痛风管理ppt课件

,台灣的痛風與高尿酸血症治療指引,1,2,高尿酸血症與痛風之治療台灣指引(2007年第一版),1.無症高酸血症的治2.急性痛風關節炎的藥物治3.發作間歇期4.慢性痛風石關節炎的治5.痛風合併症的治高血壓、高血脂、腎病變以及因痛風石壓迫造成的症。,3,EducationPreventionInitiativeforGoutManagementinTaiwan,1stmeetingon2012.11.042ndmeetingon2013.03.17DiscussionManagementofasymptomatichyperuricemiawithandwithoutcomorbiditiesCut-offvaluesindifferentscenarios:Initiationofurate-loweringtherapy?Drugchoiceforurate-loweringtherapyTreatmentdurationAllocationofeditorialworksConfirmationoffollowingmeetingtime,4,TaiwanGuidelineforthemanagementofGoutandHyperuricemia(2ndEdition),5,高尿酸血症與痛風之治療日本指引,Editors:TheGuidelineCommitteeoftheJapaneseSocietyofGoutandNucleicAcidMetabolism1stedition2002(Chairman:TatsuoHosoya,MD)2ndedition2010(Chairman:HisashiYamanaka,MD)Essentialpoints:Recommendationlevelswereevaluatedbymothevidencelevelandconsensuslevel.Supplementof2ndedition2012(Chairman:HisashiYamanaka,MD)Essentialpoints:DescriptionsofFebuxostatareincluded.,6,章節目錄,7,Guideline/recommendation,Systematicallydescribeddocumentsthatassistpractitionerandpatientdecisionsinaspecificmedicalsituation.(USInstituteofMedicine,1990）Improvementofqualityofmedicalcare.Implementationofstandardmedicine.IntroductionofmedicalprogressintodailypracticeInTaiwan,goutpatientshavebeentreatednotonlybyrheumatologistsbutalsobyGPs,orthopedists,meta/endocrinologistsandotherspecialists.Thus,standardizationofgoutpracticebyuseofguidelineisquitesuitable.,8,GuidelinefortheManagementofHyperuricemiaandGout2ndedition,Evidencelevel,Consensuslevel,Recommendlevel,+,Systematicreview,Delphimethod,9,References,10,11,12,1.Onetabletofcolchicine(0.5mg)isusedintheauraphaseofgoutyattacktostopfurtherdevelopmentofarthritis.Incaseoffrequentoccurrenceofgoutyattack,dailymedicationwithonetabletofcolchicine,“colchicinecover,”iseffective.2.Nonsteroidalanti-inflammatorydrugs(NSAIDs)areeffectiveintheacutephaseofgoutyattack.NSAIDsareadministeredatarelativelyhighdoseforalimitedperiodtoalleviateinflammation(NSAIDpulsetherapy).Thereby,theoccurrenceofadversedrugreactionsshouldbenoted.3.CorticosteroidsareorallyadministeredwhenNSAIDscannotbeadministeredortheiradministrationisineffectiveorwhenpolyarthritisoccurs.,治療原則:急性痛風或痛風石關節炎,13,4.Sincegoutyattackisexacerbatedwhenserumuratelevelischangedatthetimeofattack,inprinciple,medicationwithuricacidloweringdrugsshouldnotbeinitiated.5.Surgicalresectionisconsiderednecessaryinthetreatmentofsomecasesofgoutytophus,butdrugtherapyisalsonecessaryinsuchcases.,治療原則:急性痛風或痛風石關節炎,14,治療目標,StatementsThemostimportantaimoftreatmentofhyperuricemiaistoimprovelifestylechangesthatarerelatedtotheonsetofhyperuricemia,inwhichprognosis-relatedcomplications,suchasobesity,hypertension,glucoseintoleranceanddyslipidemia,arepronetooccur.Urateloweringtherapyisindicatedinpatientswithrecurrentgoutyarthritisorgoutytophi;thereby,itisdesirabletomaintainserumurateatalevelofnotmorethan6.0mg/dL.Urateloweringtherapymaybeindicatedforasymptomatichyperuricemiashowingaserumuratelevelofnotlessthan8.0mg/dLasaguide;however,itshouldbeappliedwithcaution.,15,Maintaininglowerserumuratelevelscanleadtolowerincidenceofrecurrentgoutyattacks.,ShojiA,etal:ArthritisRheum51:321-325,2004,治療目標:維持血尿酸值7.0mg/dL,測體重、血壓、血、膽固醇、三酸甘油酯、肌酸酐找出及排除會造成高酸血症的疾病、藥物、肥胖、飲食習慣，並調整生活型態,無症高酸血症,UA78,UA8.0,抽血追蹤、注意飲食(酸控制小於7mg/dL),抽血追蹤、生活型態、調整與低普飲食控制(酸控制小於7mg/dL),痛風關節炎,1.曾有急性關節炎發作(幾次?)或2.有痛風石或3.有道酸結石,生活型態調整與飲食控制及長期酸藥物治(酸控制在小於6mg/dL),26,日本指引中高尿酸血症之治療方針,無症狀高尿酸血症在下列哪些情況應予以治療?