歐洲抗風(fēng)濕病聯(lián)盟（EULAR）在2006年發(fā)布了第一版的《痛風(fēng)及高尿酸血癥的診斷和治療建議》，這是全世界最權(quán)威的痛風(fēng)防治指導(dǎo)性文檔，可以說(shuō)全世界的痛風(fēng)防治都會(huì)以此文檔作為參照。
這個(gè)文檔每5年更新一次，2011年更新了一版，參見(jiàn)老楊之前的兩篇文章：《EULAR的16條痛風(fēng)治療建議》和《EULAR的10條痛風(fēng)診斷建議》。
前段時(shí)間，EULAR再次更新了這個(gè)文檔，給出了痛風(fēng)治療的3個(gè)總原則和11條防治建議。為了避免翻譯錯(cuò)誤，老楊把英文原文也放在這兒，英文好的建議還是看英文。
因?yàn)槎际谴蟀自?，就不解釋了?/span>
A： Every person with gout should be fully informed about the pathophysiology of the disease, the existence of effective treatments, associated comorbidities and the principles of managing acute attacks and eliminating urate crystals through lifelong lowering of SUA level below a target level.
痛風(fēng)病人應(yīng)該知道痛風(fēng)的病理機(jī)制、 治療方法、可能引發(fā)的并發(fā)癥、急性發(fā)作時(shí)如何處理，以及：
痛風(fēng)必須通過(guò)將血尿酸濃度維持在某個(gè)水平之下才能消除尿酸結(jié)晶。
Every person with gout should receive advice regarding lifestyle: weight loss if appropriate and avoidance of alcohol (especially beer and spirits) and sugar-sweetened drinks, heavy meals and excessive intake of meat and seafood. Low-fat dairy products should be encouraged. Regular exercise should be advised.
痛風(fēng)病人要保持健康的生活方式：適當(dāng)減肥，不喝酒 （尤其是啤酒和烈酒） 和含糖飲料、重口味食品和過(guò)多的肉和海鮮。應(yīng)鼓勵(lì)低脂肪奶制品（參見(jiàn)《食品嘌呤表》），建議定期鍛煉（參見(jiàn)《痛風(fēng)患者該怎么運(yùn)動(dòng)？》）。
Every person with gout should be systematically screened for associated comorbidities and cardiovascular risk factors, including renal impairment, coronary heart disease, heart failure, stroke, peripheral arterial disease, obesity, hyperlipidaemia, hypertension, diabetes and smoking, which should be addressed as an integral part of the management of gout.
痛風(fēng)患者要知道痛風(fēng)會(huì)引發(fā)并發(fā)癥，了解對(duì)心血管不利的因素，包括腎功能不全、 冠心病、 心衰、 中風(fēng)、 外周動(dòng)脈疾病、 肥胖、 高脂血癥、 高血壓、 糖尿病和吸煙。
這11條的內(nèi)容中特別專(zhuān)業(yè)、不需要病人們深入了解的，老楊就不翻譯了，用省略號(hào)表示。
在老楊看來(lái)，對(duì)大部分痛風(fēng)朋友來(lái)講，這11條主要是三句話：急性發(fā)作時(shí)吃藥消炎，平時(shí)降酸治療，降酸目標(biāo)是360mmol/L。
1：Acute flares of gout should be treated as early as possible. Fully informed patients should be educated to self-medicate at the first warning symptoms. The choice of drug (s) should be based on the presence of contraindications, the patient’s previous experience with treatments, time of initiation after flare onset and the number and type of joint(s) involved.
痛風(fēng)急性發(fā)作應(yīng)該盡快盡早治療。病人應(yīng)該能夠出現(xiàn)癥狀后，自己選擇合適的藥物。
病人應(yīng)該基于自己的身體過(guò)敏等禁忌癥狀、以往的治療經(jīng)驗(yàn)、發(fā)作時(shí)間、發(fā)作的關(guān)節(jié)和數(shù)量來(lái)選擇該吃哪些藥。
2：Recommended first-line options for acute flares are colchicine (within 12 hours of flare onset) at a loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1 and/or an NSAID (plus proton pump inhibitors if appropriate), oral corticosteroid (30–35 mg/day of equivalent prednisolone for 3–5 days) or articular aspiration and injection of corticosteroids. Colchicine and NSAIDs should be avoided in patients with severe renal impairment. Colchicine should not be given to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin.
