Treatment of gout 

Summary points   What is gout   Treatment of gout   Indications for Uric acid lowering therapy   Lifestyle interventions   Pharmacists have a key role in the care of people with gout   Prevalence and impact of gout   References   Issue 8 Contents

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Lifestyle interventions

Weight management is the key component in dietary management of gout. A 5% loss in body weight leads to a 10% reduction in serum uric acid level.^16,17 Diets very low in purines are generally unpalatable and poorly tolerated over time. Patients are more likely to accept advice to reduce purine-rich foods than to be told not to eat them at all (Table 1). Patients should be encouraged to eat regular meals and to drink plenty of water.

Table 1. Dietary advice for patients with gout

What to reduce in your diet	What to include in your diet		*Studies suggest that Vitamin C might be beneficial in the prevention and management or gout and other urate-related diseases.19 **Beer confers a larger risk than spirits. Moderate wine intake does not increase risk22 ***Refer to Bandolier article, (page 33 BPJ printed version only or Bandolier 160, http://www.medicine.ox.ac.uk/bandolier/)
Red meat, shellfish, oily fish18	*Vitamin C19
Sugar and sugar-sweetened drinks20	Low fat dairy products18,21
**Alcohol, especially beer22	***Coffee23,24

When to refer to a rheumatologist

Referral is appropriate when there is:

• Persistent hyperuricaemia or gout attacks despite maximum tolerated allopurinol treatment
• Doubt about the diagnosis
• Failure to achieve prompt resolution of acute attacks
• Development of progressive bone and joint damage on x-ray

Consider CVD risk and metabolic syndrome for every patient with gout

There is increasing recognition that asymptomatic hyperuricaemia is an independent risk factor for development of CVD.²⁵ However, there is no current evidence that treatment of asymptomatic hyperuricaemia reduces the risk of subsequent CVD events.

“All patients with gout should have CVD risk assessment, and intensive management of modifiable risk factors”

Re-analysis of the Multiple Risk Factor Intervention Trial (MRFIT) has addressed the association of acute myocardial infarction (MI) in patients with gout. In this study, gout was associated with increased risk of acute MI (OR 1.3, p< 0.001), even after adjusting for BMI and metabolic syndrome.²⁶ In patients attending gout clinics in Auckland, 59% are at high risk of CVD events (>15% in the next five years) based on Framingham risk tables.²⁷

Recent analysis of the National Health and Nutrition Examination Survey (NHANES III) showed that gout is associated with increased risk of metabolic syndrome (OR 3.4, p< 0.001).²⁸ In patients attending gout clinics in Auckland, 87% have metabolic syndrome (using the revised Adult Treatment Panel (ATPIII) definition).²⁷

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