an acute flare. Older adults are often intolerant of both NSAIDs and colchicine. (See 'Older adults' above.)
•Patients with chronic kidney disease – In patients with impaired kidney function, we use glucocorticoids and avoid colchicine and NSAIDs. In patients on chronic hemodialysis, NSAIDs may be used as an alternative to glucocorticoids.
•Pregnant patients – In women who are pregnant or breastfeeding, we suggest managing gout flares with glucocorticoids. NSAIDs should be avoided after 20 weeks of gestation but may be used beforehand or in women who are breastfeeding.
●Resistant gout flares – In patients who fail to respond to two or three days of treatment with NSAIDS or colchicine, we would initiate treatment with glucocorticoids. Intraarticular glucocorticoids may be appropriate in patients with only one or two affected joints.
●Refractory gout flares – In patients who are refractory to standard therapies, options include interleukin 1 (IL-1) inhibition (ie, anakinra 100 mg subcutaneously daily until flare resolution) or one dose of canakinumab 150 mg subcutaneously.
●Prolonged therapy – Patients who have had a partial response or experience a rebound flare after an initial response may need longer courses of therapy. This includes patients in whom treatment is delayed and patients who have persistent symptoms despite treatment.





Medline ® Abstracts for References 16,18,20 of 'Treatment of gout flares'
16 | PubMedTIHigh versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study.AUTerkeltaub RA, Furst DE, Bennett K, Kook KA, Crockett RS, Davis MW SOArthritis Rheum. 2010;62(4):1060.

OBJECTIVEDespite widespread use of colchicine, the evidence basis for oral colchicine therapy and dosing in acute gout remains limited. The aim of this trial was to compare low-dose colchicine (abbreviated at 1 hour) and high-dose colchicine (prolonged over 6 hours) with placebo in gout flare, using regimens producing comparable maximum plasma concentrations in healthy volunteers.

METHODSThis multicenter, randomized, double-blind, placebo-controlled, parallel-group study compared self-administered low-dose colchicine (1.8 mg total over 1 hour) and high-dose colchicine (4.8 mg total over 6 hours) with placebo. The primary end point was>or = 50% pain reduction at 24 hours without rescue medication.

RESULTSThere were 184 patients in the intent-to-treat analysis. Responders included 28 of 74 patients (37.8%) in the low-dose group, 17 of 52 patients (32.7%) in the high-dose group, and 9 of 58 patients (15.5%) in the placebo group (P = 0.005 and P = 0.034, respectively, versus placebo). Rescue medication was taken within the first 24 hours by 23 patients (31.1%) in the low-dose group (P = 0.027 versus placebo), 18 patients (34.6%) in the high-dose group (P = 0.103 versus placebo), and 29 patients (50.0%) in the placebo group. The low-dose group had an adverse event (AE) profile similar to that of the placebo group, with an odds ratio (OR) of 1.5 (95% confidence interval [95% CI]0.7-3.2). High-dose colchicine was associated with significantly more diarrhea, vomiting, and other AEs compared with low-dose colchicine or placebo. With high-dose colchicine, 40 patients (76.9%) had diarrhea (OR 21.3 [95% CI 7.9-56.9]), 10 (19.2%) had severe diarrhea, and 9 (17.3%) had vomiting. With low-dose colchicine, 23.0% of the patients had diarrhea (OR 1.9 [95% CI 0.8-4.8]), none had severe diarrhea, and none had vomiting.

CONCLUSIONLow-dose colchicine yielded both maximum plasma concentration and early gout flare efficacy comparable with that of high-dose colchicine, with a safety profile indistinguishable from that of placebo.ADVAMC San Diego, and University of California, San Diego, CA 92161, USA. rterkeltaub@ucsd.edu PMID20131255
18 | PubMedTIColchicine and other drugs for gout.AU SOMed Lett Drugs Ther. 2009;51(1326):93. AD PMID20224523
20 Colcrys (colchicine, USP) tablets, for oral use. US Food and Drug Administration (FDA) approved product information. Revised November 2012. US Food and Drug Administration. https://www.accessdata.fda.gov/drugsatfda_docs/label/2014/022352s017lbl.pdf (Accessed on April 12, 2019). no abstract available