Surgery Godfather
Chapter 504 - 460: Medicine - A Double-Edged Sword

Chapter 504: Chapter 460: Medicine - A Double-Edged Sword

When it comes to drugs for treating gout, Fatty is even more familiar.

Originally, in order to treat his own gout, he spent almost all his free time studying the knowledge of gout.

In one’s familiar territory, people often tend to be more confident. Now Fatty is growing stronger and stronger in his confidence, speaking eloquently, realizing that it feels so good to deliver a speech on stage, he couldn’t stop himself.

"The treatment of gout is divided into acute and remission phases. The so-called acute phase is when the pain occurs. The goal of treatment at this time is to relieve pain and reduce inflammation. Pain relief means analgesia, and reducing inflammation means eliminating inflammatory responses. This inflammatory response is not the purulent inflammation that people usually think of, but a sterile inflammation, so there is no need for the intervention of antibiotics. Don’t think that anti-inflammatory means using antibiotics, that’s completely different."

The script in Fatty’s mind was originally prepared for ordinary people, but then he realized that the audience was all medical students, so there was no need to bother explaining the concept of inflammation.

"There is a kind of drug that can relieve pain and also reduce inflammation, and that is non-steroidal anti-inflammatory drugs. Representative drugs include etoricoxib, celecoxib, diclofenac, ibuprofen, etc., among which etoricoxib is recommended by some guidelines. Remember, during an acute attack, it is not about lowering uric acid, but alleviating pain and inflammation. If you wrongly lower uric acid, it will worsen the pain. The timing for lowering uric acid is two weeks after acute pain is controlled. Of course, if you are currently undergoing hyperuricemia treatment, you can continue to take uric acid lowering drugs without stopping them."

"There is another drug used during the acute phase — Colchicine! This drug is a cytotoxic agent for cell mitosis, and it is highly toxic. Once overdosed, there is a lack of rescue measures, so be extra careful — the drug cannot be overdosed, and a low-dose regimen must be used: a first dosing of 1 mg, followed by 0.5 mg/dose, 2 doses per day, preferably starting to take the drug within 12 hours of the acute gout attack, the therapeutic effect declines significantly after 36 hours, and once the gout symptoms are under control, stop the medication."

"So, the first-line drugs in the acute phase are two kinds — non-steroidal anti-inflammatory drugs and colchicine, these two drugs are ineffective or patients with kidney function impairment, corticosteroids can be used, but try to avoid their use."

These knowledge of Fatty are not random talks but are comprehensive summaries of textbooks, the latest guidelines, and recent summaries of top international journals. Each sentence is carefully considered and repeatedly verified.

"During the remission period of gout, the treatment goal is to lower uric acid! The familiar drugs include allopurinol, febuxostat, probenecid, benzbromarone, both allopurinol and febuxostat are drugs that inhibit uric acid synthesis, while probenecid and benzbromarone are drugs that promote uric acid excretion, the actions are different. First of all, the latest concepts tend to use drugs that inhibit uric acid synthesis, namely, allopurinol and febuxostat."

"Allopurinol is low-priced and very effective, but be aware of its hypersensitive reaction. Once a hypersensitive reaction occurs, the fatality rate is 30%. It has now been determined that HLA-B*5801 gene positivity is closely related to hypersensitivity reaction to allopurinol. The HLA-B*5801 positivity rate is higher in Asians, with Han nationality reaching 10%-15%. Therefore, before using allopurinol, a highly recommended gene detection of HLA-B*5801 should be carried out. If positive, absolutely do not take this drug; if negative, you can normally use it."

"The hypersensitivity reaction caused by Allopurinol is dose-related, so start with a small dose, usually starting at 50mg/day, increasing to 200-300mg/d after 2-3 weeks, the maximum dose should not exceed 600mg/d, to be taken three times; hypersensitivity reactions often occur before rashes, so once rashes appear after taking the medication, immediately stop taking and seek medical attention, there is no room for negotiating!"

Remember this gene, HLA-B*5801! Many young doctors, have already forgotten much about internal medicine knowledge, lacking this knowledge, for doctors, is like streaking, very dangerous.

