The role that diet plays in causing gout is smaller than people think

by Nicky Pellegrino / 22 April, 2018
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It's often said that diet is the most important cause of gout, but for most people changing it won't lower uric acid levels enough to stop the pain.

Gout, a painful and misunderstood condition, is on the rise. For a long time, sufferers have had to cope with the presumption that they’ve brought the problem on themselves through overindulgence.

“Gout is a source of a lot of jokes,” says Christchurch rheumatologist Lisa Stamp. “People see it as a disease of overweight people who enjoy too much rich food, red wine and beer. There’s been some stigma.”

The truth is that although diet plays a role, it’s much smaller than was once believed. Gout is a form of inflammatory arthritis that develops in people who have too much uric acid in their blood. Once it reaches a high enough level, the uric acid forms crystals in and around the joints – often beginning at the base of the big toe. “Through a microscope, these look like little needles,” says Stamp.

The body’s immune system reacts to the crystals by causing inflammation, which results in episodes of severe pain, heat and swelling.

It’s now known that some people are naturally more prone to gout because genetic variations affect how efficiently uric acid is transported through the kidneys and excreted in urine.

Stamp says part of the reason we’re seeing a rise in cases is that the ageing population is being treated for other health conditions using drugs that have the side effect of raising uric acid levels – diuretics, for instance.

Acute gout flare-ups are treated with anti-inflammatories and steroids, but a reduction in uric-acid levels is necessary to stop them recurring. Allopurinol is the most commonly used drug to lower uric-acid levels.

“However, with this medication, there were concerns about side effects – mainly, that if the kidneys weren’t working well, there might be a risk of a particularly severe allergic reaction,” says Stamp. “So, people were limiting the dose based on kidney function, and that meant it wasn’t lowering the uric acid enough.”

Christchurch rheumatologist Lisa Stamp.

Stamp has done research that shows higher doses of allopurinol are safe and can lower uric acid to the levels required to prevent ongoing attacks. And she has won a prestigious prize – the Medicines New Zealand Value of Medicines Award – with the judges saying her work at the University of Otago, Christchurch, will have a big effect on patient care, both here and overseas.

Stamp and her research team followed 183 gout sufferers. More than half of them had reduced kidney function and were taking allopurinol. Over the first 12 months, one group had their dose gradually increased, whereas the other group remained on the original amount.

After a year, the uric-acid level had dropped in the blood of those who had been given the extra medication and there were no serious drug-related side effects.

“If you can lower the levels, then the crystals will dissolve away, but it takes a long time,” says Stamp. “Once the uric acid is low enough, it can be 12-18 months before attacks of gout stop.”

As for diet, she takes a pragmatic approach. Some foods have been identified as triggers, such as red meat, seafood, alcohol and sugary drinks. Stamp tells patients that if they find something that brings on an attack, they should consume less of it.

“Radically altering your diet is difficult to maintain and ultimately for most people it’s not going to lower uric acid enough to stop them getting gout,” she says. “But if you lower levels with medication, then you should be able to eat the foods you love without provoking a gout flare-up.”

Stamp is now involved in a study looking at how genes may influence the body’s response to medication. And she is also focusing on investigating natural therapies for their effectiveness. So far, it’s bad news for vitamin C supplements, which she found didn’t lower uric acid levels, and she has turned her attention to tart cherry juice and fish oil.

“There are a lot of myths about natural treatments, so I’m trying to look at them systematically,” says Stamp.

“People like trying them, but they can be expensive, so it’s useful to be able to advise patients on what they should be spending money on.”

This article was first published in the March 31, 2018 issue of the New Zealand Listener.

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