多病共存下痛风全科诊疗1例

张峥璐; 乌依罕

doi:10.16766/j.cnki.issn.1674-4152.004152

多病共存下痛风全科诊疗1例

doi: 10.16766/j.cnki.issn.1674-4152.004152

张峥璐^{1, 2},
乌依罕^3, ,

1.
内蒙古医科大学内蒙古临床医学院，内蒙古呼和浩特 010010
2.
乌兰察布市大六号镇中心卫生院全科医学科，内蒙古乌兰察布 012400
3.
首都医科大学附属北京友谊医院全科医学科，北京 101100

基金项目:

内蒙古自治区卫生健康委员会公立医院科研联合基金科技项目 2023GLLH0034

详细信息

通讯作者:
乌依罕，E-mail：mon_wyhan@163.com

中图分类号: R58.7
计量
- 文章访问数: 10
- HTML全文浏览量: 11
- PDF下载量: 2
- 被引次数: 0
出版历程
- 收稿日期: 2024-12-13
- 网络出版日期: 2025-10-31

A case of gout management in general practice with multiple comorbidities

ZHANG Zhenglu^{1, 2},
WU Yihan^{3
, ,}

1.
Inner Mongolia Clinical College of Medicine, Inner Mongolia Medical University, Hohhot, Inner Mongolia 010010, China

摘要

摘要: 随着社会经济发展，痛风发病率逐年攀升，并与多系统疾病紧密相连，这对全科医生的接诊、综合治疗及管理能力提出了更高要求。本文详述了1例多病共存痛风患者的诊疗全程，介绍其病史后，运用全人问诊和莫塔安全诊断策略展开流程式诊断，综合考量制定个性化方案。药物治疗中谨慎选药并权衡相互作用，非药物治疗涵盖饮食、运动、心理与社区随访等维度。此过程尽显全科医疗在痛风综合管理中的优势与价值，为痛风临床治疗及全科医生处理多病共存病例积累了宝贵经验，对提升基层痛风及共病诊疗水平具有重要的指导意义，也为改善患者生活质量和预后提供了有益参考。
- 痛风 /
- 多病共存 /
- 高尿酸血症 /
- 全科诊疗
Abstract: With the development of the social economy, the incidence of gout has been rising year by year and is closely associated with multiple systemic diseases. This poses higher requirements for the reception, comprehensive treatment, and management abilities of general practitioners. This article details the entire diagnosis and treatment process of a gout patient with multiple comorbidities. After elaborating on the patient' s medical history, a process-based diagnosis was carried out using the patient-centered interview concept and Murtagh' s safe diagnostic strategy, and a personalized treatment plan was formulated through comprehensive consideration. In drug treatment, medications were carefully selected and the interactions between them were weighed. Non-drug treatments covered aspects such as diet, exercise, psychological counseling, and community follow-up. This process fully demonstrated the advantages and value of general practice in the comprehensive management of gout, accumulated valuable experience for the clinical treatment of gout and the handling of patients with multiple comorbidities by general practitioners, which is of great significance in improving the diagnosis and treatment level of gout and related comorbidities at the primary level, and also provides a useful reference for improving the quality of life and prognosis of patients.
- Gout /
- Multimorbidity /
- Hyperuricemia /
- General practice

HTML全文

表 1 健康问题和危险因素评估表

Table 1. Assessment of health problems and risk factors

类别	具体内容
目前存在健康问题	1. 痛风：诊断明确^{[1, 4]}，完善病原学检查后及结合病史、体征等已排除布鲁氏菌病、类风湿性关节炎、骨关节炎、焦磷酸钙晶体相关关节病^[5-8]；
	2. 高血压3级，很高危：结合既往病史与疾病指南确诊^[12]；
	3. 代谢综合征：腰围≥90 cm，患高血压且HDL-C < 1.04 mmol/L，符合诊断标准^[13]；
	4. 酒精性肝病：长期饮酒史、轻度肝损害，影像学及化验指标支持诊断^[14]；
	5. 脑梗死、胆结石术后：既往病史明确。
存在危险因素	1. 不可控：年龄、性别、家族遗传病病史；
	2. 可控：吸烟、饮酒、饮食习惯、运动、肥胖；
	3. 其他：高血压、血脂异常、代谢综合征、酒精性肝病、脑梗死。
知、信、行评价及资源评估	1. 知：对痛风疾病认识少，日常饮食控制差；
	2. 信：明确诊断后规范治疗，依从性好；
	3. 行：无特殊；
	4. 家庭社会资源：经济一般，有城乡居民医保，家庭关系和睦，家人支持度高。

