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 medicationwithuricacid loweringdrugsshouldnotbeinitiated 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 Urate loweringtherapyisindicatedinpatientswithrecurrentgoutyarthritisorgoutytophi thereby itisdesirabletomaintainserumurateatalevelofnotmorethan6 0mg dL Urate loweringtherapymaybeindicatedforasymptomatichyperuricemiashowingaserumuratelevelofnotlessthan8 0mg dLasaguide however itshouldbeappliedwithcaution 15 Maintaininglowerserumuratelevelscanleadtolowerincidenceofrecurrentgoutyattacks ShojiA etal ArthritisRheum51 321 325 2004 治療目標 維持血尿酸值 6 0mg dL Urate loweringtherapyisindicatedinpatientswithrecurrentgoutyarthritisorgoutytophi thereby itisdesirabletomaintainserumurateatalevelofnotmore6 0mg dL Evidencelevel 2a Recommendationlevel A 16 痛風有多痛 Gout一字源自於古希臘字Gutta而來 其意義為Adrop 中醫則描述為白虎歷節 其來如風 風吹腳痛 極痛時謂之Podagra 帝王病 富貴病是也 17 ColdapplicationNSAID pulsetherapyColchicine dose CorticosteroidACTHUricacidloweringagents 秋水仙 最古老的痛風藥 傳統上一小時一粒 但是 18 急性治療開始時機 19 痛風只是冰山的一角 Whenwedon taddressgoutasachronicdisease Wetreatthis Butnotthis 20 痛風很少是單一事件 Datafrom5707participantsaged20yearsandolderintheNationalHealthandNutritionExaminationSurvey NHANES 2007 2008 AmJMed 2012Jul 125 7 679 687 21 HjortnaesJ etal JRheumatol34 1882 1887 2007 Subjects 431patientsfromtheSMARTStudy Netherland Methods Toanalyzetherelationshipbetweenserumurateandcomponentsofthemetabolicsyndrome Results ElevatedSUAlevelsarestronglyassociatedwiththemetabolicsyndrome Theassociationbetweenserumuratelevelsandthemetabolicsyndrome ChoiHK etal AmJMed120 442 447 2007 Prevalenceofthemetabolicsyndromeaccordingtoserumuratelevels Subjects 8 669participantsinNHANES 1988 1994 US Methods Determinedtheprevalenceofthemetabolicsyndromeatdifferentserumuricacidlevels Results Theprevalenceofthemetabolicsyndromeincreasessubstantiallywithincreasinglevelsofserumuricacid 痛風與代謝症候群的相關性 Theincidenceofmetabolicsyndromeincreaseswiththeincreaseinlevelsofserumurate Althoughnotincludedinthediagnosticcriteria hyperuricemiaisconsideredtobeabiomarkerofmetabolicsyndrome Evidencelevel 3 Recommendationlevel B Evidencelevel 3 Recommendationlevel B 22 尿酸與死亡率的關係 J型曲線 Mortality all cause squares cardiovascular diamonds andcancer related circles AmJKidneyDis 2006Nov 48 5 761 71 Rheumatology Oxford 2013Jan 52 1 127 34 P NS P 0 02 CKD5onrenalreplacement 294patients follow up27months 354110subjectsatCGMH withoutgout Lowestmortality 5 3 8 9 23 無症 高 酸血症的治 2007 基本上是採取較為保守的態 除非合併有HGPRT酵素 Hypoxanthine GuaninePhosphoribosylTransferase 缺乏 血液疾病或癌症將接受化學治 或器官移植患者使用環孢 造成 酸值升高高的 酸值並 意謂著一定會產生痛風 因此單純無症 的高 酸血症並非使用 酸藥物治 的適應症建議先找出及排除會造成高 酸血症的疾病 藥物 肥胖 飲食習慣等 24 尿酸結晶 MSU 是什麼 Lightmicrosopy phagocytizedMSUcrystal Polarizedmicroscopy strongnegativebirefringence 25 台灣指引中高尿酸血症之治療方針 高 酸血症 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 UA7 8 UA 8 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 dL 8mg dL 9mg dL不應予以治療 27 尿酸是引發痛風最顯著之危險因子 Thenumberofgoutattacksincreaseswithanincreaseinserumuratelevelsinsubjectswithhyperuricemia sUA 7 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 879men 48 514women aged 35years 1994 2003 ArthritisRheum2009 61 225 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 Gout 6mg dLTophi 5mg dL 78910SUAmg dL Buthowaboutasymptomatichyperuricemia Treatif 8or9mg 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 Educationandproperguidanceaimedatmodifyingthepatient slifestyleplayacrucialroleinimprovingtheclinicalcourseofthediseasewithorwithoutdrugtherapy Lifestylemodificationconsistsofthreeparts nutritiontherapy restrictionofalcoholconsumption andrecommendationforphysicaltraining Modestweightlosshasbeenshowntoreduceserumuratelevel Nutritiontherapyforhyperuricemia goutincludesappropriateconsumptionofcaloriesandwaterandreducedconsumptionofdietarypurineandfructose Patientswithmetabolicsyndromeshouldbeadvisedtoperformphysicalactivitytoimprovetheirclinicalimpairments 45 凝聚共識來研擬華人區痛風之診療指引 ImplementationtodailypracticeinTaiwanUtilizationforhealthcarepolicymakingReviseplaninevery4 5yearsInclusionofnewdrugsincludingFebuxostatDirectionforpatients perspectiveInternationalharmonization Chinese Japanese Caucasian 46 歡迎蒞臨台灣 47