Metabolic Syndrome and Comorbidities

Comorbidities

• Metabolic syndrome is a multiplex risk factor for atherosclerotic cardiovascular disease that consists of dyslipidaemia, raised blood pressure, increased blood glucose, and both prothrombotic and pro-inflammatory states.
• Metabolic syndrome is present in 63% of those with gout compared with 25% of those without gout.
• Obesity, weight gain, and hypertension are independent risk factors for the development of gout.

Diet

• A purine-rich diet increases the risk of gout.
• Consumption of meat increases the incidence of gout.
• A diet high in purine-rich vegetables does not increase the risk of gout.
• The consumption of low-fat dairy products reduces the relative risk of gout.
• Vitamin C (ascorbic acid) has a modest uricosuric effect.
• Coffee consumption may reduce the risk of the development of gout.

Medication

• The use of both loop and thiazide diuretics is the most common risk factor for secondary gout, especially in the elderly.
• Drugs that decrease renal uric acid clearance include:
  • Diuretics
  • Salicylates (Low Doses)
  • Ethanol
  • Levodopa
  • Pyrazinamide
  • Ethambutol
  • Cyclosporine
  • Cytotoxic drugs

Clinical Presentation

• Acute gout attacks are characterized by rapid onset of pain, swelling, and inflammation.
• Gout is an inflammatory condition of the arthritis-type that results from deposition of uric acid crystals in joint spaces or surrounding tissues.
• It is associated with hyperuricemia, defined as a serum uric acid (SUA) level of 6.8 mg/dL (404 μmol/L) or greater.

Gout

• Gout is the most common inflammatory joint disease in men and is strongly age-related.
• Gout is a type of arthritis caused by uric acid crystal deposition in joints and soft tissues, resulting in intense pain of sudden onset, swelling, and inflammation.
• The base of the big toe is most commonly affected, but it can occur in any joint.
• Attacks typically last 3–10 days and are usually recurrent.

Management

• Allopurinol and uricosurics should not be started during an acute attack.
• Simple analgesics may be used in addition if necessary.
• Diuretics should be stopped if for hypertension.
• Losartan should be considered as an alternative antihypertensive due to its modest uricosuric effects.
• Lifestyle changes include:
  • Resting the joint during an acute attack
  • Using ice packs and splinting
  • Adopting a weight reduction programme if obese
  • Avoiding high-protein, low-carbohydrate diets
  • Moderating exercise once the acute attack has subsided
  • Avoiding foods with a high purine content such as red meat, shellfish, and yeast extracts.

Management of Chronic or Recurrent Gout

• Allopurinol should be started at 50–100mg daily and increased by 100mg every 2–4 weeks until symptom control is achieved.