Doctors are always walking on thin ice, only by constantly accumulating knowledge, can they deftly navigate through risks.

"Febuxostat has potential cardiovascular risks, which means it increases the occurrence of myocardial infarction and stroke. If people with cardiovascular diseases, such as hypertension, and coronary heart disease, etc., should use febuxostat with caution."

"Probenecid and benzbromarone are drugs that promote uric acid excretion, so if there is an excretory disorder type of hyperuricemia, which are ineffective with the first two drugs, they can be selected. For these two drugs, if there are kidney stones, kidney function impairment, do not use, both drugs will affect the kidneys, probenecid has a greater impact on the kidneys than benzbromarone, also, benzbromarone causes the greatest liver damage among the four drugs. In 2003, benzbromarone was withdrawn from the European market due to liver damage, but in 2004 it was re-registered in some countries."

Any drug carries risks while also treating, drugs are a double-edged sword, you have to take advantage of the benefits and avoid risks."

"According to the principle of playing to one’s strengths and avoiding weaknesses, of the above four drugs, actually if HLA-B*5801 is negative, allopurinol is the first choice; if HLA-B*5801 is positive and there are no cardiovascular diseases, febuxostat is selected; if HLA-B*5801 is positive, and there are cardiovascular diseases, and kidney function is not problematic, probenecid and benzbromarone can be chosen, and liver function must be monitored when using benzbromarone."

The introduction of these four drugs, Fatty has spoken straightforward but concisely. For more details, there are hundreds of tightly packed words in the instructions.

Someone in the audience felt scared: "Your words make my chill run down my spine, my dad has been taking allopurinol and never tested for HLA-B*5801."

A graduate student is more familiar with benzbromarone: "The liver damage caused by benzbromarone is its weakness, it is best to regularly check liver function during intake. Around 2003, Europe reported a case of severe liver damage related to the drug, but that was under the condition of a higher dose of 100mg-200mg of benzbromarone in the European population, with a statistical incidence rate of only 1/17,000. Our clinical common prescription dose now is 50mg, very few patients can be prescribed to 100mg, at this medication dose, cases of liver damage caused by benzbromarone are extremely rare. However, we should be cautious because of its antecedent case."

"For febuxostat in Asians, there is currently no data indicating a higher rate of cardiovascular events, so the safety is pretty good, but those suffering from cardiovascular diseases should try to avoid it." Another graduate student added.

"Dr. Liang, after listening to your lecture, these fragmented pieces of knowledge have been comprehensively connected. Now I have a clear understanding in my mind, and next time I treat patients, if I encounter ones with gout, the choice of medication will be much more flexible." Someone sincerely appreciated Fatty.

It seems that Fatty has indeed put in a lot of thought, these commonly used drugs for gout treatment, especially several kinds of uric acid lowering drugs, where the advantages lie, where the disadvantages lie, where the risks are, and how to use them, are all very clear.

"After saying so much, the key point has not been mentioned, under what circumstances is it necessary to lower uric acid, and to what level should uric acid be lowered?" After listening for so long, one intern was still confused.

Fatty thought everyone would already know these basics: "These are all in textbooks and guidelines, I just skimmed over it. If you look at the most recent treatment guidelines: if the patient has already developed tophi, chronic gouty arthritis, or frequent gouty arthritis attacks, the target for uric acid reduction is blood uric acid < 300 μmol/L, until the tophi are completely dissolved and the symptoms of frequent arthritis attacks improve, the treatment target can be changed to blood uric acid < 360 μmol/L and maintained for a long period."

"Is it better the lower the blood uric acid is?" an intern dared to ask.

Fatty immediately criticized, "Which department’s intern are you? You haven’t grasped medical basics! Uric acid in the human body within the normal range has important physiological functions, excessively low blood uric acid can increase the risk of neurodegenerative diseases such as Alzheimer’s disease, Parkinson’s disease, etc., so it’s not the case that lower is better. When reducing uric acid during treatment, blood uric acid should not be less than 180 μmol/L."