下载: 导出CSV

表 2 全科管理方案

Table 2. General practice management scheme

治疗分类	具体内容
药物治疗	1.痛风止痛。
	用药：塞来昔布胶囊，0.2 g/次，2次/d。
	原因：患者口服阿司匹林，痛风急性发作时，NSAIDs中非选择性药物(如吲哚美辛、双氯芬酸)会干扰小剂量阿司匹林抗凝活性，增加上消化道不良反应；而选择性COX-2抑制剂(依托考昔、塞来昔布)治疗2~5 d止痛效果与非选择性相当，且胃肠道、头晕不良反应发生率低，用药时关注肾功、消化道反应^[15]。
	2.降尿酸。
	启动时机：痛风发作控制2~4周后^[16-17];
	控制目标：因患者有脑血管病病史，建议血尿酸控制在 < 300 μmol/L，不建议长期 < 180 μmol/L，以防认知障碍、血管内皮功能障碍等风险^[18]。
	药物选择：
	别嘌醇：超敏反应与HLA-B*5801基因型相关(汉族人群携带频率10%~20%)，患者经济一般未做基因检测，暂不使用^{[1, 19]}。
	非布司他：对心血管安全性尚无定论，鉴于患者有脑梗死及高血压病史，暂不优先考虑^[20]。
	苯溴马隆：患者无泌尿系结石和肾功能不全，虽白种人中有引发暴发性肝坏死报道，但亚裔人群极为罕见, 可能与亚裔人群CYP2C9基因多样性不同相关^[21]，结合指南，初始剂量25 mg/次，1次/d，2~4周关注尿酸达标情况，必要时可增量至100 mg/d，用药期间关注肝功，嘱大量饮水、监测尿pH值，当pH值< 6.0时，用碳酸氢钠片碱化尿液，使晨尿pH值维持在6.2~6.9，同时关注胃肠道反应; 预防发作：降尿酸治疗初期(3~6个月)，因血尿酸波动约12%~61%的患者易痛风复发，在给予小剂量NSAID药物后痛风发作频率下降至20%左右^{[1, 16-17]}；故用小剂量选择性COX-2抑制剂塞来昔布胶囊0.2 g/次，1次/d，至少维持3~6个月, 关注不良反应^{[1, 16-17]}。
	3.抗血小板。
	用药：阿司匹林，维持原剂量服用。
	原因：患者有脑梗死病史，虽小剂量阿司匹林(75~325 mg/d)会使血尿酸轻度升高，但考虑其抗血小板对心脑血管的保护作用，不停药^[1]。
	4.降压。
	用药调整：改为厄贝沙坦片150 mg/次，1次/d，联合苯磺酸氨氯地平片5 mg/次，1次/d。
	原因：患者有高血压病史，原口服降压药含利尿剂氢氯噻嗪成分，且复合制剂下降压效果尚可；长效钙通道阻滞剂在降压同时兼有降尿酸作用^[22]，用药后嘱患者动态关注血压、心率变化，必要时调整方案。
	5.调脂。
	用药：阿托伐他汀钙片，10 mg/晚。
	原因：患者血脂异常(高胆固醇血症)且有脑血管病病史，该药可促进尿酸排泄，降低尿酸水平，关注不良反应^[23]。
	6.保肝。
	用药：多稀磷脂酰胆碱，456 mg/次，3次/d。
	原因：结合患者饮酒史及辅助检查支持酒精性肝病诊断，用于保护肝细胞、促使修复及再生，同时监测肝功能及胃肠道等不良反应^[14]。
非药物治疗	1.急性期处理：痛风急性发作时，患者卧床休息，患肢制动，局部冷敷。
	2.健康科普：患者近1年左足第一跖趾关节反复疼痛，告知需重视定期体检查尿酸值、调整饮食，及时咨询医生用药相关问题，避免疾病加重。
	3.饮食调整：
	戒酒：制定具体戒酒计划;
	营养支持：戒酒基础上，提供高蛋白、低脂饮食，补充多种维生素;
	食物选择：依据指南^[24]，明确牛羊肉、动物内脏、浓肉汤等高嘌呤食物，调配蒙古族特色奶茶避免果糖摄入，告知患者多吃蔬菜、奶类、大豆、适量吃鱼、禽、蛋、瘦肉、少盐、少油控糖，建议每日饮水量维持在2 000 mL以上，提供痛风饮食管理手册。
	4.运动康复：
	急性发作期：指导患者合理休息与关节周围肌肉等长收缩锻炼;
	非急性发作期：为患者制定个性化运动处方，指导运动训练及关节功能康复训练^[11]。
	5.健康管理：患者完善STOP-Bang问卷提示有OSA高危倾向，告知患者减重、减腹围的重要性，监控血压、血糖、血脂等危险因素，并按照慢性病管理规范严格管理。
	6.社区随访：将患者纳入社区随访，评估短期和长期的尿酸、血压、血脂、肝功能、肾功能等水平，提高治疗依从性，随访戒酒是否达到预期目标，监测治疗过程中药物不良反应和疾病并发症，为其及家属提供心理支持；若治疗过程中痛风病情再次难以控制、出现重症痛风或高尿酸血症等急慢性并发症，进行双向转诊，避免延误病情，减轻就医负担。