合併CKD合併高血壓合併糖尿病合併心血管疾病無上述合併症,血中尿酸值到達多少應予以治療?7mg/dL8mg/dL9mg/dL不應予以治療,27,尿酸是引發痛風最顯著之危險因子,Thenumberofgoutattacksincreaseswithanincreaseinserumuratelevelsinsubjectswithhyperuricemia(sUA7.0mg/dL).,Serumurate(mg/dL),100,80,60,40,20,CampionEW,etal:AmJMed82:421-426,1987,LinKC,etal:JRheumatol27:1501-1505,2000,Serumurate(mg/dL),Subjects：2,046healthymalesubjectsregisteredinthe“NormativeAgingStudy”Method：Aprospectivecohortstudytoobservetherelationshipbetweenserumuratelevelsatthestartofthestudyandthecumulativeinitialgoutyattackfrequency.Results：Cumulativeincidenceofinitialgoutyattacksincreasedwithincreaseinserumuratelevels.,Subjects：223asymptomatichyperuricemicsubjectsMethod：Five-yearcumulativeincidenceofonsetofgoutwasinvestigated.Results：Theincidenceincreasedwithincreaseinserumuratelevels.,Cumulativeincidenceofinitialgoutattacksfor5yrs(%),Cumulativeincidenceofinitialgoutattacksfor5yrs(%),28,6,356Japanesemen,aged35-60yearswithsystolicbloodpressureBloodpressurewasmeasuredandType2diabeteswasdefined.SerumuricacidlevelwasassociatedwithanincreasedriskforhypertensionbutnotforType2diabetes.,Theassociationbetweenserumuratelevelsandhypertension,TaniguchiY,etal:JHypertens19:1209-1215,2001(modified),Serumurate(mg/dL）,尿酸與心血管疾病之相關性,Serumuratelevelisanindependentpredictivefactorforthedevelopmentofhypertension.,Evidencelevel:1b,Recommendationlevel:A,Adjustedrelativeriskofprevalenceofhypertension(95%CI),29,From4MJHealthScreeningCentersinTaiwan(41,879men61:225-32.,30,SurvivorshipfromTotalCVDMortalityStratifiedbyIncreasingSerumUricAcidLevels,ChenJH,etal.Serumuricacidlevelasandindependentriskfactorforall-cause,cardiovascular,andischemicstrokemortality:aChinesecohortstudy.ArthritisRheum2009;61:225-32.,31,無症狀的高尿酸血症是否需要治療？,VeteransAdministrationNormativeAgingStudy(Campionelal.1987),ChoiHK,etal.PathogenesisofGoutAnnIntMed2005;143:499-516.,TaiwanTargetSUA?Gout6mg/dLTophi8or9mg/dLafterotherfactorscorrected?,32,痛風病患降尿酸藥物的使用時機,33,降尿酸藥物種類,34,Ccr:creatinineclearance,eGFR:estimatedglomerularfiltrationrate,降尿酸藥物之選擇,35,Allopurinol嚴重藥物過敏,Allopurinol過敏症候群雖然不常見，但卻有致命的危險性。自民國69年到82年間，本院總共有38個allopurinol過敏症候群的病例。臨床症狀包括:發燒、皮膚出疹、白血球增多、嗜伊性白血性增多、腎功能變差及肝功能受損。其中九個病人死亡，死亡率為百分之二十四，死亡主要的原因是感染。類固醇的使用與否，與死亡率及存活率無關。百分之二十六的病人服用allopurinol，是因為無症狀的高尿酸血症，這是必須避免的，因為無症狀的高尿酸血症並不是使用allopurinol的適應症。影響死亡率的最重要的因子是毒性表皮壞死(與其他皮膚病變相比，p值小於0.001)。能減少它發生機率的辦法是嚴格的依照allopurinol的使用適應症，且根據病人的腎功能去調節藥物的劑量。中華微免雜誌ChineseJMicrobiolImmunol1994;27:140-147李信興林孝義王世叡蔡瀛陽臺北榮民總醫院過敏免疫風濕科,36,37,Allopurinol過敏症候群,IndicationofallopurinolTophi(combinationwithuricosuricifseveretophi)UrolithiasisImpairedrenalfunction(Ccr800mg/day,38,39,GeneticMarkerforSevereCutaneousAdverseReaction(SCAR)InducedbyAllopurinol-Taiwan,Allopurinol-SCAR:HSS,SJS,TENHLA-B*5801:NECESSARYbutnotSUFFICIENTforallopurinol-SCARAllopurinol-SCAR(N=51)vsallopurinol-tolerant(N=135)100%vs15%,OR580.3(95%CI:34.4-9780.9,P=4.7x10-24)Allopurinol-SCARvshealthycontrol(N=93):100%vs20%,OR393.51(95%CI:23.2-6665.26,P=8.1x10-18)ExtendedhaplotypeHLA-A*3303-Cw*0302-B*5801-DRB1*0301Byanalysesof5homozygousHLA-B*5801patientsAllopurinol-SCARvstolerantvshealthycontrol:41%vs7%vs10%,HungSI,etal.ProceedingsoftheNationalAcademyofSciencesoftheUnitedStatesofAmerica.102(11):4134-9,2005Mar15.,40,HLA-B5801(+)不宜使用allupurinol?,41,Febuxostat:non-PurineXOinhibitor,Statusofthedevelopment:EU:RegulatoryApproval(April2008),LaunchedinFrance,UK,GermanyandIreland(March2010)U.S.:RegulatoryApproval(February2009),Launched(March2009)SouthKorea:RegulatoryApproval(June2009)Japan:JNDA(re-submission)(December2009)TaiwanNDAsubmission:TFDAsubmissiononAug.2010INDsubmission:approvedon18November2010,42,Febuxostat用法,43,Treatmentofgoutyarthritis,Onetabletofcolchicine,Aura,Maximum,Recovery,NSAID,NSAIDpulsemethod,44,生活方式之調整,StatementsHyperuricemiaandgoutarelifestyle-relateddiseases.Educationandproperguid