Because of accumulation of information on hyperuricemia and gout since 2010, the 3^rd edition of the guideline for the management of hyperuricemia and gout is now going to be processed. After setting the important clinical issues on hyperuricemia and gout, seven clinical questions accompanied by several advantage and disadvantage outcomes have been selected. Using the systematic reviews on reports related to outcome of each clinical question, bias risk of each evidence has been estimated. Taken together with the estimation of body of evidence, the recommendation for the each clinical question will be determined. In addition to clinical questions, review paper regarding the clinical issues of hyperuricemia and gout will be prepared. Thus, this guideline is expected to cover the decision making regarding the important clinical issues on hyperuricemia and gout.

Tumor lysis syndrome (TLS) causes hyperuricemia in patients with malignancies under chemotherapeutic treatment. Lowering serum uric acid (S-UA) levels is the most important. Febuxostat has been officially used for chemotherapy-associated hyperuricemia since May 2016 in Japan. Rasburicase and febuxostat reduce S-UA. Rasburicase is effective for high-risk TLS, and febuxostat for low-intermediate risk. Here, febuxostat was evaluated as a treatment for cancer-related hyperuricemia after becoming officially employed for TLS (June 2016 - November 2017). Sixty milligram was taken by mouth. The first chemotherapeutic treatment was started within a day after the first 60 mg dosing. The primary endpoint was S-UA normalization (≤ 7 mg/dL) on day 7 of chemotherapy. Twenty-four patients were evaluated (median: 70 years, range: 52-89 years, 14 males/10 females). The baseline S-UA was 7.2±2.7 mg/dL (mean±SD), and S-UA on the 7th day of chemotherapy was 2.5± 1.3 mg/dL (P<0.0001, by paired t-test). All patients met the primary endpoint. In addition, the baseline creatinine was 1.1±0.6 mg/dL (mean±SD), and the value on the 7th day of chemotherapy was 0.8±0.3 mg/dL (P=0.031, by paired t-test). Developing TLS was not observed. Severe adverse reactions were not noted. Thus, 60-mg febuxostat was effective against cancer-associated hyperuricemia.

Aim: Evidence has emerged that glycosuria is associated with lowering of serum uric acid (UA) levels in patients with diabetes mellitus (DM). The present study investigated whether glycosuria, per se, is involved in the lowering of UA levels in type 2 diabetic patients without hypoglycemic agents with uricosuric property.

Subjects & Methods: Individuals who underwent a annual medical check-up and met the inclusion criteria were recruited for this cross-sectional analysis. Diabetic patients being treated with sodium glucose cotransporter 2 (SGLT2) inhibitors were excluded from the analysis. The final participants were a total of 11,649 males, which consisted of euglycemics, prediabetics, and diabetics. Multiple regression analysis was employed to estimate factors influencing serum UA level.

Results: The UA level in the overall diabetics (5.9 ± 1.4mg/dL, n=704) was comparable with that in euglycemics (6.0 ± 1.1mg/dL, n=9,871). Prediabetics had the highest UA level among the subgroups (6.6 ± 1.3mg/dL, n=1,074). The UA level in diabetics with glycosuria (5.5 ± 1.3mg/dL, n=197) was lower than that in diabetics without glycosuria (6.0 ± 1.2mg/ dL, n=507, p<0.01). In addition, the severity of glycosuria had a negative correlation with the lowering of UA levels in diabetics. In addition, poor diabetic control was associated with the severity of glycosuria. Multiple regression analysis revealed that factors to predict the lowering of UA levels in diabetics were: age, estimated glomerular filtration rate (eGFR), and presence of glycosuria.

Conclusion: There is a close association between glycosuria and lowering of serum UA levels in patients with DM not being treated with SGLT2 inhibitors.

痛風関節炎は，「関節あるいは関節周囲に沈着した尿酸塩結晶により引き起こされる関節炎」と定義され，診断を確定するには，関節穿刺を行い関節液中に白血球に貪食された尿酸塩結晶を確認することが必要であるが，急性期に施行することは容易ではない．そこで，最近は非侵襲的に関節内の情報を得ることができる関節エコー検査が注目されている．今回我々は，痛風発作が疑われた症例の関節エコー検査所見のうち，滑膜肥厚と結晶沈着の意義について後ろ向きに検討した．検査時に痛みのある急性期群（113人，131関節）と痛みが治まっている間欠期群（30人，37関節）の観察関節における滑膜肥厚の程度を，関節リウマチの滑膜肥厚の評価に用いられるOMERACT（Outcome Measures in Rheumatology Clinical Trials）の定義に従ってグレード1～3に分類した．その結果，間欠期群に比して，急性期群の滑膜肥厚のグレードは高い傾向にあった．また，MTP関節では両群とも滑膜肥厚のグレードが上がるにつれて結晶沈着率の上昇傾向が認められた．以上のことから，滑膜肥厚は結晶沈着と密接な関係があり，さらには痛風発作との関連がある可能性が示唆された．

当院で高尿酸血症・痛風の内服治療を行っている患者208名に対して，Ⅰ服薬，Ⅱ治療，Ⅲ食事に関しての3項目，各項目5問ずつ，合計15問のアンケート調査を行った．管理栄養士が個別に3 回シリーズで指導しているためか，Ⅲの食事についての正解率は全体で88.1%と他の項目に比べて最も高かった．Ⅰの服薬については全体正解率が57.2%と3項目中で最も低く，中でも看護師による指導の行われていない飲食後の服薬の是非についての正解率が30～40％と低かった．Ⅱの治療については全体の正解率は67.8%であったが，血清尿酸値と尿pHの治療目標値についての設問が看護師による指導は行われていたが，正解率20～40％と低い結果であった．3項目について正解率の違いを治療期間別と年齢別で検討してみたが，通院1年未満の患者でⅠの服薬の正解率が低く，70歳代の患者でⅠの服薬とⅡの治療についての正解率が低い傾向にあったが，いずれも有意な違いではなかった．高尿酸血症・痛風の治療は生涯にわたって継続すべきものであり，良好な治療を継続する上では，医療スタッフによる繰り返しの指導が必要であると考えられた．今回のアンケート結果を参考に患者指導の内容や時期などを 改良した新しい指導計画案を作成した．これをもとに，患者の生活習慣の改善と服薬アドヒアランス向上につなげていきたい．