下载: 导出CSV

参考文献(25)

[1]	方宁远, 吕力为, 吕晓希, 等. 中国高尿酸血症相关疾病诊疗多学科专家共识(2023年版)[J]. 中国实用内科杂志, 2023, 43(6): 461-480. FANG N Y, LV L W, LV X X, et al. China multi-disciplinary expert consensus on diagnosis and treatment of hyperuricemia and related diseases (2023 edition)[J]. Chinese Journal of Practical Internal Medicine, 2023, 43(6): 461-480.
[2]	李杰, 青笛, 石婷婷, 等. 以全科临床诊疗思维诊治钩虫病致贫血1例报道[J]. 中华全科医学, 2023, 21(6): 1081-1084. doi: 10.16766/j.cnki.issn.1674-4152.003054 LI J, QING D, SHI T T, et al. Diagnosis and treatment of anemia caused by ancylostomiasis with clinical diagnostic and therapeutic thinking in general practice: a case report[J]. Chinese Journal of General Practice, 2023, 21(6): 1081-1084. doi: 10.16766/j.cnki.issn.1674-4152.003054
[3]	柴栖晨, 王静. 全科医学临床诊疗思维研究: 腹痛[J]. 中国全科医学, 2021, 24(17): 2241-2244. CHAI Q C, WANG J. Clinical diagnostic and therapeutic perspectives in primary care practice: a case study of abdominal pain[J]. Chinese General Practice, 2021, 24(17): 2241-2244.
[4]	曾学军, 张昀. 《2018版欧洲抗风湿病联盟痛风诊断循证专家建议更新》解读[J]. 中华内科杂志, 2019, 58(10): 745-750. ZENG X J, ZHANG Y. The interpretation of 2018 updated European League Against Rheumatism evidence?based recommendations for the diagnosis of gout[J]. Chinese Journal of Internal Medicine, 2019, 58(10): 745-750.
[5]	国家卫生健康委办公厅, 国家中医药局综合司. 布鲁氏菌病诊疗方案(2023年版)[J]. 中国感染控制杂志, 2024, 23(5): 661-664. General Office of the National Health Commission, General Department of the State Administration of Traditional Chinese Medicine. Diagnosis and treatment scheme for Brucellosis(2023 Edition)[J]. Chinese Journal of Infection Control, 2024, 23(5): 661-664.
[6]	国家皮肤与免疫疾病临床医学研究中心(北京协和医院), 中国医师协会风湿免疫专科医师分会, 中国康复医学会风湿免疫病康复专业委员会, 等. 2024中国类风湿关节炎诊疗指南[J]. 中华内科杂志, 2024, 63(11): 1059-1077. National Clinical Research Center for Dermatology and Immune Diseases (Peking Union Medical College Hospital), Rheumatology and Immunology Specialist Physicians Branch of Chinese Medical Doctor Association, Rheumatology and Immunology Rehabilitation Professional Committee of Chinese Rehabilitation Medical Association, etc. 2024 Chinese Guidelines for the Diagnosis and Treatment of Rheumatoid Arthritis[J]. Chinese Journal of Internal Medicine, 2024, 63(11): 1059-1077.
[7]	张伟, 胡晰杨, 张云娜, 等. 双能量CT联合肌骨超声鉴别诊断焦磷酸钙沉积病与痛风性关节炎的价值[J]. 实用医学杂志, 2024, 40(17): 2477-2482. ZHANG W, HU X Y, ZHANG Y N, et al. The combination of dual-energy CT and musculoskeletal ultrasonography has shown promise in distinguishing between calcium pyrophosphate deposition disease and gouty arthritis[J]. The Journal of Practical Medicine, 2024, 40(17): 2477-2482.
