Overview: Gout

• Gout is a painful deposition of uric acid crystals in the synovial tissues of the body. Acute attacks usually manifest as a pain ful monarticular inflammatory arthritis, classically of the first metatarsophalangeal joint, although other joints as well as the kidneys may be affected.

• A polyarticular presentation is more common with increasing age and length of disease.

• Purines are ubiquitous in the body and in nature. As adenine and guanine, they form part of the building blocks of DNA and RNA. Uric acid is the product of purine metabolism by the enzyme xanthine oxidase. Uric acid is excreted primarily by the kidneys, but also by the small bowel.

• The buildup of uric acid crystals can result from overproduction (10% of cases) or underexcretion (90%) or a combination of the two.

• A 24-hour urine assay with a finding of more than 800 mg of uric acid supports the diagnosis of overproduction, whereas a finding of less than 600 mg suggests underexcretion.

Important points to consider

• Gout is a metabolic disease that independently increases the risk of all-cause and cardiovascular mortality. Like other metabolic diseases (e.g.. diabetes), gout warrants aggressive lifestyle counseling and modification.

• In response to newer evidence, experts are no longer advocating the avoidance of purine-rich vegetables or an overall purine-restricted diet. Avoidance of animal meat seems to have a larger impact than does reduced purine intake.

• Newer research shows that vitamin C is protective against gout.

• An observed response to the therapeutic application of ice may help distinguish gout from other inflammatory arthritides.

Prevention Prescription

• Encourage weight loss and maintenance of a healthy body mass index.

• Decrease consumption of red meat and most seafood.

• Increase intake of vegetables, legumes, nuts, and vegetable proteins.

• Decrease intake of sugar-containing beverages and fructose.

• Limit alcohol to no more than one to two drinks per day, and drink wine rather than beer or liquor.

• Increase intake of low-fat dairy, up to two servings per day.

• Maintain adequate hydration. Consider moderate coffee consumption.

• Increase food intake of vitamin C and consider supplementing with 500 mg. Increase intake of cherries; half a pound per day should be adequate. Increase intake of omega-3 fatty acids or take a supplement.

Integrative therapeutics review

Lifestyle Modification

• Encourage weight loss if overweight.

• Maintain hydration.

• Limit intake of beer and liquor.

Nutrition

• Decrease consumption of red meat and most seafood.

• Increase intake of vegetables, legumes, nuts, and vegetable proteins.

• Decrease intake of sugar-containing beverages and fructose.

• Increase intake of low-fat dairy, up to two servings per day.

• Consider moderate intake of coffee.

Supplements

• Increase intake of vitamin C through foods; consider supplementing with 500 mg daily.

• Eat more cherries: up to half a pound (2 cups) per day.

• Supplement with eicosapentaenoic acid (EPA) and/or gamma-linolenic acid (GLA): EPA, 500 mg daily or evening primrose oil, 3000 mg daily.

• Eat more pineapple or take bromelain supplements, at 500 mg daily.

• Consume more apples, grapes, onions, and tea or take quercetin supplements, at 500 mg twice daily.

Botanicals

• Hibiscus tea can be used for borderline high blood pressure and may lower uric acid levels.

Physical Medicine

• Acupuncture can help relieve a gouty attack.

• Ice and rest painful joints.

Pharmaceuticals

• Acute treatment

• Use nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., indomethacin, 50 mg three times daily) for first-line treatment unless contraindications exist.

• Consider colchicine, but use only a low-dose regimen of 1.8 mg divided over 1 hour (1.2 mg and repeat 0.6 mg in 1 hour).

• Use glucocorticoids in patients unable to take NSAIDs or colchicine.

Prevention

• Use probenecid for inadequate uric acid excretion. Start at 250 mg twice daily, and increase to 500 mg twice daily as needed.

• Use allopurinol for all causes of uric acid excess. Start at 100 to 300 mg daily. Increase as needed to reduce serum uric acid to less than 6 mg/dL..

Key Web Sources

• http://gouteducation.org/

• http://www.goutpal.com/