UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2018 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Lifestyle modification and other strategies to reduce the risk of gout flares and progression of gout

Author
Michael A Becker, MD
Section Editor
Nicola Dalbeth, MBChB, MD, FRACP
Deputy Editor
Paul L Romain, MD

INTRODUCTION

Gout is monosodium urate crystal deposition disease. The long-term goals of therapy in patients who have already experienced signs and symptoms of the disease (established or prevalent gout) are to prevent recurrent gout flares and to reverse prior signs of the disease by achieving and maintaining subsaturating serum urate concentrations. This is achieved by a combination of approaches, including lifestyle modification and other strategies for risk reduction, as well as urate-lowering drug therapy.

The prevention of gout flares and disease progression in people with gout by nonpharmacologic lifestyle modifications for urate lowering and by risk reduction involving drug choices for management of comorbid diseases (eg, hypertension) will be reviewed here. Treatment with urate-lowering drugs, the role of surgery for treating tophi, the clinical manifestations and diagnosis of gout, the prophylaxis and treatment of episodes of acute gouty arthritis, and issues related to asymptomatic hyperuricemia are discussed separately. (See "Pharmacologic urate-lowering therapy and treatment of tophi in patients with gout" and "Clinical manifestations and diagnosis of gout" and "Treatment of gout flares" and "Asymptomatic hyperuricemia".)

RATIONALE FOR MANAGEMENT APPROACHES

Gout is monosodium urate crystal deposition disease and can be regarded as a "threshold" disease, in which the long-term goals of therapy in patients who have already experienced signs and symptoms of the disease (established or prevalent gout) are to prevent recurrent gout flares and to reverse prior signs of the disease. This is accomplished by achieving and maintaining subsaturating serum urate concentrations because the symptoms and signs of gout do not occur in the absence of urate saturation of extracellular fluids, reflected by elevated serum urate concentrations, and urate crystal deposition in tissues and inflammatory responses to such crystal deposition. Moreover, there is no evidence that serum urate reduction to levels that remain above the limit of solubility carries with it clinical benefits equivalent to those achievable at sustained subsaturating levels.

Management for the prevention of recurrent gout flares and damage to joints and other tissues from urate crystal deposition includes urate-lowering drug therapy, lifestyle modification, and other strategies for risk reduction. Long-term success in maintaining subsaturating urate levels results in clinical benefits that include cessation of gout flares, resolution of tophi, and improvement in patient physical function and health-related quality of life. However, resolution of the urate crystal burden in patients with established gout may require many months to several years to attain, even after subsaturating serum urate levels are achieved. During this period of crystal dissolution, a risk for acute flare remains and is the primary basis for gout flare prophylaxis with antiinflammatory agents.

MANAGEMENT PRINCIPLES

Upon resolution of an acute gouty attack, the patient is said to have entered an intercritical (between attacks) period (see "Clinical manifestations and diagnosis of gout", section on 'Intercritical gout and recurrent gouty arthritis'); during this period, the following issues relevant to prevention of gout flares and disease progression should be addressed:

                      
To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Dec 2017. | This topic last updated: Jan 03, 2018.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2018 UpToDate, Inc.
References
Top
  1. 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; 64:1431.
  2. Khanna D, Khanna PP, Fitzgerald JD, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res (Hoboken) 2012; 64:1447.
  3. Richette P, Doherty M, Pascual E, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis 2017; 76:29.
  4. Hui M, Carr A, Cameron S, et al. The British Society for Rheumatology Guideline for the Management of Gout. Rheumatology (Oxford) 2017; 56:e1.
  5. Qaseem A, Harris RP, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med 2017; 166:58.
  6. Yamanaka H, Japanese Society of Gout and Nucleic Acid Metabolism. Japanese guideline for the management of hyperuricemia and gout: second edition. Nucleosides Nucleotides Nucleic Acids 2011; 30:1018.
  7. Graf SW, Whittle SL, Wechalekar MD, et al. Australian and New Zealand recommendations for the diagnosis and management of gout: integrating systematic literature review and expert opinion in the 3e Initiative. Int J Rheum Dis 2015; 18:341.
  8. Sivera F, Andrés 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; 73:328.
  9. Rees F, Jenkins W, Doherty M. Patients with gout adhere to curative treatment if informed appropriately: proof-of-concept observational study. Ann Rheum Dis 2013; 72:826.
  10. Choi HK, Atkinson K, Karlson EW, et al. Alcohol intake and risk of incident gout in men: a prospective study. Lancet 2004; 363:1277.
  11. Choi HK, Liu S, Curhan G. Intake of purine-rich foods, protein, and dairy products and relationship to serum levels of uric acid: the Third National Health and Nutrition Examination Survey. Arthritis Rheum 2005; 52:283.
  12. 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; 350:1093.
  13. Becker MA, Jolly M. Hyperuricemia and associated diseases. Rheum Dis Clin North Am 2006; 32:275.
  14. Grundy SM, Brewer HB Jr, Cleeman JI, et al. Definition of metabolic syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation 2004; 109:433.
  15. Choi HK, Ford ES, Li C, Curhan G. Prevalence of the metabolic syndrome in patients with gout: the Third National Health and Nutrition Examination Survey. Arthritis Rheum 2007; 57:109.
  16. Zhang Y, Chaisson CE, McAlindon T, et al. The online case-crossover study is a novel approach to study triggers for recurrent disease flares. J Clin Epidemiol 2007; 60:50.
  17. Neogi T, Chen C, Niu J, et al. Alcohol quantity and type on risk of recurrent gout attacks: an internet-based case-crossover study. Am J Med 2014; 127:311.
  18. Nielsen SM, Bartels EM, Henriksen M, et al. Weight loss for overweight and obese individuals with gout: a systematic review of longitudinal studies. Ann Rheum Dis 2017; 76:1870.
  19. Choi HK, Atkinson K, Karlson EW, Curhan G. Obesity, weight change, hypertension, diuretic use, and risk of gout in men: the health professionals follow-up study. Arch Intern Med 2005; 165:742.
  20. Zhang Y, Woods R, Chaisson CE, et al. Alcohol consumption as a trigger of recurrent gout attacks. Am J Med 2006; 119:800.e13.
  21. Maglio C, Peltonen M, Neovius M, et al. Effects of bariatric surgery on gout incidence in the Swedish Obese Subjects study: a non-randomised, prospective, controlled intervention trial. Ann Rheum Dis 2017; 76:688.
  22. Dessein PH, Shipton EA, Stanwix AE, et al. Beneficial effects of weight loss associated with moderate calorie/carbohydrate restriction, and increased proportional intake of protein and unsaturated fat on serum urate and lipoprotein levels in gout: a pilot study. Ann Rheum Dis 2000; 59:539.
  23. Dalbeth N, Chen P, White M, et al. Impact of bariatric surgery on serum urate targets in people with morbid obesity and diabetes: a prospective longitudinal study. Ann Rheum Dis 2014; 73:797.
  24. Romero-Talamás H, Daigle CR, Aminian A, et al. The effect of bariatric surgery on gout: a comparative study. Surg Obes Relat Dis 2014; 10:1161.