[8]	中国骨关节炎诊疗指南专家组, 中国老年保健协会疼痛病学分会, 黄东, 等. 中国骨关节炎诊疗指南(2024版)[J]. 中华疼痛学杂志, 2024, 20(3): 323-338. HUANG D, FENG Z G, HU R, et, al. Chinese guidelines for diagnosis and treatment of osteoarthritis (2024 edition)[J]. Chinese Journal of Painology, 2024, 20(3): 323-338.
[9]	《中国老年型糖尿病防治临床指南》编写组. 中国老年2型糖尿病防治临床指南(2022年版)[J]. 中国糖尿病杂志, 2022, 30(1): 2-51. TIAN H, LI C L, JI L N. Clinical guidelines for prevention and treatment of type 2 diabetes mellitus in the elderly in China (2022 edition)[J]. Chinese Journal of Diabetes, 2022, 30(1): 2-51.
[10]	HORSBURGH A, SUMMERS S J, LEWIS A, et al. The relationship between pain and interoception: a systematic review and meta-analysis[J]. J Pain, 2024, 25(7): 104476. DOI: 10.1016/j.jpain.2024.01.341.
[11]	中华医学会, 中华医学会杂志社, 中华医学会全科医学分会, 等. 痛风及高尿酸血症基层诊疗指南(2019年)[J]. 中华全科医师杂志, 2020, 19(4): 293-303. Chinese Medical Association, Chinese Medical Association Press, General Practice Branch of Chinese Medical Association, etc. Guidelines for Primary Care Diagnosis and Treatment of Gout and Hyperuricemia (2019)[J]. Chinese Journal of General Practitioners, 2020, 19(4): 293-303.
[12]	王增武. 《中国高血压防治指南(2024年修订版)》更新要点解读[J]. 中国心血管杂志, 2024, 29(5): 391-395. WANG Z W. Interpretation to the update key points of 2024 Chinese guidelines for the management of hypertension[J]. Chinese Journal of Cardiovascular Medicine, 2024, 29(5): 391-395.
[13]	中国医师协会中西医结合医师分会内分泌与代谢病学专业委员会. 代谢综合征病证结合诊疗指南[J]. 世界中医药, 2023, 18(22): 3157-3166. Endocrinology and Metabolic Diseases Committee of Integrated Traditional Chinese and Western Medicine Branch of Chinese Medical Doctor Association. Guidelines for the diagnosis and treatment of metabolic syndrome combined with disease and syndrome[J]. Chinese Journal of General Practice, 2023, 18(22): 3157-3166.
[14]	中华医学会, 中华医学会杂志社, 中华医学会消化病学分会, 等. 酒精性肝病基层诊疗指南(2019年)[J]. 中华全科医师杂志, 2020, 19(11): 990-996. Chinese Medical Association, Chinese Medical Association Press, Gastroenterology Branch of Chinese Medical Association, etc. Guidelines for the primary diagnosis and treatment of alcoholic liver disease (2019)[J]. Chinese Journal of General Practitioners, 2020, 19(11): 990-996.
[15]	MIRABITO K M, NEUMAN R I, VISSER W, et al. Aspirin for the prevention and treatment of pre-eclampsia: a matter of COX-1 and/or COX-2 inhibition[J]. Basic Clin Pharmacol Toxicol, 2020, 127(2): 132-141. doi: 10.1111/bcpt.13308
[16]	TERKELTAUB R. Emerging Urate-Lowering drugs and pharmacologic treatment strategies for gout: a narrative review[J]. Drugs, 2023, 83(16): 1501-1521. doi: 10.1007/s40265-023-01944-y
