(GuidelineforManagementofGout)

.. 2555
( .. 2544)

30

.. 2553-2555

. ............................................................................................................07
...............................................................................................09
..............................................................................................................................................09
........................................................................................................................................ ..11

1 (levelsofevidence)................................31

(gradingofrecommendations)
2 ...............................................32
3 ............................................................................33
4 ....................34
5 ...........................................................35
6 allopurinol..................36
7 allopurinol desensitization............................................................37
8 .....................................................38
9 colchicine..................38


(Guideline for Management of Gout)

1-2 10
2 1
65 7 85 32-3
4 (metabolic
syndrome)5 6



(
1) electronic database (Medline) systematic review database (Cochrane systematic review) .. 2554

1.

2.

1.
8

2.

7
6 6.8

6.8 37 7-8

( 2)
1. ( 3)

1-2
1-2
2. 24



30
3.
1100 11 (level of

evidence, LoE 4)


tumor lysis syndrome

4.
12
5.

13-14

(denite)
(monosodium urate crystal)
negative birefringent
compensated polarized light
15
Rome

(Rome criteria)16 2 3 17-18

1. 2
2. 7 6

3. (tophus)


17

3
1. (acute gouty arthritis)
2. (intercritical gout)

3. (chronic tophaceous gout)
10


1.
2.
3.
4.
5.

(1b, A)

1.
19 (2b, B)
2. acute gout, intercritical gout, chronic gout20 (1b, A)
3.
drug interaction 21 (1b, B)

(Non-pharmacological therapy)


(4, D)
-
o (purine)
22-23 (2b, B)
o 24 (3, C)
o 25 () (3, C)
o 22 26 27
28-29 (3, C) (3, C)

11


22
o 500
30 (1b, A)
31
-
o (1b, A) 32
33 3435 36-37
o
(ideal body weight)35, 38-39 ( 2b, B)
40
o
(4, D)
41 (2b, B)
(4, D)
33
(1b, A)
o
2
- (intense physical
exercise)42 (B)
(moderate physical exercise)43

(Pharmacological therapy)
( 4) 6
(4, D), (4, D),
(ice pack)44-45 (1b, A)
(colchicine)46 /
(non-steroidal anti-inammatory drugs, NSAIDs)1
12

 (1b, A)

47 (4, D)

(NSAIDs)
NSAIDs
7 48
(1b, A) (aspirin)
indomethacin
2 NSAIDs
NSAIDs 1


NSAIDs 49
gastro-protective agent proton pump inhibitor 50-51 (1a, A)
coxibs 15 (1b, A) NSAIDs
52-53

(Colchicine)
Colchicine 46
0.6 2-4 54-55
2 54, 56
(1b, A)
, myopathy neuropathy57
58 simvastatin rhabdomyolysis
(creatinephosphokinase,
CPK) 2 pravastatin
uvastatin

13

clarithromycin59, erythromycin60, cyclosporine, ketoconazole, cimetidine

colchicine

(Corticosteroid)

61-63 NSAIDs colchicine
(1b, A)
(intraarticular
corticosteroid injection)64 (2b, B)

0.5

tramadol (opiate
analgesic) colchicine
NSAIDs (4, D)
(intercritical period) (chronic gout)
( 5) 7





2 65 ; ; 66 (Strength of
Recommendation, SoR C); ;
uric acid nephropathy 67 (SoR B); (SOR B)
68-69 (SoR B)
14



6 21, 70-71
(LoE 3)
5 70, 72-73



1-2



(4, C)
1-4
74

(Uricostatic agent)
Allopurinol
Allopurinol cost-effectiveness 65 (1b, A)
50 100
50 100 1 4 74
900 75-76 active metabolite
(half life)
77, 78 (
6)8

78 (3, C) creatinine clearance
(CCr) 20
(uricosuric agents) benzbromarone 21, 72

15

 ( 2)
(allopurinol hypersensitivity syndrome) 0.3
(Steven-Johnson syndrome, exfoliative
dermatitis, toxic epidermal necrolysis)
(eosinophilia) 78
77 (ampicillin)
(thiazide)
(uricosuric agent)
allopurinol desensitization (
7)9 6-mercaptopurine azathioprine allopurinol
6-mercaptopurine azathioprine 6mercaptopurine azathioprine 30 - 50
79 warfarin allopurinol warfarin
warfarin international normalized ratio
(INR)

