Discover how apples can help manage gout symptoms. Find out the nutritional benefits of apples, the relationship between apples and uric acid levels, and the recommended intake of apples for individuals with gout.

The Nutritional Benefits of Apples

Apples are among the most widely consumed fruits globally, thriving on the domestic apple tree, or Malus domestica, which is native to Central Asia. These versatile fruits are rich in antioxidants, vitamin C, and fiber, making them incredibly fulfilling while containing relatively few calories.

The nutritional information for one medium-sized apple (100 grams), uncooked and unpeeled, is as follows:

• Calories: 52
• Water: 86%
• Sugar: 10.4 grams
• Fiber: 2.4 grams
• Protein: 0.3 grams
• Carbs: 13.8 grams
• Fat: 0.2 grams

Apples and Gout: The Relationship

Can apples help to decrease the symptoms of gout? Let’s explore the reasons behind it.

1. The Vitamin C Content of Apples Helps Lower Uric Acid Levels

According to a 2005 study published in “Arthritis and Rheumatism,” a diet high in vitamin C appears to reduce uric acid levels and may help prevent and treat gout. One large apple contains 10.3 milligrams of vitamin C, which is more than 11% of a man’s and almost 14% of a woman’s daily needs. Consuming apples can help you meet the recommended daily allowance of vitamin C, which may be beneficial for individuals with gout.

2. Apples Contain Low Amounts of Purines

Apples of all varieties are regarded as having low purines, which are chemicals that produce uric acid in the body upon their breakdown. A 223-gram apple has about 31 milligrams of purines, which can be a perfect diet option for a patient with gout. Additionally, applesauce, apple juice, and dried apples are also low in purines and permitted for a gout diet.

Are Green Apples Good for Gout?

Yes, green apples can be particularly beneficial for individuals with gout. Green apples contain a higher dietary fiber content compared to other apple varieties, which can help reduce uric acid levels. The fiber in green apples removes excess uric acid from the body by absorbing it from the bloodstream. Additionally, apples contain a lot of malic acids, which help the body’s defenses against the effects of uric acid.

When Is the Best Time to Eat Apples for Gout Patients?

According to research findings, individuals with gout should not consume an apple on an empty stomach, as it can cause constipation and bloating. The ideal time to consume an apple is during the morning, typically right after breakfast.

Can Apples Increase the Risk of Developing Gout?

Apples can potentially increase the risk of developing gout if not consumed in moderation. This is because apples have a high proportion of fructose, a sugar that occurs naturally. According to a 2008 study published in the “British Medical Journal,” males who consume a lot of fructose from fruits like apples are at an increased risk of developing gout because it may raise uric acid levels. Therefore, it is important for individuals with gout to consult a doctor before consuming fructose-rich fruits like apples, grapes, watermelon, and peaches.

What Is the Recommended Intake of Apples for Gout Patients?

The University of Pittsburgh Medical Center suggests consuming two to four portions of fruit every day if you have gout. A single fruit serving equals one medium-sized whole apple, one cup of sliced or diced apples, one cup of apple juice, and half a cup of dried apples. Choose just 100% fruit juice and stay away from apple items that have been given a sugar boost, such as sweetened applesauce.

Conclusion

In conclusion, apples can be a beneficial addition to the diet of individuals with gout. The vitamin C content, low purine levels, and high fiber content of apples can help lower uric acid levels and manage gout symptoms. However, it is important to consume apples in moderation and consult a healthcare professional, as excessive consumption of fructose-rich fruits like apples can potentially increase the risk of developing gout. By incorporating apples into a balanced diet and following the recommended intake guidelines, individuals with gout can leverage the nutritional benefits of this versatile fruit to manage their condition effectively.

Is Apple Good For Gout?

The accumulation of uric acid causes joints to swell resulting in a condition known as gout. This condition causes pain in the bones and joints. Consuming foods that may help to lower uric acid can reduce the symptoms associated with gout. And apples are one of those foods. It can decrease the amount of uric acid in your body so if you consume apples in moderation, you may be able to control the symptoms of gout without needing to visit the doctor as often.