  25. Roubenoff R, Klag MJ, Mead LA, et al. Incidence and risk factors for gout in white men. JAMA 1991; 266:3004.
  26. Porter R, Rousseau GS. Gout: The Patrician Malady, Yale University Press, New Haven 1998.
  27. Zhang Y, Chen C, Choi H, et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012; 71:1448.
  28. Teng GG, Pan A, Yuan JM, Koh WP. Food Sources of Protein and Risk of Incident Gout in the Singapore Chinese Health Study. Arthritis Rheumatol 2015; 67:1933.
  29. Loenen HM, Eshuis H, Löwik MR, et al. Serum uric acid correlates in elderly men and women with special reference to body composition and dietary intake (Dutch Nutrition Surveillance System). J Clin Epidemiol 1990; 43:1297.
  30. Dalbeth N, Wong S, Gamble GD, et al. Acute effect of milk on serum urate concentrations: a randomised controlled crossover trial. Ann Rheum Dis 2010; 69:1677.
  31. Dalbeth N, Gracey E, Pool B, et al. Identification of dairy fractions with anti-inflammatory properties in models of acute gout. Ann Rheum Dis 2010; 69:766.
  32. Dalbeth N, Ames R, Gamble GD, et al. Effects of skim milk powder enriched with glycomacropeptide and G600 milk fat extract on frequency of gout flares: a proof-of-concept randomised controlled trial. Ann Rheum Dis 2012; 71:929.
  33. Choi HK, Curhan G. Soft drinks, fructose consumption, and the risk of gout in men: prospective cohort study. BMJ 2008; 336:309.
  34. Choi HK, Willett W, Curhan G. Fructose-rich beverages and risk of gout in women. JAMA 2010; 304:2270.
  35. Jamnik J, Rehman S, Blanco Mejia S, et al. Fructose intake and risk of gout and hyperuricemia: a systematic review and meta-analysis of prospective cohort studies. BMJ Open 2016; 6:e013191.
  36. Dalbeth N, Phipps-Green A, House ME, et al. Body mass index modulates the relationship of sugar-sweetened beverage intake with serum urate concentrations and gout. Arthritis Res Ther 2015; 17:263.
  37. Batt C, Phipps-Green AJ, Black MA, et al. Sugar-sweetened beverage consumption: a risk factor for prevalent gout with SLC2A9 genotype-specific effects on serum urate and risk of gout. Ann Rheum Dis 2014; 73:2101.
  38. Raivio KO, Becker 7A, Meyer LJ, et al. Stimulation of human purine synthesis de novo by fructose infusion. Metabolism 1975; 24:861.
  39. Gelber AC, Solomon DH. If life serves up a bowl of cherries, and gout attacks are "the pits": implications for therapy. Arthritis Rheum 2012; 64:3827.
  40. Zhang Y, Neogi T, Chen C, et al. Cherry consumption and decreased risk of recurrent gout attacks. Arthritis Rheum 2012; 64:4004.
  41. Huang HY, Appel LJ, Choi MJ, et al. The effects of vitamin C supplementation on serum concentrations of uric acid: results of a randomized controlled trial. Arthritis Rheum 2005; 52:1843.
  42. Juraschek SP, Miller ER 3rd, Gelber AC. Effect of oral vitamin C supplementation on serum uric acid: a meta-analysis of randomized controlled trials. Arthritis Care Res (Hoboken) 2011; 63:1295.
  43. Choi HK, Gao X, Curhan G. Vitamin C intake and the risk of gout in men: a prospective study. Arch Intern Med 2009; 169:502.
  44. Stamp LK, O'Donnell JL, Frampton C, et al. Clinically insignificant effect of supplemental vitamin C on serum urate in patients with gout: a pilot randomized controlled trial. Arthritis Rheum 2013; 65:1636.
  45. Choi HK, Willett W, Curhan G. Coffee consumption and risk of incident gout in men: a prospective study. Arthritis Rheum 2007; 56:2049.
  46. Choi HK, Curhan G. Coffee, tea, and caffeine consumption and serum uric acid level: the third national health and nutrition examination survey. Arthritis Rheum 2007; 57:816.
  47. Lyu LC, Hsu CY, Yeh CY, et al. A case-control study of the association of diet and obesity with gout in Taiwan. Am J Clin Nutr 2003; 78:690.
  48. Joosten LA, Netea MG, Mylona E, et al. Engagement of fatty acids with Toll-like receptor 2 drives interleukin-1β production via the ASC/caspase 1 pathway in monosodium urate monohydrate crystal-induced gouty arthritis. Arthritis Rheum 2010; 62:3237.
