12 avril 2014

Quand débuter l'allopurinol?

Est-ce que l'allopurinol peut être débuté durant la crise de goutte ou doit on attendre un certain temps après la résolution de la crise?

Résumé de l'article suivant:
Allopurinol during acute gout attacks did not differ from delayed allopurinol for pain or recurrence.

Tiré du American College of Physician Journal Club, Volume 158, number 8, 16 avril 2013
( http://annals.org.acces.bibl.ulaval.ca/article.aspx?articleid=1676475 )

The trial shows that administering allopurinol concurrently with indomethacin and colchicine within 7 days of onset of an acute attack of gout does not increase pain, induce recurrent flares, or change inflammatory markers compared with starting allopurinol 10 days after initiating antiinflammatory therapy. The trial seems to have been well-done, and based on the findings it seems safe to start allopurinol during an acute attack, provided effective antiinflammatory therapy has already been started.

However, just because a therapy may be safe doesn’t mean that it should always be introduced. 3 major professional bodies—American College of Rheumatology, European League Against Rheumatism, and British Society for Rheumatology and British Health Professionals in Rheumatology—do not recommend starting urate-lowering therapy for a first acute attack of gout. Rather, all 3 groups emphasize dietary and lifestyle changes as an essential step in initial management. Such changes include the following:
1) reducing ingestion of red meat, liver,kidney, shellfish, yeast extract, and overall protein;
2) increasing ingestion of fruits, vegetables, and soy products;
3) restricting alcohol intake;
4) losing weight if obese; and
5) discontinuing diuretics when possible.

These 3 professional bodies recommend starting urate-lowering therapy only after a patient has had subsequent attacks or has a high urate load as evidenced  by tophi, gouty arthropathy, or nephrolithiasis. Based on the trial, it seems to be safe to start allopurinol simultaneously with antiinflammatory drugs but only if urate-lowering therapy is truly indicated. Certainly, dietary and lifestyle changes would be preferred as initial therapy to reduce uric acid.

Il n'y a pas d'avantage à le donner en crise aiguë, car selon l'étude il ne réduit pas les douleurs. Toutefois, si le médecin décide d'initier l'allopurinol avant la résolution de la crise, il n'est pas nécessaire d'intervenir, car cette pratique semble sécuritaire.

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