痛风指南相关评论：指南虽好，细节不足

点评专家：新罕布什尔州Geisel 医学院的风湿病专家Christopher M. Burns博士

撰写痛风治疗指南是一项困难的任务，从这一点来看，撰写组已经做得非常好了。

不过，在治疗痛风时，细节上的微妙差异可能会对治疗效果产生巨大影响。假如医生们把这部指南当成烹饪教程来用，他们可能就会遇到一些问题。

例如，这部指南涉及秋水仙碱作为一线药物在急性痛风发作中的使用：这是个好选择，然而已有随机对照试验数据表明，相当多的患者对小剂量治疗无应答。这部指南推荐的秋水仙碱剂量高于既往推荐的小剂量，这样做可能的确更好，不过肯定还是会有不少患者对秋水仙碱治疗无应答。

新指南可能误导初级保健医生的另一个例子是关于何时开始降低尿酸治疗(ULT)的建议。指南推荐的ULT启动指征包括确诊为痛风性关节炎和每年至少发作2次。我和同事认为，这样的指征可能将太多患者排除在治疗外。有很多患者每年仅发作1次，但已出现了通风相关性关节损害，而按照上述标准，他们不适宜接受ULT。风湿科医生可能根据经验做出自己的判断，而内科医生和初级保健医生很可能完全依从指南，从而导致部分患者得不到治疗。

此外，新指南建议对不能口服药物的患者使用促肾上腺皮质激素(ACTH)。然而，ACTH不仅价格昂贵，而且FDA已将痛风撤出ACTH的适应证列表，所以我怀疑这一建议在临床实践中是否行得通。

在讨论使用强的松预防痛风发作时，新指南建议采用≤10 mg的剂量。我认为作者试图在疗效与安全性之间求得最佳结合点，结果却是两边不讨好。因为人们通常希望避免长期使用激素，因此作者建议采用小剂量强的松，问题是10 mg剂量很可能是无效的。有数据提示，需要采用更大剂量强的松才能有效预防痛风发作，可能需达到20 mg/d。

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Writing guidelines on gout is a difficult task. I think they made a very good effort to cover as many treatment issues as they could.

Most patients with gout in the United States are cared for by primary care physicians. The guidelines will be helpful to both primary practitioners and rheumatologists, but the subtleties may be lost on the general practitioner, whereas the rheumatologist would pick these up right away. The devil is often in the details when it comes to treating gout. If physicians use the guidelines employing a cookbook approach, they might run into some problems.

For instance, the guidelines cover the use of colchicine as a first-line agent for an acute attack: It’s a good choice, but even the randomized controlled trials that have been published on this, especially using the low-dose approach, show that a significant proportion of patients will not respond to this regimen. The guidelines recommend a dosage higher than what has been advised previously for the low-dose colchicine approach. This may actually be a better method, so I hope this will allow primary practitioners to be able identify more people using this approach. But there are definitely going to be people who do not respond to the colchicine.

Another example of where the guidelines may mislead primary care physicians is the recommendation on when to start urate-lowering therapy (ULT). Their indications for starting pharmacologic ULT include an established diagnosis of gouty arthritis and at least two attacks per year. My colleagues and I think that may exclude too many people. Theoretically, you could have a patient with one attack per year who is having gout-related joint damage and, with this criteria, wouldn’t qualify for ULT. A rheumatologist would pick that up right away, but general practitioners who adhere to these guidelines might end up undertreating some patients.

Also, they recommend using adrenocorticotropic hormone (ACTH) for people who cannot take oral medications. Not only is ACTH is extremely expensive, but the Food and Drug Administration has taken gout off the list of indications for ACTH, so I doubt it would be readily available in a real clinical situation.

When the recommendations discuss using prednisone as a prophylactic against gout attacks, they suggest using 10 mg or less. I think that the authors are trying for the best of both worlds and ending up not having either. We generally try to avoid using steroids long term, so the authors suggest using low-dose prednisone; the problem is that 10 mg would probably be ineffective. There are data suggesting that gout prophylaxis requires higher doses, maybe as much as 20 mg/day. You could try 10 mg but I anticipate that it is not going to work very well.

In their defense, were the authors to go into the subtleties and side effects, what to do with a patient with liver or coronary disease, or issues of cost effectiveness, the guidelines would have become an unmanageable length. But the devil is in the details.

That said, it’s a major effort here. It’s good work. They tried to answer a lot of questions.

Dr. Christopher M. Burns is a rheumatologist at the Geisel School of Medicine at Dartmouth, Hanover, N.H. He reported having no financial disclosures.