Monday, May 14, 2012

Some Ideas on Gout

As I was taking part in the 3e National Expert Meeting on gout, I´ve prepared myself for the talks and sub meetings with rereading old material and looking for some new research on gout. 3e stands for evidence, experts, exchange. The topics have been diagnosis and management of gout. The following text is by no way a summary of the 3e meeting – after the national meetings have been conducted, the iniative meets on international level and after that meeting we shall see the final results on gout, and these results will be published by 3e.
The 3e meeting has been a good stimulus for me to put together some of the material I had collected over the past years and of which I already had published some here on this blog or on twitpic:
An expedition into the world of gout
Hyperuricemia and Gout ACR2011

Gout is a systemic disease
New research found that gout dos not only affect joint. Uric acid may be found even in the eyes. Most prominent and known for a long time are the deposits under the skin, the tophi. I have already shown a very drastic example on twicpic. Uric acid has been found in the pancreas, which may sound exotic, but as no one has researched the question of deposits of uric acid in the different tissues of inner organs systemically, it might turn out that this is a frequent finding with people suffering from hyperuricemia. One can find these deposits with a newly developed technique in CT, the dual energy CT.
Cardiovascular mortality rises 9% in men and 26% in woman with each increase by 1 mg/ml of uric acid level in a study of 6000 people over 16 years.
Reducing elevated uric acid leads to a reduction of hypertension.
High uric acid levels are also associated with a high incidence of kidney failure as shown in an Austrian study with 21.000 healthy people.
High uric acid levels seem to promote osteoarthritis.

Interleukin 1ß
Interleukin 1ß plays a role in gouty inflammation in activating the inflammasom complex. Therefore IL-1-inhibitors try to get approval for gout. On May the 8th 2012 FDA's Arthritis Advisory Committee voted 11-0 against approval of rilonacept (Arcalyst) to prevent gout flares in adults initiating uric acid-lowering therapy. Rilonacept showed a treatment effect to prevent gout flares in adults initiating uric acid-lowering therapy (0.3 flares vs.1.0 flares in the placebo group), but was also associated with an increased risk of malignancy (6 in the verum group and none in the placebo group!). It's more than debatable if 16-week safety studies are adequate to say anything on long term safety.
Canakinumab has been tested in different dosages for the same purpose, but it is unclear why one should use such a high risk and tigh end cost therapy other than to make the pharmaceutical firm happy.

Reducing elevated uric acid levels after a gout attack
Why start reducing high, even very high uric acid levels right with the gout attack? Lots of GPs do, but there is no good reason behind this strategy. Uric acid has accumulated during years, if you abruptly reduce the blood level of uric acid you might induce repeated gout attacks. First control the attack and then slowly and continuously reduce the elevated uric acid level. Even starting with low dose allopurinol warrants a low dose colchicine therapy to prevent a gout attack in the wake of normalizing uric acid levels. The cartilage has a slow metabolism and stores uric acid which could be released into the joint space and fall out as crystals there.

Hyperuricemia and diet
Gout is a disease of hyperalimentation and a diet being rich in purines. Your diet might overload the body with purines or reduce the capacity to eliminate them.
A very high risk is associated with alcohol, which reduces elimination, that means vodka, whiskey, brandy etc., but also beer as it contains purines from the yeast. Wine is exonerated, in little quantities. Most people know that meat, red meat, organ meats, fish and shellfish increase uric acid levels. Another risk factor is high intake of fructose, which is used to to sweeten soft drinks, and also fruits juices and fruits high in fructose might add. There migh be niche for diet drinks (artificial sweeteners) after all. Asparagus and other vegetables containing containing purines don't increase the risk of gout attacks.
Reduction of uric acid levels: low fat milk products, coffee (to a lesser degree decaffinated coffee, but not tea), vitamin C. [source Medical Tribune, Germany]

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