It used to be called rich man's disease but gout is now more and more prevalent among young people due to poor eating habits and lifestyle choices.
Management of recurrent gout
by Robin Fox, GP
Breda's comments in green
An overweight 60 year old man tells you he has had four episodes of gout over the past year and wants to know how to reduce the chance of further attacks. He takes amlodipine for hypertension.
Is it really gout? A typical history of rapid onset, severe, self limiting joint pain reaching its maximum over 6-12 hours, with swelling and erythema (from eruthros, red = redness of the skin caused by dilatation and congestion of the capillaries, often a sign of inflammation or infection) suggests gout, particularly if it involves the first metatarsophalangeal joint (big toe) at some point. (This joint is affected in 90% of cases and is the first joint affected in 70%.) The presence of tophi (deposits of uric acid) support the diagnosis. Previous evidence of monosodium urate crystals from a joint aspirate (during or between attacks) would be the gold standard. A concentration of serum uric acid (SUA) of 
380 µmol/l at least one month after an acute attack or 330 µmol/l during an attack makes gout an unlikely diagnosis.
Complications - These might include renal stones, nephropathy, or tophi.
Consider - associated metabolic syndrome may be present.
Risk factors for gout
Common risk factors
- Increasing age
- Male sex (less marked with age)
- Consumption of beer or spirits
- Drugs: loop or thiazide diuretics, low dose aspirin (including 75 mg), ciclosporin, tacrolimus, ethambutol, pyrazinomide, nicotinic acid
- Renal impairment
- Obesity
- Hypertension
- Excessive intake of purine rich foods (kidney, meat extract, fish, game, and poultry)
- Psoriasis
- Myeloproliferative disorders (malignant diseases of certain bone marrow cells including those that give rise to the red blood cells, the granulocytes and the platelets - eg myelophthisic anaemia and erythroblastic leukemia)
- Administration of cytotoxic drugs (tumour lysis syndrome)
- Inherited enzyme deficiencies
- Lead poisoning (consider occupational exposure if there are no other risk factors)
What you should do
During the consultation (pay attention to differential diagnosis, guys)
- Measure his body mass index, waist circumference,and fasting glucose and lipid concentrations (to check for presence of metabolic syndrome).
- Calculate and manage his
- Test his blood for SUA and renal function.
- Refer him for radiography only if you are unsure of the diagnosis.
- · Explain that gout is caused by the formation of uric acid crystals in the joint, and give him printed information such as that provided by Patient
Reducing the risk of further attacks
- Advise him to lose weight. Dieting and exercise may reduce his serum urate concentration by around 100 µmol/l and will lessen his risk of developing metabolic syndrome.
- He should drink 2 l of fluid a day (especially if he has a history of renal stones). Restricting purine rich foods is difficult and usually less effective than weight loss where this is appropriate; dietary advice is available from the UK Gout Society (www.ukgoutsociety.org).
- Advise him to reduce his alcohol intake. He should avoid beer (rich in purine) and, ideally, spirits. Wine is not a major risk factor.
OTHER USEFUL DIETARY RECOMMENDATIONS:-
Increase:
- Consume plenty of green leafy vegetable and fruit juices - fluid promotes excretion of uric acid.
- Take probiotics - start with REPLETE (BioCare) and continue with 2 Bioacidophilus capsules daily, for 3 months.
Further
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