  49. Sacks FM, Svetkey LP, Vollmer WM, et al. Effects on blood pressure of reduced dietary sodium and the Dietary Approaches to Stop Hypertension (DASH) diet. DASH-Sodium Collaborative Research Group. N Engl J Med 2001; 344:3.
  50. Rai SK, Fung TT, Lu N, et al. The Dietary Approaches to Stop Hypertension (DASH) diet, Western diet, and risk of gout in men: prospective cohort study. BMJ 2017; 357:j1794.
  51. Juraschek SP, Gelber AC, Choi HK, et al. Effects of the Dietary Approaches to Stop Hypertension (DASH) Diet and Sodium Intake on Serum Uric Acid. Arthritis Rheumatol 2016; 68:3002.
  52. Tykarski A. Evaluation of renal handling of uric acid in essential hypertension: hyperuricemia related to decreased urate secretion. Nephron 1991; 59:364.
  53. Bruderer S, Bodmer M, Jick SS, Meier CR. Use of diuretics and risk of incident gout: a population-based case-control study. Arthritis Rheumatol 2014; 66:185.
  54. Hunter DJ, York M, Chaisson CE, et al. Recent diuretic use and the risk of recurrent gout attacks: the online case-crossover gout study. J Rheumatol 2006; 33:1341.
  55. Würzner G, Gerster JC, Chiolero A, et al. Comparative effects of losartan and irbesartan on serum uric acid in hypertensive patients with hyperuricaemia and gout. J Hypertens 2001; 19:1855.
  56. Adverse reactions to bendrofluazide and propranolol for the treatment of mild hypertension. Report of Medical Research Council Working Party on Mild to Moderate Hypertension. Lancet 1981; 2:539.
  57. Reyes AJ. Cardiovascular drugs and serum uric acid. Cardiovasc Drugs Ther 2003; 17:397.
  58. Choi HK, Soriano LC, Zhang Y, Rodríguez LA. Antihypertensive drugs and risk of incident gout among patients with hypertension: population based case-control study. BMJ 2012; 344:d8190.
  59. Ruilope LM, Kirwan BA, de Brouwer S, et al. Uric acid and other renal function parameters in patients with stable angina pectoris participating in the ACTION trial: impact of nifedipine GITS (gastro-intestinal therapeutic system) and relation to outcome. J Hypertens 2007; 25:1711.
  60. Chanard J, Toupance O, Lavaud S, et al. Amlodipine reduces cyclosporin-induced hyperuricaemia in hypertensive renal transplant recipients. Nephrol Dial Transplant 2003; 18:2147.
  61. Yu TF, Gutman AB. Study of the paradoxical effects of salicylate in low, intermediate and high dosage on the renal mechanisms for excretion of urate in man. J Clin Invest 1959; 38:1298.
  62. Yu TF, Dayton PG, Gutman AB. Mutual suppression of the uricosuric effects of sulfinpyrazone and salicylate: A study in interactions between drugs. J Clin Invest 1963; 42:1330.
  63. Caspi D, Lubart E, Graff E, et al. The effect of mini-dose aspirin on renal function and uric acid handling in elderly patients. Arthritis Rheum 2000; 43:103.
  64. Segal R, Lubart E, Leibovitz A, et al. Renal effects of low dose aspirin in elderly patients. Isr Med Assoc J 2006; 8:679.
  65. Zhang Y, Neogi T, Chen C, et al. Low-dose aspirin use and recurrent gout attacks. Ann Rheum Dis 2014; 73:385.
  66. Feher MD, Hepburn AL, Hogarth MB, et al. Fenofibrate enhances urate reduction in men treated with allopurinol for hyperuricaemia and gout. Rheumatology (Oxford) 2003; 42:321.
  67. Sack J, Blau H, Goldfarb D, et al. Hyperuricosuria in cystic fibrosis patients treated with pancreatic enzyme supplements. A study of 16 patients in Israel. Isr J Med Sci 1980; 16:417.
  68. Stapleton FB, Kennedy J, Nousia-Arvanitakis S, Linshaw MA. Hyperuricosuria due to high-dose pancreatic extract therapy in cystic fibrosis. N Engl J Med 1976; 295:246.
  69. Singh JA, Strand V. Gout is associated with more comorbidities, poorer health-related quality of life and higher healthcare utilisation in US veterans. Ann Rheum Dis 2008; 67:1310.
  70. Sarawate CA, Patel PA, Schumacher HR, et al. Serum urate levels and gout flares: analysis from managed care data. J Clin Rheumatol 2006; 12:61.
  71. Becker MA, Chohan S. We can make gout management more successful now. Curr Opin Rheumatol 2008; 20:167.
  72. Doherty M, Jansen TL, Nuki G, et al. Gout: why is this curable disease so seldom cured? Ann Rheum Dis 2012; 71:1765.