(Uricosuric agents)
800
; allopurinol; allopurinol
allopurinol (SOR B)
probenecid sulnpyrazone
allopurinol75 (2a, B)
(SoR B)
1000 (SoR B)

2
(alkalinization; urine pH 6.5-7) potassium
citrate80 potassium bicarbonate81 sodamint81-82
16

Sulnpyrazone
phenylbutazone
(anti-platelet aggregation)

83-86 CCr 60
200-800 2 50
2 (SoR B)

84
sulfonamide, sulfonylurea, warfarin, aspirin
sulnpyrazone

Probenecid
sulnpyrazone
(SoR B)
87 500-3000 2
250 2 88
probenecid
methotrexate, ketorolac, furosemide, sulfonylurea, penicillin, ampicillin, nafcillin,
rifampicin, indomethacin, dapsone, heparin (
heparin), aspirin ( probenecid)

Benzbromarone

allopurinol21, 89-91 (1b, A) probenecid 91 (1b, A)
21 (CCr
20 )88 92 25 200
93

17

hepatic necrosis 1 17000 94-96

6
warfarin warfarin
INR 97 troglitazone
98

(
8)10 losartan34, 99 (2b, B) fenobrate32-33, 100
(1b, A)

allopurinol
allopurinol
probenecid 101 (2b, B), benzbromarone 72, 102 (2b, B)
sulnpyrazone103 (3, B)

47, 104-105 colchicine 0.6 1.2

colchicine
6 106-108(1b, A) colchicine
( 9) 11
colchicine NSAIDs coxib
109 (4, D)
18



1-4 110
3-6
111 (4, D)

12, 112


111, 113

; ;
; ;

19


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29

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30

 1
(levels of evidence)
(grading of recommendations)
(Levels of Evidence, LoE)
1a
1b
2a
2b
3
4

meta-analysis randomized controlled trials

(RCT)
RCT 1
well-designed controlled study
randomization 1
well-designed quasi-experimental study 1

well-designed non-experimental descriptive studies

comparative studies, correlation studies and case control studies
/

(Grading of Recommendations, SoR)

A
B
C
D

1
2 1
3 1 2
4 2 3

31

32

phosphoribosyl pyrophosphate synthetase

hypoxanthine
guanine phosphoribosyl transferase

G-6-phosphatase

warfarin, nicotinic acid, fructose

myeloproliferative
disease, polycythemia vera,
hemoglobinopathy, hemolytic
anemia, pernicious anemia

multiple myeloma,
leukemia, lymphoma, sarcoma

, polycystic kidney, lead nephropathy

Pre-eclampsia, eclampsia

hyperparathyroidism, hypothyroidism,
,

,
( 2 ),
pyrazinamide, ethambutol, cyclosporine, levodopa, nicotinic
acid

Pagets disease,
cystinuria

(psoriasis)

Sarcoidosis

, fructose, cytotoxic
agent

33

 46

34

 57

35

 68
allopurinol
( Hande KR.)77
creatinine clearance ()
0
10
20
40
60
80
100
120
140

36

100 3
100 2
100
150
200
250
300
350
400

 7 9
allopurinol desensitization114

1-3
4-6
7-9
10-12
13-15
16-18
19-21
22-24
25-27
28

50
100
200
500
1
5
10
25
50
100

0.25
0.5
1
2.5
5
25
50
125
0.5 100
1 100

: allopurinol 100 2 100

10 100 allopurinol
200 1 5

37

 8 10

Acetoheximide
Ascorbic acid
Amlodipine
Atorvastatin
Azapropazone
Benzbromarone
Calcitonin
Calcium ipodate

Citrate
Dicumarol
Diflunisal
Estrogens
Fenofibrates
Glyceryl guaiacolate
Glycine
Losartan

Meclofenamic acid
Orotic acid
Phenolsulfonphthalein
Probenecid
Phenylbutazone
Salicylates (5gm/24hrs)
Sulfinpyrazone

9 11
colchicine
( Terkeltaub RA.) 7
creatinine clearance ()

> 50

0.6 . 2

35-49
10-34
< 10

0.6 . 1
0.6 . 2-3
colchicine

: 70 colchicine 50

38


.. 2553-2555

39

 .. 2553-2555

...
. ..
...
..
..
...
...
. ..
...
...
...
. () ..

40