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Crystal arthritides – gout and calcium pyrophosphate arthritis

Part 3: Treatment

Kristall-Arthritiden – Gicht und Kalziumpyrophosphat-Arthritis

Teil 3: Behandlung

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Abstract

The treatment of gout is based on several principles. Symptom control and termination of the inflammatory process are important early goals, whereas the urate level should be lowered in the long term to prevent further gout attacks and complications. The non-pharmacological approach is based on individually informing the patient on dietary measures and changes of life style. Besides physical measures, such as cold applications on the affected joint, various medications are available for treatment of an acute gout attack. The choice of drug depends on the individual risk profile. If non-steroidal anti-inflammatory drugs (NSAID) and coxibs are chosen it should be taken into account that the use is restricted in patients with renal insufficiency. Moreover, these drugs may have gastrointestinal side effects and are associated with increased cardiovascular morbidity and mortality. Colchicine has gastrointestinal side effects at high dosages but can also be used for differential diagnostics if there is a quick response to treatment. Steroids are an effective alternative and can be given orally or parenterally in patients with dysphagia. Moreover, steroids can be used in cases of renal insufficiency. After symptoms of the acute attack have subsided, urate lowering therapy should be initiated to prevent further attacks. Low-dose urate lowering therapy can be started during an acute gout attack when acute therapy is initiated. Allopurinol is still the medication of choice but its use is restricted in patients with renal insufficiency. A rare but serious side effect is allopurinol hypersensitivity syndrome. Febuxostat can be an alternative in patients who do not tolerate allopurinol. In February 2016, lesinurad, an URAT-1 and OAT-4 inhibitor, was approved in combination with allopurinol or febuxostat. Data on the effectiveness and safety of synthetic uricases and biologicals are still sparse for elderly patients. These substances are reserved for severe cases of gout.

Zusammenfassung

Die Therapie der Gicht beim älteren Menschen basiert auf mehreren Prinzipien. Während beim akuten Gichtanfall die Erreichung einer schnellen Beschwerdefreiheit durch Beendigung der akuten Inflammation im Vordergrund steht, zielt die dauerhafte Senkung der Harnsäure auf eine Vermeidung weiterer Anfälle und Vermeidung von Komplikationen hin. Die individuelle Information des Patienten hinsichtlich diätischer Maßnahmen und einer Umstellung der Lebensweise stellt die Basis der nichtpharmakologischen Therapie dar. Zur Unterbrechung des akuten Gichtanfalls stehen neben physikalischen Maßnahmen wie der Kühlung des betroffenen Gelenks verschiedenste Medikamente zur Verfügung. Die Auswahl ist abhängig vom individuellen Risikoprofil. Beim Einsatz von NSAR und Coxiben müssen die Nierenfunktion und das Auftreten von gastrointestinalen Schleimhautschäden wie auch die erhöhte kardiovaskuläre Morbidität/Mortalität bedacht werden. Colchizin hat in höherer Dosierung zahlreiche gastrointestinale Nebenwirkungen, kann aber bei Ansprechen der Therapie auch zur Differenzialdiagnose genutzt werden. Glukokortikoide können oral oder bei Schluckstörung i. v. eine Alternative darstellen und bei bestehender Niereninsuffizienz eingesetzt werden. Unter Therapie eines akuten Gichtanfalls kann bereits eine niedrig dosierte harnsäuresenkende Therapie eingeleitet werden. Allopurinol hat sich in der Praxis bewährt, Limitationen bestehen bei Niereninsuffizienz. Das Allopurinol-Hypersensitivitätssyndrom stellt eine seltene schwerwiegende Nebenwirkung dar. Febuxostat kann bei Unverträglichkeit von Allopurinol eine Alternative sein. Im Februar 2016 wurde Lesinurad, ein URAT-1- und OAT-4-Inhibitor, in Kombination mit Allopurinol oder Febuxostat zugelassen. Für die Therapie mit synthetischen Urikasen oder Biologikals existieren für geriatrische Patienten noch wenige Daten. Diese bleiben schweren Verläufen vorbehalten.

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Correspondence to S. Schlee.

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S. Schlee,C. Bollheimer, T. Bertsch, C.C. Sieber and P. Härle declare that they have no competing interests.

This article does not contain any studies with human participants or animals performed by any of the authors.

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Schlee, S., Bollheimer, L.C., Bertsch, T. et al. Crystal arthritides – gout and calcium pyrophosphate arthritis. Z Gerontol Geriat 51, 703–710 (2018). https://doi.org/10.1007/s00391-017-1199-1

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  • DOI: https://doi.org/10.1007/s00391-017-1199-1

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