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author of this article: zhen bacteria

i don’t know when, but the gout patients who walked into the outpatient clinic of director wang jing (pseudonym) were born in the 2000s and 10s.

this time, it was a 15-year-old high school student whose blood uric acid level soared to 836 μmol/l during a physical examination.

in addition to conventional medication recommendations, wang jing, chief physician of the rheumatology and immunology department of a central hospital in liaoning, emphasized the need to control weight and the intake of sugary drinks and high-purine foods. after following the doctor's advice, the patient's two consecutive re-examinations showed improvement.

however, 2 weeks later, the 15-year-old patient came to the clinic again.

when xiaoyue came to the clinic limping, dragging his swollen left foot that couldn't fit into shoes, director wang jing sighed: "the gout is still here."

the "10s" generation walked into the gout clinic

from hyperuricemia to gout, it only takes a few months.

not only director wang jing lamented, but doctors in hangzhou, shanghai and other regions also felt that there were more and more young patients in outpatient clinics, and they were getting younger and younger."15 to 30% of patients come to see a doctor because of hyperuricemia or gout, and most of them are young and middle-aged men, and there is also an increasing trend of minor cases."huang yan, the attending physician at the rheumatology and immunology department of zhejiang hospital, said.

dr. liu guanghui from the endocrinology department of shanghai tongji hospital said: "in the past five years, the number of patients with hyperuricemia and even gout has increased significantly in children and adolescents. now almost 20 to 30% of patients in outpatient clinics have this condition, and the age of the patients varies. the lower limit is also constantly refreshed.”

in this regard, dr. liu guanghui revealed: "the youngest gout patient i treated in the outpatient clinic was only 13 years old. the child was very fat, with a bmi of over 32. his feet were in unbearable pain. he limped to the outpatient clinic and was tested for uric acid. 670μmol/l, plus joint energy spectrum ct, tophi can already be seen in the foot joints and ankle joints.with this condition, i can't even attend physical education classes. when i have an acute attack, i can't even cover myself with a quilt, let alone walk. i have to rely on a wheelchair to push me to school.」

the relationship between hyperuricemia and gout is a coherent disease progression in pathophysiology.

regarding the diagnostic criteria for adult hyperuricemia, the guidelines stipulate that for both men and women, if the blood uric acid level exceeds 420 μmol/l twice on different days, it is called hyperuricemia. [1]

at present, it is difficult to use unified standards to define hyperuricemia in children and adolescents. combining the cutoff values ​​provided by the mayo clinic and a study in zhejiang, the reference values ​​of uric acid for minors of different ages were obtained. [2]

image source: document 2

generally speaking, it takes 5 to 10 years from asymptomatic hyperuricemia to gout. however, as uric acid levels continue to increase, the time for gout to appear becomes shorter. due to alcohol consumption and degradation of metabolic function, most people with gout are young and middle-aged men aged 30 to 50.

image source: visual china

but why are more and more young people starting to have high levels of uric acid?

a cross-sectional study on 31 provinces in mainland china explored changes in the incidence of hyperuricemia in chinese adults and analyzed high-risk factors in different age groups from 2015 to 2018. [3]

image source: document 3

its survey data shows that the overall prevalence of hyperuricemia among chinese adults was 11.1% in 2015, rising to 14.0% in 2018. among them, the prevalence rate among men increased from 19.3% to 24.4%; the prevalence rate among women increased from 2.8% to 3.6%.

18～the prevalence rate among 29-year-olds has reached an astonishing 32.3%, which means that 1 in 3 young people has hyperuricemia.the study also analyzed that among young people aged 18 to 29 in china, it may be the result of unhealthy lifestyles, including high work pressure, the habit of eating out, lack of physical activity and high fructose intake.

dr. liu guanghui analyzed the reasons for the high incidence of hyperuricemia and gout in children and adolescents: "in fact, it often comes from lifestyle and dietary structure. underage patients do not have strong self-control and like to drink soft drinks containing fructose, and they prefer highly processed drinks. meat food.

another important factor is obesity, "obesity is an independent risk factor for hyperuricemia, coupled with the high academic pressure and compressed exercise time, some children may often stay up late. over time, a vicious cycle will be formed, which can easily lead to the occurrence of hyperuricemia and even gout. "

a study surveyed 54,580 children and adolescents aged 3 to 19 years old. the overall prevalence of hyperuricemia was 23.3%, and the prevalence among non-overweight, overweight, obese and extremely obese children was 18.2% and 37.6% respectively. , 50.6% and 64.5%. [4]

image source: document 4

gout in adolescents, conservative treatment or medication?

accompanying rejuvenation is controversy over treatment.

assessment and nutritional management of obesity and hyperuricemia in children and adolescents in 2023 [2] pointed out: obesity and hyperuricemia in children require the participation of a multidisciplinary team, including patient education, nutritional intervention, exercise management, changes in lifestyle habits, comprehensive measures such as drug treatment and surgical treatment are used for individualized diagnosis and treatment. the treatment target serum uric acid level in adolescents should be <540µmol/l.

image source: visual china

for children whose blood uric acid is >540-600µmol/l after strict nutritional intervention, it is recommended to add drug treatment. commonly used anti-hyperuricemia drugs include three categories: xanthine oxidase inhibitors (allopurinol, febuxostat), drugs that promote uric acid excretion (benbromarone, probenecid, etc.), and urate oxidase analogs (rasburicase, pegolonase, etc.).

the guidelines themselves are not complicated. what is complicated is how to make children and families accept them.

dr. huang yan said: “when it comes to choosing treatment options for children with hyperuricemia, we usually advocate improving their diet and living habits first. some children will see a certain improvement in their blood uric acid levels after improving their living habits. but there are still some children who do not reach the target level.”

although the guidelines clearly provide drug treatment options, in reality, parents can easily become concerned after doctors consider giving drug treatment to children based on the guidelines.

when encountering some children whose uric acid still cannot be reduced after 3 months of diet control, dr. huang yan will recommend that parents add acid-lowering drug treatment. however, a considerable number of parents are very worried about the side effects of drug treatment.

for example, allopurinol and febuxostat are both first-line drugs for lowering uric acid. the main adverse reactions include skin damage, liver damage, etc., especially for allopurinol. it is usually recommended to conduct pharmacogenetic screening before taking the drug. in comparison, febuxostat is a selective xanthine oxidase inhibitor with mild side effects and can be used as the first choice uric acid-lowering drug for teenagers.

after answering questions and popularizing science, some people listened, while others were still unwilling to take medicine.

when encountering such a situation, dr. huang yan will insist on using medication according to the principle. "first of all, according to the principle, for children who do not meet the medication standards, even if the parents ask for it, we will definitely not use it. but if the children meet the medication standards, we will definitely not use it." but if the parents don’t agree, then we still follow the parents’ opinions and continue conservative treatment.”

for a disease that requires long-term health management, out-of-hospital management and in-hospital management are equally important. sometimes, family factors even play a greater role.

"hyperuric acid plays a large role in the occurrence of children." dr. huang yan recalled that in the past, some children would get more than expected in terms of material and various desires, thus affecting the development of the disease.

dr. liu has also encountered similar cases. "many children can trace their parents back to high uric acid or gout patients, and some family living habits are not conducive to the disease. in reducing hyperuricemia and gout in children, the difficult issue of morbidity often requires the joint efforts of family members.”

"many diseases occur because genetic factors load the bullet, but poor lifestyle ultimately pulls the trigger."dr. liu said this when conducting popular science education to the families of the children.