痛風(fēng)急性治療藥物包括：
秋水仙堿 （發(fā)作12 小時(shí)內(nèi)）：第一次劑量1mg，然后第一天之內(nèi)，每隔1個(gè)小時(shí)服用0.5mg。（可以參見(jiàn)《秋水仙堿的那些事》）
老楊提醒：國(guó)內(nèi)也有同樣的做法，但會(huì)注明第1天總劑量不能超過(guò)6mg。建議大家以安全第一為準(zhǔn)則，聽(tīng)從醫(yī)生建議。
NSAID（非甾體類(lèi)抗炎藥）
口服糖皮質(zhì)激素 （潑尼松龍30-35 毫克/天 3-5 天）
關(guān)節(jié)穿刺，注射皮質(zhì)類(lèi)固醇激素
對(duì)于腎功能重度損害的患者，應(yīng)避免服用秋水仙堿和非甾體抗炎藥。...
3：In patients with frequent flares and contraindications to colchicine, NSAIDs and corticosteroid (oral and injectable), IL-1 blockers should be considered for treating flares. Current infection is a contraindication to the use of IL-1 blockers. ULT should be adjusted to achieve the uricaemia target following an IL-1 blocker treatment for flare.
痛風(fēng)經(jīng)常發(fā)作，且對(duì)秋水仙堿、 非甾體類(lèi)抗炎藥和皮質(zhì)類(lèi)固醇激素過(guò)敏的患者 ，可以考慮采用IL-1 blockers （白細(xì)胞介素-1受體阻滯劑）。...
4：Prophylaxis against flares should be fully explained and discussed with the patient. Prophylaxis is recommended during the first 6 months of ULT. Recommended prophylactic treatment is colchicine, 0.5–1 mg/day, a dose that should be reduced in patients with renal impairment. In cases of renal impairment or statin treatment, patients and physicians should be aware of potential neurotoxicity and/or muscular toxicity with prophylactic colchicine. Co-prescription of colchicine with strong P-glycoprotein and/or CYP3A4 inhibitors should be avoided. If colchicine is not tolerated or is contraindicated, prophylaxis with NSAIDs at low dosage, if not contraindicated, should be considered.
進(jìn)行降酸的前6個(gè)月可能會(huì)痛風(fēng)急性，這很正常，可以每天服用0.5-1 毫克的秋水仙堿預(yù)防，但是如果腎功能不正常，應(yīng)減少劑量。
當(dāng)病人的腎功能損害或他汀類(lèi)藥物治療的情況下，患者和醫(yī)生應(yīng)該意識(shí)到，秋水仙堿可能的副作用。...
5：ULT should be considered and discussed with every patient with a definite diagnosis of gout from the first presentation. ULT is indicated in all patients with recurrent flares, tophi, urate arthropathy and/or renal stones. Initiation of ULT is recommended close to the time of first diagnosis in patients presenting at a young age (<40 years)="" or="" with="" a="" very="" high="" sua="" level="" (="">8.0 mg/dL; 480mmol/L) and/or comorbidities (renal impairment, hypertension, ischaemic heart disease, heart failure). Patients with gout should receive full information and be fully involved in decision-making concerning the use of ULT.
