Do not abuse painkillers during gout attacks and do not neglect long-term treatment

□ Hu Zhongdong Zhang Yu

Recently, the news that "a man with gout blindly took painkillers for a long time and suffered kidney failure before he was 40" became a hot search. The man had a 10-year history of gout and took painkillers on his own when gout attacked. Before he was 40, he had severe deformities in multiple joints and even kidney failure.

Is it okay to just take painkillers to relieve the pain of gout? Will the uric acid level in gout be high? Must the uric acid level be as low as possible? Let's analyze them one by one.

Rumor: Gout can be treated by taking painkillers.

Analysis: Gout is a syndrome characterized by recurrent acute arthritis and chronic manifestations, such as tophi, ankylosing joints, joint deformities, renal parenchymal damage, urinary tract stones, and hyperuricemia. Gout patients often have metabolic abnormalities and are prone to complications such as obesity, hypertension, hyperlipidemia, and type 2 diabetes.

Some people with gout do not restrict their diet and take painkillers to relieve pain when an attack occurs. Although the principle of acute gout treatment is indeed to quickly control joint inflammation and pain, gout is a chronic disease and oral uric acid-lowering drugs are needed for long-term treatment after the acute stage of gout.

Long-term control of blood uric acid levels can reduce the frequency of gout attacks. Abuse of painkillers will not only delay treatment, but also damage liver function and gastric mucosa, causing gastric bleeding. More seriously, if gout crystals block the renal tubules, it will lead to renal failure.

The truth: Painkillers can only relieve the symptoms of gout attacks, but they do not really play a role in lowering uric acid and treating gout. Uric acid-lowering treatment should be started after the acute gout symptoms disappear completely (≥2 weeks). Otherwise, gout will recur and even lead to serious complications such as renal insufficiency and uremia.

Rumor: If you have joint pain but your uric acid level is not high, it is definitely not gout.

Analysis: The human body's blood uric acid level fluctuates, and the test results are closely related to the meal habits of the day before the test, such as whether a low-purine diet is consumed, and the stage of the disease.

Not all gout patients have high uric acid levels. 30% of patients have normal uric acid levels during acute attacks. This is because during an acute attack of gout, the human body is in a state of stress, and the body fully exerts its self-regulatory function, secreting anti-inflammatory factors, and a large amount of uric acid is precipitated from the blood and deposited in the joints. At this time, the uric acid content in the blood is relatively reduced, and the test results of some patients are normal.

The truth: If you have joint pain but low uric acid levels, do not easily deny the diagnosis of gout. People with particularly typical gout symptoms should have their blood uric acid levels rechecked after the acute phase.

Myth: Antibiotics are used to treat gout attacks.

Analysis: Gout is an aseptic inflammation caused by supersaturated urate crystals deposited in joints and surrounding soft tissues. In acute attacks, the affected joints become red, swollen, hot, painful, and dysfunctional, but because they are sterile, antibiotics are ineffective. Even if early gout is not treated, it will gradually improve within 3-10 days, and patients may mistakenly believe that antibiotics have a certain effect on the treatment of gout. Most antibiotics are excreted through the kidneys, which may interfere with the normal excretion of uric acid, causing an increase in blood uric acid and exacerbating the condition.

The truth: Unless there is conclusive evidence that the gout patient has an infection, antibiotics are prohibited during a gout attack.

Rumor: Gout can be controlled through diet alone.

Analysis: The occurrence of hyperuricemia and gout is closely related to diet and lifestyle. A healthy diet, such as a variety of foods, limited purines, sufficient vegetables and milk, limited fructose, sufficient water intake, and limited alcohol intake, combined with weight control, can reduce the incidence of gout and control blood uric acid levels. However, hyperuricemia and gout are caused by the combined effects of genetic factors, lifestyle, and environment. Only 20% of the uric acid in the human body is produced by the metabolism of purines in the food consumed, and the other 80% comes from the metabolism of the body's own cells.

The truth: Simply controlling diet cannot completely suppress gout, and most gout patients require drug intervention.

Rumor: You can stop taking the medicine once your blood uric acid level reaches the standard.

Analysis: Many people believe that drugs for the treatment of gout are toxic to the liver and kidneys and should be avoided as much as possible. Whether the drug can be discontinued is mainly determined by the patient's blood uric acid level, the dose of uric acid-lowering drugs, and whether there is tophi. If the patient does not have tophi, on the basis of lifestyle intervention, low-dose uric acid-lowering drugs can maintain long-term uric acid standards, or even simply through lifestyle intervention, blood uric acid can be brought to the standard. Only then may it be considered to discontinue uric acid-lowering drugs. The discontinuation process must follow the principle of gradual reduction and regular review.

The truth: You cannot stop taking medication at will after your blood uric acid level reaches the target. For patients with asymptomatic hyperuricemia and gout, whether they are in the treatment stage or the medication withdrawal stage, regular follow-up is required to closely monitor blood uric acid and evaluate target organs such as the kidneys.

Rumor: The lower the blood uric acid level, the better.

Analysis: For gout patients, the blood uric acid level is strictly controlled. Long-term control of blood uric acid <360μmol/L (micromoles/liter) can not only dissolve urate crystals, reduce the number and size of crystals, but also prevent the formation of new crystals. For patients with tophi, the guidelines recommend a level below 300μmo/L.

Uric acid in the blood is a natural antioxidant in the body that can protect the nervous system and improve human immunity. Low levels of uric acid in the blood may increase the risk of neurological diseases such as Alzheimer's disease and Parkinson's syndrome.

The truth: For patients with asymptomatic hyperuricemia, the lower the blood uric acid level, the lower the incidence of gout, but the lower the blood uric acid level is not necessarily better. It is generally recommended that the target level for lowering uric acid should not be lower than 180 μmol/L.

According to the monitoring data of chronic diseases and risk factors in my country in 2018, the prevalence of hyperuricemia among adult residents in my country reached 14.0%, and the prevalence among young men (18-29 years old) reached 32.3%, showing a significant trend of younger age. There is still a long way to go from high uric acid to gout attacks. Only by reasonable diet control, appropriate exercise, and standardized drug treatment can uric acid be kept stable and reach the standard for a long time and the number of gout attacks can be reduced.

(The author Hu Zhongdong is a speaker and deputy chief physician for the Healthy China Action, and Zhang Yu is a researcher at the Chinese Center for Disease Control and Prevention)