Gout

It's been several years now since we at 'the Berries' looked at gout as a topic for discussion.

Most physicians feel fairly confident about making the diagnosis of gout, particularly when it presents with the classical symptoms of a red swollen painful MP joint of the great toe.

After reading a recent article in Bandolier, I thought that it might be worthwhile to revisit the topic, particularly with respect to the foods that might aggravate (or help) the condition, as patients often ask questions about dietary management.

Uric acid is the end product of purine metabolism and it is cleared primarily by the kidneys and the gut. An increase in the consumption of purines may increase the amount of uric acid in the blood, but this increase should be compensated for by an increase in the excretion of uric acid. In 75-90% of people with gout, clearance of uric acid by the kidneys is reduced. When this happens the uric acid levels in the blood rise, with high levels considered to be > 416 µmol per liter in men and > 357 µmol per liter in women. These higher concentrations of uric acid can remain stable in a supersaturated state but when triggered the uric acid can precipitate out in a joint as crystals, causing the well- known symptoms. Predictors of the development of clinical gout, other than the serum urate level, include hypertension, the use of thiazides and loop diuretics, obesity, and a high alcohol intake, all of which appear to contribute in an additive manner to the risk of gout.

The American College of Rheumatology has 11 criteria for the diagnosis of gout, and the presence of six more or less suggests that gout is present. They are:

• More than one attack of active arthritis
• Maximum inflammation develops within one day
• Oligoarthritis attack
• Redness observed over joint
• First metatarsalophalangeal joint painful or swollen
• Unilateral first metatarsalophalangeal joint attack
• Unilateral tarsal joint attack
• Tophus (proven or suspect)
• Hyperuricaemia
• Asymetrical swelling within a joint on radiography
• Complete termination of an attack

If left untreated gout will go thought 4 stages.

1. The accumulation of crystals in peripheral connective tissues in and around synovial joints, especially in the lower limbs.
2. The first attack with swelling pain redness and heat in a single joint. The pain is maximal within 24 hours and gradually subsides over a week or so.
3. A second attack often occurs within a year and as the patient ages the severity and frequency of attacks may increase.
4. Uric acid deposits can accumulate in soft tissues (tophi) particularly around the upper surfaces of the fingers and hands, but other places as well, including forearms or Achilles tendons or ears.

Remember, sometimes it looks like gout (red and hot) but it isn't. The mimics are infection and seronegatives like Reiter's syndrome and Psoriatic arthritis. These conditions can also cause a joint to be red and hot so always aspirate, if possible, to make the diagnosis. The toe is difficult for the faint at heart, but aspiration can be done. Knees and other big joints should always be aspirated. Also, all 1st MTP pain is not gout. Consider Osteoarthritis as well. OA is not nearly as angry looking as gout, but it can cause a joint to be a bit red and sore.

For the management of acute gouty attacks I would refer you to the article in the Berries Archives. Little has changed since that article by Dr Rangno was written in 1999.

The principal indications for long-term uric acid-lowering therapy in patients with gout are macroscopic subcutaneous tophi, frequent attacks of gouty arthritis (i.e., three or more per year), or a documented state of uric acid overproduction. The medications used either reduce the production of uric acid or increase its excretion by the kidneys.

The usual choice for reducing uric acid levels is allopurinol, because it inhibits xanthine oxidase and can depress new purine synthesis. Allopurinol in a dosage of 300 mg per day has been reported to reduce serum urate concentrations to less than 420 µmol per L in 70 percent of patients. The initiation of allopurinol therapy can also precipitate an acute gout attack so using an NSAID or colchicine along with allopurinol should be considered when starting this drug. It is best not to start allopurinol until the gout is gone, and advise the patient to expect an increase in gout for 3 months after starting (warn the patient not to stop the allopurinol during this time).

Probenecid can be used to prevent proximal tubular reabsorption of urate. Probenecid, in a dosage of 1 to 2 g per day, achieves satisfactory control in 60 to 85 percent of patients. It is important to note that the drug also blocks the tubular secretion of other organic acids. This may result in increased plasma concentrations of penicillins, cephalosporins, sulfonamides and indomethacin. Other uricosuric medications include fenfibrate and losartin. These meds might be considered for patients with gout who also suffer from hypertension or hyperlipidemia.

Patients will often ask what foods they should avoid to prevent attacks. Many of our patients should reduce the consumption of all foods and alcohol in an effort to treat their obesity. Foods specifically associated with high purine levels include:

• Beer, other alcoholic beverages.
• Anchovies, sardines in oil, fish roes, herring.
• Yeast.
• Organ meat (liver, kidneys, sweetbreads)
• Legumes (dried beans, peas)
• Meat extracts, consomme, gravies.
• Mushrooms, spinach, asparagus, cauliflower.

However, rather than imposing specific restrictions on diet, the focus should be on promoting a healthy diet.

The American Medical Association recommends the following dietary guidelines for people with gout, advising them to eat a diet:

• high in complex carbohydrates (fiber-rich whole grains, fruits, and vegetables)
• low in protein (15% of calories and sources should be soy, lean meats, or poultry)
• no more than 30% of calories in fat (with only 10% animal fats)

Recommended Foods To Eat

• Fresh cherries, strawberries, blueberries, and other red-blue berries
• Bananas
• Celery
• Tomatoes
• Vegetables including kale, cabbage, parsley, green-leafy vegetables
• Foods high in bromelain (pineapple)
• Foods high in vitamin C (red cabbage, red bell peppers, tangerines, mandarins, oranges, potatoes)
• Drink fruit juices and purified water (8 glasses of water per day)
• Low-fat dairy products
• Complex carbohydrates (breads, cereals, pasta, rice, as well as aforementioned vegetables and fruits)
• Chocolate, cocoa
• Coffee, tea
• Carbonated beverages
• Essential fatty acids (tuna and salmon, flaxseed, nuts, seeds)
• Tofu, although a legume and made from soybeans, may be a better choice than meat

Foods considered moderately high in purines but which may not raise the risk of gout include: asparagus, cauliflower, mushrooms, peas, spinach, whole grain breads and cereals, chicken, duck, ham, turkey, kidney and lima beans. It is important to remember that purines are found in all protein foods. All sources of purines should not be eliminated.

- John Hickey

Thanks to Dr. Diane Wilson, a community Rheumatologist in Lunenberg, Nova Scotia for reviewing the draft copy of this article.

References:

1. Joel R. Pittman, Pharm. D., and Michael H. Bross, M.D. American Family Physician, Vol. 59/No. 7 (April 1, 1999) Diagnosis and Management of Gout (Level 5 evidence, Review article)
 
2. Gout: Bandolier Evidence Based Medicine site. http://www.jr2.ox.ac.uk/bandolier/booth/booths/gout.html 08/05/07 (Level 5 evidence, Review article)
 
3. Terkeltaub RA Gout , N Engl J Med 349:1647, October 23, 2003 Clinical Practice (level 5 evidence - Review article)
 
4. Campion EW, Glynn RJ, DeLabry LO. Asymptomatic hyperuricemia: risks and consequences in the Normative Aging Study. Am J Med 1987;82:421-426.( Level 3 evidence)

You can search for abstracts of the above references by following this link: PubMed