- Add notes to any clinical page and create a reflective diary
- Automatically track and log every page you have viewed
- Print and export a summary to use in your appraisal
Asymptomatic hyperuricaemia is NOT gout and does not warrant management with drugs. This is a topical issue as it is becoming increasingly recognised that nearly 25% of men with raised serum urate levels but no evidence of clinical gout, will go on and develop gout in the next 5-6 years. Also, hyperuricaemia may be a marker for the risk of subsequent cardiovascular disease and in the future may require treatment. Despite these concerns a patient with asymptomatic hyperuricaemia should be given advice on lifestyle modification:
- Drink alcohol sensibly - beer or spirits should be avoided (there is a particularly strong link with beer, stout and port wines), but wine in moderation is not associated with an increased risk.
- There is a good evidence base that reducing alcohol intake to moderate levels is helpful..
- Avoid dehydration.
- Dietary intervention - reduction of purine-based foods.
- A large longitudinal study found that increased intake of meat or seafood significantly increased the incidence of gout.
- Highest purine levels are found in heart, herring, sardines and mussels.
- Other foods which are very rich in purines include liver, kidneys, red meat, yeast extracts, seafood (herring, sardines, and shellfish) and asparagus, beans, cauliflower, lentils, mushrooms, oatmeal and spinach.
- Soya foods are also high in purines but are less likely to lead to gout than meats and seafood.
- It is the quantity of purine-rich food consumed that is more important than the absolute purine content in each food.
- Soft drinks containing high levels of fructose can affect the levels of purines and should also be avoided.
- There is no evidence to support a reduction in purine-rich vegetables such as peas, beans, mushrooms or cauliflower, unless intake is extreme.
- Weight reduction - there are no controlled trials available, but some evidence suggests a link between obesity and high uric acid levels.
- Take regular exercise.
- Stop smoking.
- Recent evidence from a 20-year follow-up study, suggests that high vitamin C intake make prevent gout.
Manage risk factors
These may include:
- Drugs causing hyperuricaemia:
- Thiazides and loop diuretics
- Low dose salicylates eg aspirin < 1 g/day, pyrazinamide, ethambutol, nicotinic acid, ciclosporin
- Impaired renal function
- Hyperlipidaemia, especially hypertriglyceridaemia
- Vascular disease
- Chemotherapy - consider starting prophylaxis before treatment begins
- Myeloproliferative disease
NB: Aspirin in low doses (75–150 mg/day) has insignificant effects on the plasma urate and should be used as required for cardiovascular prophylaxis.
- It is important to explain that medication is normally lifelong and regular monitoring is needed.
- Advise the person that allopurinol may cause acute attacks of gout just after initiating treatment, and for some weeks afterwards.
- Explain that they should start their anti-inflammatory treatment as soon as possible and not stop their allopurinol during acute attacks.
Uric acid-lowering drug therapy should also be offered to patients with:
- Renal insufficiency
- Uric acid stones and gout
- Need for continuing diuretic treatment
- Allopurinol should never be started during an acute attack. Wait for 1-2 weeks after the attack resolves.
- Start with a low dose (50-100 mg) and increase in 50-100 mg increments every 2-4 weeks until serum uric acid (SUA) level is below 300 micromol/L.
- Maximum dose is 900 mg daily.
- The timescale for increasing in dose may need to be slower in some patients, with frequent checks of renal function, if renal function is known to be impaired.
- Co-prescribe colchicine or a low dose non-steroidal anti-inflammatory drug (NSAID) to prevent an attack of gout whilst initiating therapy, and continue until after hyperuricaemia has settled (usually a total of three months).
- If an acute attack develops during treatment, maintain the dose but add colchicine or NSAIDs.
- If neither NSAIDs nor colchicine are tolerated, or both are contra-indicated, consider low dose oral prednisolone. However, it may be preferable to seek specialist advice.
- It is not indicated for asymptomatic hyperuricaemia.
- It is useful where renal function is impaired or renal stones are present.
- Densitisation therapy is sometimes used in cases where the only adverse effect is a mild rash.
- Check the SUA level and renal function every 3 months in the first year, then annually, and aim for an SUA below 300 micromol/L.
This can be used as alternative to allopurinol if toxicity occurs, or as an adjunct in resistant cases.
- It can be difficult to obtain (a generic form is available) and is contra-indicated in renal failure and urolithiasis.
- Dose is 200-800 mg/day in patients with normal renal function
- Although not a urate-lowering drug per se, colchicine is sometimes prescribed at low dose in early gout - to 'buy time' in patients undergoing lifestyle modification, before a commitment to urate-lowering drugs is made.
- Low dose corticosteroids and NSAIDs have also been used to buy time, in the same way as colchicine.
- Probenecid is a less powerful uricosuric agent and is relatively contra-indicated in urolithiasis.
- Benzbromarone can also be used in patients with mild/moderate renal insufficiency at a dose of 50-200 mg/day. However, it carries a small risk of hepatotoxicity.
Further reading & references
- Diet for gout patients; dietitians.co.uk - As MSWord document.
- Chen LX, Schumacher HR; Gout: an evidence-based review. J Clin Rheumatol. 2008 Oct;14(5 Suppl):S55-62.
- Zhang W, Doherty M, Bardin T, et al; EULAR evidence based recommendations for gout. Part II: Management. Report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis. 2006 Oct;65(10):1312-24. Epub 2006 May 17.
- Corder, R. (2009) The Wine Diet, London: Sphere.
- Choi HK, Atkinson K, Karlson EW, et al; Alcohol intake and risk of incident gout in men: a prospective study. Lancet. 2004 Apr 17;363(9417):1277-81.
- Gout, Clinical Knowledge Summaries (2007)
- Choi HK, Atkinson K, Karlson EW, et al; Purine-rich foods, dairy and protein intake, and the risk of gout in men. N Engl J Med. 2004 Mar 11;350(11):1093-103.
- Choi HK, Atkinson K, Karlson EW, et al, Obesity, weight change, hypertension, diuretic use, and risk of gout in men: the health professionals follow-up study. Arch Intern Med. 2005 Apr 11;165(7):742-8.
- Choi HK, Gao X, Curhan G; Vitamin C intake and the risk of gout in men: a prospective study. Arch Intern Med. 2009 Mar 9;169(5):502-7.
- Wood J, Gout and its management, The Pharmaceutical Journal 1999; 262(7048):808-811.
- Feldman EB, Wallace SL; Hypertriglyceridemia in Gout. Circulation. 1964 Apr;29:SUPPL:508-13.
- Yu TF, Secondary gout associated with myeloproliferative diseases. Arthritis Rheum. 1965 Oct;8(5):765-71.
- Guideline for the management of gout, British Society for Rheumatology (2007)
- Summary of Product Characteristics (SPC) - Zyloric® Tablets; Summary of Product Characteristics (SPC) - Zyloric® Tablets (allopurinol), GlaxoSmithKline UK, electronic Medicines Compendium. September 2006
- Underwood M; Diagnosis and management of gout. BMJ. 2006 Jun 3;332(7553):1315-19.
|Original Author: Dr Gurvinder Rull||Current Version: Dr Gurvinder Rull|
|Last Checked: 20/04/2011||Document ID: 330 Version: 8||© EMIS|
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.