A chapter from HANDLING THE HARD QUESTIONS:
What Our Patients Are Asking Us About Rheumatic DiseaseRead and download this booklet on our Workforce Resource homepage
Each day, rheumatology nurses, nurse practitioners, and physician assistants field dozens of questions from their patients with rheumatic diseases, and they need to be able to properly and effectively communicate appropriate responses. This pocket guide includes a brief summary of evidence surrounding some of the most common—and challenging—questions that patients with rheumatoid arthritis, psoriatic arthritis, gout, and systemic lupus erythematosus are asking about. We hope you find this guide useful for your professional development and that it assists you with your day-to-day patient management.
Are there certain foods and drinks I am going to need to avoid? | Gout
The answer is “probably,” with the caveat that opinions aren’t as strongly held as they were a generation ago.
The onset of gout was once thought to be heavily influenced by food and alcohol intake, but as mentioned in the previous question, the vast majority of gout cases are now known to be due to the kidney’s inability to excrete enough uric acid into the urine. However, for some people, hyperuricemia is the result of uric acid overproduction.
Uric acid is a byproduct of the metabolism of purines, which come from both internal and external sources, such as food and drink. For a time, dietary sources of purine-rich foods were believed to universally increase the risk of gout. However, recent evidence suggests the picture is more complicated, as some purine-rich foods such as beer and high fructose corn syrup have been shown to increase uric acid levels while others, such as purine-rich vegetables (e.g., spinach, asparagus), do not.1,2
The overall picture, however, is a bit murky as guidance on dietary modifications in patients with gout is mixed. Several guidelines provide very specific recommendations, claiming that gout patients should avoid or limit their intake of purine-rich animal proteins (e.g., organ meats, shellfish, beef, lamb, pork), foods high in fructose, and sugar-sweetened beverages as well as alcohol, especially beer and spirits. Conversely, low-fat dairy, coffee, vitamin C, cherries, and cherry extracts, as well as certain diets, have been shown to decrease serum urate levels and the risk of gout.2-5
Other guidelines are less specific and suggest patients should reach or maintain ideal weight, engage in regular exercise, stop smoking (if applicable), and avoid known dietary triggers that are specific to them, with an emphasis on sugar-sweetened drinks and excess alcohol.6,7 These less prescriptive recommendations likely reflect the finding that very little high-quality evidence has shown gout-specific dietary modifications (e.g., avoid purine-rich foods) are better than general dietary counseling (i.e., promote weight loss if appropriate, regular exercise, and reduced alcohol intake) on gout outcomes.5,8
However, given the frequency of cardiovascular comorbidities in many patients with gout, specific dietary recommendations as well as other lifestyle modifications are likely beneficial from a cardiovascular health perspective.5
References
1. Benn CL, Dua P, Gurrell R, et al. Physiology of hyperuricemia and urate-lowering treatments. Front Med (Lausanne). 2018;5:160.
2. Hainer BL, Matheson E, Wilkes RT. Diagnosis, treatment, and prevention of gout. Am Fam Physician. 2014;90(12):831-836.
3. Major TJ, Topless RK, Dalbeth N, Merriman TR. Evaluation of the diet wide contribution to serum urate levels: meta-analysis of population based cohorts. BMJ. 2018;363:k3951.
4. Khanna D, Fitzgerald JD, Khanna PP, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. Arthritis Care Res (Hoboken). 2012;64(10):1431-1446.
5. Richette P, Doherty M, Pascual E, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. 2017;76(1):29-42.
6. Sivera F, Andres M, Carmona L, et al. Multinational evidence-based recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion of a broad panel of rheumatologists in the 3e initiative. Ann Rheum Dis. 2014;73(2):328-335.
7. Finch A. The management of gout. Aust Prescr. 2016;39(4):119-122.
8. Qaseem A, Harris RP, Forciea MA, Clinical guidelines committee of the American College of P. Management of acute and recurrent gout: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(1):58-68.