What are the recommendations for preventing gout?

Recommendations for Preventing Gout

To prevent gout, patients should modify lifestyle factors including limiting alcohol intake, losing weight if overweight, reducing fructose and purine intake, increasing low-fat dairy consumption, and considering vitamin C supplementation, while appropriate pharmacological therapy should be initiated for those with recurrent attacks. 1, 2

Dietary Modifications

Foods and Beverages to Limit or Avoid

• Alcohol consumption should be reduced or avoided, with particular emphasis on limiting beer and spirits, as they increase uric acid levels through adenine nucleotide degradation and lactate production 2
• Complete alcohol abstinence is recommended during periods of active gout arthritis, especially when medical control is inadequate 2
• Purine-rich foods including organ meats, red meat, and certain seafoods should be limited as they raise serum uric acid levels 2, 3
• Sugar-sweetened beverages and energy drinks containing high-fructose corn syrup should be limited as they can raise uric acid levels 2, 4
• Foods rich in fructose, including certain sweet fruits and fruit juices, should be moderated 2

Foods to Encourage

• Low-fat or non-fat dairy products are strongly encouraged as they are associated with lower risk of gout and may have antihyperuricemic effects 2, 4
• Cherries may help reduce serum urate levels and the frequency of gout attacks 2
• Vegetables, nuts, legumes, and whole grains are healthy choices that may help prevent gout by reducing insulin resistance 4
• Coffee and vitamin C supplementation could be considered as preventive measures as these can lower urate levels 4

Weight Management

• Weight reduction through daily exercise and limiting excess calorie intake is recommended for overweight and obese patients with gout 2, 1
• Despite limited high-quality evidence, weight loss is widely acknowledged as beneficial for overweight gout patients 1

Pharmacological Management

Urate-Lowering Therapy

• Urate-lowering therapy (ULT) is indicated in patients with recurrent acute attacks, arthropathy, tophi, or radiographic changes of gout 1
• Allopurinol is confirmed as effective long-term ULT and should be started at a low dose (100 mg daily) and increased at weekly intervals by 100 mg until a serum uric acid level of 6 mg/dL or less is attained 1, 5
• The average dosage is 200-300 mg/day for patients with mild gout and 400-600 mg/day for those with moderately severe tophaceous gout 5
• Febuxostat is an alternative first-line medication, though it has been associated with increased cardiovascular mortality 6

Prophylaxis Against Acute Attacks

• For prophylaxis against acute attacks during initiation of ULT, either colchicine 0.5-1 mg daily or an NSAID (with gastroprotection if indicated) is recommended 1
• Prophylaxis should continue for at least three months after uric acid levels fall below the target goal in those without tophi, and for six months in those with a history of tophi 3

Managing Associated Conditions

• Diuretics should be stopped if possible when gout is associated with their use, as they can increase uric acid levels 1, 3
• Losartan, an angiotensin receptor blocker, increases urinary excretion of uric acid and may be preferred in patients with hypertension and gout 3, 4
• Associated comorbidities like hyperlipidemia, hypertension, hyperglycemia, and obesity should be addressed as part of comprehensive gout management 2

Important Considerations and Pitfalls

• Diet and lifestyle measures alone typically provide only a 10-18% decrease in serum urate levels, which may be insufficient for patients with significantly elevated uric acid levels 2
• For most patients with gout, dietary modifications should be combined with appropriate pharmacological urate-lowering therapy for optimal management 2, 7
• Overlooking the impact of alcohol, particularly beer, on triggering gout flares is a common pitfall 2
• Ignoring the importance of weight management in overweight/obese patients with gout can lead to suboptimal outcomes 2
• Adherence to medication is often low in gout patients, and adherence to dietary recommendations tends to be even lower 1