Table of Content

Key Points

• Gout is a condition that develops when uric acid builds up in the body and causes pain and swelling in the joints and bones.
• You can fight off gout by eating foods like apples that could lower your uric acid levels.
• Apples are a great source of fiber, vitamin C, and antioxidants.
• The vitamin C content of apples helps to lower uric acid levels in your body.
• Green apples contain high dietary fiber content as compared to other species of apples, so it is more effective in reducing gout symptoms.
• You should avoid consuming an apple on an empty stomach as it can cause constipation and bloating.

This blog discusses the answer to the question is apple good for gout or not. 

About Apples and their Nutritional Value

Apples are among the most consumed fruits in the world. They thrive on the domestic apple tree, or Malus domestica, which is a native of Central Asia.

Apples are rich in antioxidants, vitamin C, and fiber. Considering how few calories they contain, they are also incredibly fulfilling.

According to studies, eating apples has many health advantages such as fighting the symptoms of gout.

Apples are typically consumed raw but can also be added to a variety of dishes, juices, and beverages.

Nutritional Facts about Apples

The nutritional information for one medium-sized apple (100 grams), uncooked and unpeeled, is as follows:

• Calories: 52
• Water: 86%
• Sugar: 10. 4 grams
• Fiber: 2.4 grams
• Protein: 0.3 grams
• Carbs: 13.8 grams
• Fat: 0.2 grams

Apples and Gout – What is the relationship?

Can apples help to decrease the symptoms of gout? If yes, then let us explore the reasons behind it.

1- The vitamin C content of apples helps to lower uric acid levels

According to a 2005 study, “Arthritis and Rheumatism” a diet high in vitamin C appears to reduce uric acid levels and may help prevent and treat gout.

Men need about 90 milligrams of vitamin C daily, whereas women only need about 75. 10.3 milligrams of vitamin C, or more than 11% of a man’s and almost 14% of a woman’s daily needs, may be found in one large apple.

You may be able to consume the recommended daily allowance of apples by including them in your diet.

2- Apples contain low amount of purines

Apples of all varieties are regarded as having low purines. Purine is a chemical that produces uric acid in the body upon its breakdown.

Less than 50 milligrams of purines are present in low-purine foods for every 100 grams of a substance. A 223-gram apple has about 31 milligrams of purines which can be a perfect diet pack for a patient with gout.

Additionally, apple sauce, apple juice, and dried apples are low in purines and permitted for a gout diet.

The majority of vegetables, low- or nonfat dairy products, rice, bread, pasta, and all fruits are also good low-purine foods.

Are green apples good for gout?

Green apples contain high dietary fiber content as compared to other species of apples, so it can help reduce uric acid levels.

The fiber in green apples removes excess uric acid from your body by absorbing it from the bloodstream.

Additionally, apples contain a lot of malic acids, which help the body’s defenses against the effects of uric acid.

What is the best time to eat apples for a gout patient?

According to research findings, you should not consume an apple on an empty stomach as it can cause constipation and bloating.

So, the ideal time to consume an apple is during the morning, typically right after breakfast.

Can apples increase the risk of developing gout or not?

Apples can increase the risk of developing gout if not consumed in moderation. Because it has a high proportion of fructose, a sugar that occurs naturally.

According to a 2008 study that appeared in the “British Medical Journal,” males who consume a lot of fructose from fruits like apples, are at an increased risk of developing gout because it may raise uric acid levels.

Therefore ask a doctor before consuming fructose-rich fruits like apples, grapes, watermelon, and peaches if you suffer from gout.

What is the recommended intake of apples for gout?

The University of Pittsburgh Medical Center suggests consuming two to four portions of fruit every day if you have gout.

A single fruit serving equals one medium-sized whole apple, one cup of sliced or diced apples, one cup of apple juice, and half a cup of dried apples.

Choose just 100% fruit juice and stay away from apple items that have been given a sugar boost, such as sweetened applesauce.

Drink less fruit juice and consume whole, unpeeled apples more frequently instead, since fruit juice is poor in fiber and heavy in sugar.

Final Notes

Apples have been used for thousands of years for the treatment of different conditions. They are high in vitamin C and low in purines which makes them an excellent option to include in your diet for gout.

Moreover, you cannot eliminate the gout symptoms just by relying on a diet. Discussing with a doctor is really important to deal with the symptoms of gout. Book an appointment with a doctor of gout through Marham.

FAQs

1- What is the best fruit for gout?

The vitamin C in strawberries, grapefruit, oranges, and pineapples, decreases uric acid levels and helps to avoid gout attacks. 