The intern immediately blushed, not having thoroughly understood the textbook, he needed to go back and review carefully.

"For those who have developed gout, that is, uric acid higher than normal, it’s recommended to reduce uric acid treatment; for those without gout symptoms, having only hyperuricemia, you can first try to change your lifestyle - balanced diet, exercising, quitting alcohol, drinking plenty of water, etc. Additional evidence, I hope none of you don’t know the diagnostic criteria for hyperuricemia? Two consecutive days of fasting blood uric acid levels--- for men higher than 420μmol/L, for women higher than 360μmol/L."

"So, does anyone have more questions?" Fatty had enjoyed himself, and he needed to rest.

Fatty finally understood why, when he was studying for a master’s degree and PhD, the supervisor would always forget about the time once he seized upon a question during rounds, elaborating on it endlessly.

Turns out, lecturing feels so satisfying!

"Professor Liang, if you change your profession and become a lecturer at a health product company, with your current teaching standard, an annual income of one million wouldn’t be a problem." Zhang Lin said seriously.

Liang Fatty waved his hand: "I can fight within the framework of evidence-based medicine, when talking about seriously legitimate things. But once I step outside this framework and start to improvise to cure all kinds of diseases, I’d be completely speechless."

"Does anyone else have questions? Ask away if you do. You should master this knowledge now. In the future, when you are about to get married and your father-in-law has a gout attack, you can alleviate his pain within a few hours, his goodwill towards you will double!" Zhang Lin shouted, ready to end the lecture.

"Dr. Yang! Anything else to summarize?" Zhang Lin turned to Yang Ping.

Fatty had given an immensely insightful lecture, Yang Ping thought there was nothing else to add, he stood up, reminding everyone: "When you are explaining this knowledge to your friends and family, you must tell them that all this medical knowledge is meant to help them seek medical help better, and it cannot replace seeing a doctor. Because usually people outside the medical profession lack basic medical knowledge, if they make decisions on their own, they can easily make mistakes, respect should be given to the unknown aspect of every domain, especially when it involves health!"

"Yes! An important reminder: if you’re sick, see a doctor! This knowledge is to help you make better decisions, not to replace a trip to the hospital!" Liang Fatty found Yang Ping’s words reasonable.

Fatty had seen that kind of relative who, after reading few medical health books, thought they knew better than doctors.

The growth of a doctor is far from as simple as reading a few books. Undergraduate studies last five years, if they pursue further education, a master’s degree takes three years, and a doctorate another three to four years. Even if they take an integrated bachelor’s-master’s-doctoral program, they have to study for eight years. After graduation, they need to accumulate many years of clinical experience under the guidance of their senior doctors. It takes three years to take a residency exam and five years for an attending physician exam. If they reach the deputy senior level and above, they basically have decades of work experience. During this period, they accumulate a large number of books and papers that need a dedicated study to store. Only then are they qualified to treat people.

"Learning never ends, we are dealing with people’s lives and health, the more knowledge we have, the deeper it is, the better it is! Respect must be given to knowledge. Don’t just skim over it, we should strive to understand it thoroughly. Then, when we face complex risks, we’ll be calm and confident." Yang Ping encouraged everyone.

"If there’s nothing else, let’s disperse. Dr. Liang, you get ready. I am going to recommend you go to the hospital’s health lectures." Yang Ping finally said.

Those are the real big classrooms, this is just internal warm-up, merely a rhetoric practice.

After the meeting adjourned, everyone trickled out.

"A lot of old ladies attend the hospital’s health lectures. You wouldn’t be trying to test your luck to see if you could find a potential mother-in-law in the future, would you?" Zhang Lin pondered.

Fatty sneered: "Disgusting! With my current conditions, do you know how many head nurses want to introduce girlfriends to me?"

"Hold on, let me think, didn’t I hear that the mom of a flight attendant from Southern Airlines was hospitalized in some department, and you were taking care of her? I heard her mom is a loyal fan of our hospital’s health lectures?" Zhang Lin stroked his chin.

Fatty blushed and was so flustered he couldn’t speak.

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