720 North Tustin Avenue
Suite 104
Santa Ana, CA 92705-3606
Phone: (714) 565-1032
Fax: (714) 565-1035

Jeremy E. Kaslow, MD, FACP, FACAAI Physician and Surgeon
Board Certified Internal Medicine

Medical Doctors are licensed and regulated by the Medical Board of California
(800) 633-2322

Gout and Hyperuricemia

Gout is a form of arthritis that is characterized by sudden, severe attacks of pain, redness and tenderness in joints. The cause of gout is a high blood level of uric acid (hyperuricemia).  Under the right circumstance, if uric acid is at a level >6.4 mg%, an attack of gout can occur.  Your chances are increased if you are cold or dehydrated.  Uric acid is a waste product formed from the breakdown of purines (adenine, guanine, and xanthine), which are naturally found inside your cells and in certain foods.

Acquired Causes of Hyperuricemia

Increased urate production

  • Nutritional Excess:  purine, ethanol (alcohol), fructose consumption
  • Nutritional Insufficiency:  P bioflavonoid complex (they inhibit xanthine oxidase, which converts xanthines into uric acid), vitamin E complex (anti-oxidant action is substituted by uric acid)
  • Hematologic:  Myeloproliferative and lymphoproliferative disorders, polycythemia
  • Drugs:  Ethanol/alcohol, cytotoxic drugs, vitamin B12 (treatment of pernicious anemia)
  • Miscellaneous: Obesity, psoriasis, hypertriglyceridemia

Decreased renal excretion of urate

  • Drugs: Ethanol, cyclosporine (Sandimmune), thiazides, furosemide (Lasix) and other loop diuretics, ethambutol (Myambutol), pyrazinamide, aspirin (low-dose), levodopa (Larodopa), nicotinic acid (Niacin or Niaspan)
  • Renal/Kidney: Hypertension, polycystic kidney disease, chronic renal failure (any etiology)
  • Metabolic/endocrine: Dehydration, lactic acidosis, ketosis, hypothyroidism, hyperparathyroidism
  • Miscellaneous: Obesity, sarcoidosis, toxemia of pregnancy

The Purine Content of Foods and Beverages

  • High (Best to avoid):
  • Liver, kidney, anchovies, sardines, herring, mussels, bacon, codfish, scallops, trout, haddock, veal, venison, and turkey.
  • Moderate (May eat occasionally):
  • Asparagus, beef, bouillon, chicken, crab, duck, ham, kidney beans, lentils, lima beans, mushrooms, lobster, oysters, pork, shrimp, spinach
  • Smaller amounts of purines are found in all meats, fish and poultry.  For this reason, limit animal protein in your diet to no more than 5 to 6 ounces of lean meat, poultry or fish a day.  Some additional dietary considerations include:
  • Avoid alcohol.  It increases the risk of hyperuricemia because it interferes with the removal of uric acid from the body. If you're having a gout attack, avoid alcohol completely.
  • Drink plenty of water. Fluids can help remove uric acid from the body.
  • Maintain a healthy weight. Excess weight puts more stress on your joints and increases the risk of hyperuricemia and gout.  Lose weight if you're overweight but avoid fasting or rapid-weight-loss diets because they can transiently increase uric acid levels in the blood. Also, avoid low-carbohydrate diets that are high in protein and fat, which can increase hyperuricemia.
  • Avoid fructose, which is found in sodas, fruit juices, energy and electrolyte drinks, table sugar, etc. increase the production of uric acid.
  • Avoid disodium phosphate, which is often used in supplements and as a laxative, as it interacts with uric acid and forms insoluble sodium urate and precipitates gout.  High sodium content may be the culprit although sea salt appears neutral in effect.
  • Eat fresh food rich in potassium since according to Royal Lee, DDS it seems protective against gout.  He used black molasses, raw sugar, fresh vegetables and their leaves, and root vegetables.
  • Eat foods rich in bioflavonoids, which Royal Lee called vitamin P.  He recommended dark grape juice concentrate (not the juice itself).
  • Supplement with Vitamin E complex.
  • Homeopathic Formic Acid reportedly reduces uric acid to xanthine and thereby renders it harmless.

Treatment of gout includes not only moderating your food choices but may include medications:

Drugs Used in the Management of Acute Gout

  • NSAIDS (selected) Contraindicated in patients with peptic ulcer disease or systemic anticoagulation; side effects include gastric ulceration, kidney damage, liver dysfunction, and interference with platelet function (clotting); may cause fluid overload in patients with congestive heart failure
    • Indomethacin (Indocin) 25 to 50 mg four times daily
      Naproxen (Naprosyn) 500 mg two times daily
      Ibuprofen (Motrin) 800 mg four times daily
      Sulindac (Clinoril) 200 mg two times daily
      Ketoprofen (Orudis) 75 mg four times daily

  • Colchicine 0.6 mg orally every hour until relief or side effects occur, or until a maximum dosage of 6 mg is reached.  There are dose-dependent gastrointestinal side effects such as diarrhea.
  • Corticosteroids
  • Urate-Lowering Drugs for the Treatment of Gout and Hyperuricemia
  • Sulfinpyrazone (Anturane)
  • Probenecid (Benemid)
  • Allopurinol (Zyloprim) 50-100mg daily increasing as needed until the serum uric acid is <6 mg %.  The indications are typically chronic tophaceous "erosive" gouty arthritis; secondary hyperuricemia related to the use of cytolytics in the treatment of hematologic malignancies; gout complicated by renal disease or renal calculi.  Becuase it inhibits uric acid synthesis, allopurinol is best for patients who overproduce uric acid (i.e., those who excrete >800 mg of urate in 24 hours).  It has its peak effect in reducing urate synthesis at two weeks.  Allopurinol's side effects include rash, gastrointestinal symptoms, headache, urticaria (hives) and interstitial nephritis.  Rarely potentially fatal hypersensitivity syndrome may occur (usually in patients with underlying renal insufficiency or concurrent thiazide use).

Comments about coffee and caffeine:  Caffeine is a xanthine that breaks down into substances similar to uric acid, which the body excretes through the kidneys. An excess of uric acid in the urine can cause kidney stones.  A large-scale study published in Arthritis Care & Research (June 2007) found that coffee consumption was associated with lower uric acid levels but that this appears to be due to components other than caffeine.  Because coffee and tea consumption was estimated from a food questionnaire, the results must be reviewed with caution.  These results were similar to those found in the only previous study on the topic, which was conducted in Japan. In that study there was an association between decaffeinated coffee consumption and uric acid levels. The researchers stated "These findings suggest that components of coffee other than caffeine contribute to the observed inverse association between coffee intake and uric acid levels..."

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