2- How do you break up gout crystals?

If you have gout, drink at least 10-12 eight-ounce glasses of water every day. This will aid in the removal of uric acid crystals from your body.

3- What is a fast cure for gout?

The fastest way to cure gout is the use of anti-inflammatory drugs like naproxen which can be purchased over the counter.

Gout and Apples – Experiments on Battling Gout

Apples in a Gout Diet

As far back as the Garden of Eden, apples have been considered the quintessential “perfect” food and for good reason. Apples are one of the most cultivated and consumed fruits in the world. As the old saying goes “An apple a day keeps the doctor away”. Truth is it really does since apples contain nutrients that can regulate blood sugar levels, metabolize bacteria and fight cancer but they are also an important food for your gout diet. Apples are extremely rich in antioxidants, flavanoids and dietary fiber.

We all know about the tremendous gout health benefits of apple cider vinegar but eating an apple goes a long way in fighting gout. (Make sure to read my post on Apple Cider Vinegar) Apples contain flavonols such as quercetin, myricetin and kaempferol which are most powerful inside the peel and the flesh that is nearest the skin. So it’s important not to peel apples and bite into the skin for full health benefits.

Flavonols as well as plenty of other phytonutrients help boost your cardiovascular system, helps rid your bloodstream of any excess sugar and stimulates your pancreas to produce more insulin. It also reduces glucose absorption in your digestive tract lowering the impact of sugar in your bloodstream. The enzymes in apples help prevent carbohydrates from immediately breaking down into simple sugars.

Studies have shown that apples can help reduce the risk of stroke. 9,208 men and women were followed for 28 years and the study found that those who ate the most apples had the lowest risk of stroke. Florida State University dubbed apples the “miracle fruit” since they found in their 2011 study that those in the study group who ate the most apples would have the lowest risk of developing cholesterol down the road and producing more of the good cholesterol which we call HDL. Furthermore, a study involving 187,382 people found that those that ate more than 3 servings of apples per week had a 7% lower chance of developing type 2 diabetes.

Why Granny Smith Apples Are The Preferred Choice

This next study is important cause I find its’ conclusions very true since I’ve felt the same experience with Granny Smith apples. I’ve noticed a good way to keep the pounds off and control hunger more than anything which leads to eating less and losing weight is to eat a Granny Smith apple before a meal and you will notice that your hunger will subside and you’ll end up eating less. This is what I call a “diet hack”, a shortcut to losing weight. Take my advice, it works and so do the researchers of this 2014 study agree as well. The study studied seven varieties of apples on how the bioactive compounds affected the good gut bacteria of diet-induced obese mice. The researchers found that compared to all the other apple varieties, Granny Smith apples had the most beneficial effect on gut bacteria and that’s why I eat mostly eat Granny Smith apples myself compared to all the other apples.

“The researchers explain that Granny Smiths are high in non-digestible dietary fiber and polyphenols, and low in carbohydrates. Even after chewing and exposure to stomach acid and digestive enzymes, the compounds are unscathed when they reach the colon. The bacteria present in the colon then ferment the compounds, producing butyric acid that spurs on the growth of friendly gut bacteria,” according to Medical News Today. If you are overweight and want to lose pounds, make sure to add Granny Smith apples in your diet. You’ll thank me!

Gout And Eating Apples

When it comes to gout, you should know what apples contain about 14 milligrams of purine compounds per 100 grams of fruit, so it is very low in purines. Applesauce, apple juice and dried apples are also low in purines. Make sure to watch out for the sugar content but for the most part they are allowed in a gout diet. Apples are also high in vitamin C which may help support healthy uric acid levels.

Although there haven’t been any studies as of yet that have analyzed the impact of apples on gout patients, one study shows promise and concluded that apples can combat against inflammatory diseases. This study clearly outlines the anti-oxidative and anti-inflammatory role of apple, so a similar response could be expected with gout sufferers after consuming an apple. Another 2013 study on colorectal cancer found that apples possess anti-inflammatory characteristics as it inhibits the activity of COX-2 which is another player when you suffer from gout inflammation.