[17]	RUSSELL M D, RODDY E, RUTHERFORD A I, et al. Treat-to-target urate-lowering therapy and hospitalizations for gout: results from a nationwide cohort study in England[J]. Rheumatology (Oxford), 2023, 62(7): 2426-2434. doi: 10.1093/rheumatology/keac638
[18]	LI Y, LIN Z, WANG Y, et al. Are hyperuricemia and gout different diseases? Comment on the guidelines for the diagnosis and management of hyperuricemia and gout with the healthcare professional perspectives in China[J]. Int J Rheum Dis, 2023, 26(9): 1866-1868. doi: 10.1111/1756-185X.14592
[19]	VAN N D, CHU H C, VIDAL C, et al. Genetic susceptibilities and prediction modeling of carbamazepine and allopurinol-induced severe cutaneous adverse reactions in Vietnamese[J]. Pharmacogenomics, 2021, 22(1): 1-12. doi: 10.2217/pgs-2019-0146
[20]	吴欣, 孙文艳, 季爱昌, 等. 非布司他对痛风病人三酰甘油水平的影响[J]. 青岛大学学报(医学版), 2022, 58(2): 178-182. WU X, SUN W Y, JI A C, et, al. Effect of febuxostat on triglyceride level in patients with gout[J]. Journal of Qingdao University (Medical Science Edition), 2022, 58(2): 178-182.
[21]	YAN C Q, LIANG C, LAN Z R, et al. Comparison of the efficacy of febuxostat vs. benzbromarone in the treatment of gout: a meta-analysis in Chinese gout patients[J]. Eur Rev Med Pharmacol Sci, 2023, 27(24): 11988-12003.
[22]	ZHANG D, HUANG Q F, SHENG C S, et al. Serum uric acid change in relation to antihypertensive therapy with the dihydropyridine calcium channel blockers[J]. Blood Press, 2021, 30(6): 395-402. doi: 10.1080/08037051.2021.1996220
[23]	AKBARI A, RAZMI M, RAFIEE M, et al. The effect of statin therapy on serum uric acid levels: a systematic review and meta-analysis[J]. Curr Med Chem, 2024, 31(13): 1726-1739. doi: 10.2174/0929867330666230207124516
[24]	国家卫生健康委食品安全标准与监测评估司, 国家食品安全风险评估中心, 成人高尿酸血症与痛风食养指南编写专家组, 等. 成人高尿酸血症与痛风食养指南(2024年版)[J]. 卫生研究, 2024, 53(3): 352-356. Department of Food Safety Standards and Monitoring and Evaluation of the National Health Commission, National Food Safety Risk Assessment Center, Expert Group for Adult hyperuricemia and gout dietary guidelines, etc. Dietary Guidelines for Adult Hyperuricemia and Gout (2024 Edition)[J]. Journal of Hygiene Research, 2024, 53(3): 352-356.
[25]	李志军. 痛风及高尿酸血症的诊断与治疗[J]. 中华全科医学, 2020, 18(1): 5-6. http://www.zhqkyx.net/article/id/35702025-3b64-4c17-b820-044055abc76e LI Z J. Diagnosis and treatment of gout and hyperuricemia[J]. Chinese Journal of General Practice, 2020, 18(1): 5-6. http://www.zhqkyx.net/article/id/35702025-3b64-4c17-b820-044055abc76e