病人一旦痛風(fēng)發(fā)作并確診，就應(yīng)該考慮是否有必要進(jìn)行降酸治療。
對(duì)于近期痛風(fēng)急性發(fā)作過(guò)、痛風(fēng)石或腎結(jié)石，都建議考慮降酸治療。
第一次痛風(fēng)發(fā)作低于40歲、尿酸水平較高 (> 8.0 mg/dL; 480mmol/L)、痛風(fēng)并發(fā)癥 （腎功能不全、 高血壓、 缺血性心臟病、 心衰），都應(yīng)該考慮降酸治療。
6：For patients on ULT, SUA level should be monitored and maintained to <6 mg/dl="" (360mmol/l).="" a="" lower="" sua="" target=""><5 mg/dl;="" 300mmol/l)="" to="" facilitate="" faster="" dissolution="" of="" crystals="" is="" recommended="" for="" patients="" with="" severe="" gout="" (tophi,="" chronic="" arthropathy,="" frequent="" attacks)="" until="" total="" crystal="" dissolution="" and="" resolution="" of="" gout.="" sua="" level=""><3 mg/dl="" is="" not="" recommended="" in="" the="" long="">
降酸的目標(biāo)應(yīng)該是血尿酸水平低于 6 mg/dL (360mmol/L)（可參考《血尿酸濃度多少才算高？》）。
對(duì)于痛風(fēng)石（可參考《痛風(fēng)石，看這篇就夠了。》）或者經(jīng)常痛風(fēng)發(fā)作的患者，降酸目標(biāo)應(yīng)該是低于5 mg/dL或 300mmol/L，這樣能夠促進(jìn)晶體更快溶解。
注意，血尿酸水平不應(yīng)該長(zhǎng)期低于3mg/dL。
7：All ULTs should be started at a low dose and then titrated upwards until the SUA target is reached. SUA <6 mg/dl="" (360mmol/l)="" should="" be="" maintained="">
降酸治療必須從低劑量開(kāi)始，然后再逐漸增加劑量，降酸治療的目標(biāo)應(yīng)該是終身血尿酸濃度維持在低于 6 mg/dL (360mmol/L)的水平。
8：In patients with normal kidney function, allopurinol is recommended for first-line ULT, starting at a low dose (100 mg/day) and increasing by 100 mg increments every 2–4 weeks if required, to reach the uricaemia target. If the SUA target cannot be reached by an appropriate dose of allopurinol, allopurinol should be switched to febuxostat or a uricosuric or combined with a uricosuric. Febuxostat or a uricosuric are also indicated if allopurinol cannot be tolerated.
腎功能正常的痛風(fēng)病人，首選別嘌醇作為降酸藥（可參考《降酸藥及其副作用》）。最開(kāi)始的劑量推薦100mg/天，之后如果為了達(dá)到血尿酸目標(biāo)，可以每2-4周增加100mg/天。
如果服用別嘌醇不能達(dá)到降酸效果，可以考慮服用非布索坦或者其他能促進(jìn)尿酸排泄的降酸藥。
另外，如果服用別嘌醇過(guò)敏的，也應(yīng)該考慮非布索坦或者其他降酸藥。
9：In patients with renal impairment, the allopurinol maximum dosage should be adjusted to creatinine clearance. If the SUA target cannot be achieved at this dose, the patient should be switched to febuxostat or given benzbromarone with or without allopurinol, except in patients with estimated glomerular filtration rate <30>
對(duì)于腎功能受損的痛風(fēng)患者，別嘌呤醇的最大劑量必須根據(jù)肌酐清除率進(jìn)行調(diào)整。（有關(guān)肌酐基礎(chǔ)知識(shí)，請(qǐng)看《痛風(fēng)了，肌酐高是咋回事？》）
如果降酸目標(biāo)無(wú)法實(shí)現(xiàn)，可以考慮換成非布索坦，如果病人的腎小球?yàn)V過(guò)率 < 30="">苯溴馬隆（可以和別嘌醇合用）（可參考《別嘌呤醇和苯溴馬隆能否一起吃?》）。
10：In patients with crystal-proven, severe debilitating chronic tophaceous gout and poor quality of life, in whom the SUA target cannot be reached with any other available drug at the maximal dosage (including combinations), pegloticase is indicated.
對(duì)于有嚴(yán)重痛風(fēng)石病人或痛風(fēng)嚴(yán)重影響生活質(zhì)量的病人，如果其他藥物不能達(dá)到降酸效果，可以考慮Krystexxa (pegloticase)。（參見(jiàn)《介紹一下普瑞凱希》）
11：When gout occurs in a patient receiving loop or thiazide diuretics, substitute the diuretic if possible; for hypertension consider losartan or calcium channel blockers; for hyperlipidaemia, consider a statin or fenofibrate.
痛風(fēng)急性發(fā)作時(shí)，病人應(yīng)該停服利尿劑，高血壓應(yīng)該考慮氯沙坦或鈣離子拮抗劑類(lèi)降壓藥，而高脂血癥患者，應(yīng)該考慮他汀類(lèi)藥物或非諾貝特。
好了，就翻譯到這兒了。
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