Finally, a word about fructose. Apples do contain a large concentration of naturally occurring sugar fructose, so again my advice is best to stick with Granny Smith apples since it also has the lowest sugar content from all variety of apples. One cup of sliced Granny Smith apples contains 10.45 grams of sugar. As gout sufferers, it is important to watch out for our daily sugar intake as you may now know from reading this website.

recommendations on nutrition – Administration of SGO

Administration of the Sysert Urban District

Official website

In the Middle Ages, gout was called the “disease of kings and aristocrats”, they dedicated not only scientific works to it, but also sang it in lyrical works x. The reason for this is the prevalence of the disease among the “best representatives” of humanity. Traditionally, the disease accompanied those who could afford to eat a lot and tasty, drink a large amount of alcohol, that is, rulers, nobility, officials, scientists and people of art close to the court.

Features of the disease: gout is manifested by increased formation of uric acid in the body and the deposition of its crystals (sodium monourates) in the tissues. In the vast majority of cases, they settle in the joints, causing inflammation, swelling and soreness.

Symptoms: gout manifests itself only at the moment when a sufficiently large volume of sodium monourate crystals has accumulated in the joints. This causes acute gouty arthritis, which can only be managed with intensive care. During the period of exacerbation, the patient is shown inpatient treatment, while when the intercritical period is reached, a corrective diet for gout is recommended in order to normalize the level of uric acid in the body.

Causes: It is believed that the tendency to gout is determined genetically. However, diet and lifestyle influence the development of the disease to the greatest extent. Modern scientific research has confirmed the direct relationship between the daily diet and the incidence of gout and the intensity of its manifestation.

The main causes of the disease are the main “scourges” of the 21st century: obesity, alcohol intake, lifestyle. Scientists noted that the incidence of the disease in cities is 13 times higher than in villages. The reason for this is the level of economic development of the regions and the availability of the “benefits of civilization” for a particular person. In each case, the direct influence of diet on the occurrence of the disease is noted. Therefore, proper nutrition for gout is an urgent issue in its manifestations, after the attenuation of inflammation and for the prevention of relapses of acute arthritis.

The diet for gout during exacerbations and remissions should exclude foods rich in purines. Reducing the amount of purines in the diet reduces the production of uric acid. The highest amount of purines is characteristic of protein products. Therefore, the list of foods that need to be limited looks impressive (legumes, fish, meat, organ meats, broths, mushrooms, yeast products, sausages, drinks high in caffeine, including strong tea and coffee)

Diet for gout of the feet provides a significant reduction in purine-containing foods in the diet, at the same time it is aimed at correcting concomitant conditions, including stimulating the excretion of uric acid by the kidneys, normalizing the work of the nervous and cardiovascular systems. Therefore, it is important to follow a few recommendations for the formation of a daily diet.

Reduce weight. Excess body weight aggravates the course of the disease, provokes a violation of the kidneys, and excludes the possibility of normal excretion of uric acid. If you are overweight, reduce the energy value of the diet. Eat the right fats. When reducing the level of animal fats in the diet, include vegetable oils, in particular, olive, sunflower, corn oils. Take multivitamins.

It is especially important for the correction of the condition to consume enough vitamins C, PP and B2. In the absence of edema and normal functioning of the kidneys, abundant fluid intake is recommended. It is important for you to drink at least two and a half liters of liquids per day, including plain water with the addition of lemon juice, as well as fruit and berry juices, herbal teas, rosehip broth, and milk. Drink alkaline mineral water. It alkalizes urine, which makes its composition active against uric acid. The alkaline reaction of urine promotes the dissolution of dangerous compounds and reduces the risk of disease progression. Eat foods that alkalize your urine. These include almost all fresh fruits and berries. Their value in the diet also lies in the high content of potassium, which has a diuretic effect. Reduce the salt content.

Salt itself promotes the deposition of uric acid crystals in the joints. Its increased content in food reduces the intensity of urine excretion and causes swelling, which eliminates the necessary diuretic effect during exacerbations. Reduce the amount of salt in your meals to a minimum. Eliminate alcohol. Alcoholic drinks disrupt the functioning of the kidneys, which eliminates the possibility of removing uric acid from the body. Even their periodic intake can provoke an attack and exacerbation. Arrange fasting days.

Once a week, unload your body from heavy food. What is good for you is one-day mono-diets on foods poor in purines. In the summer, arrange fasting days on watermelons, which perfectly remove uric acid and salts from the body. In spring and autumn, use cucumber and apple mono-diets. In winter, potatoes are suitable. All of these foods are rich in potassium and fiber that are valuable to you. In the event of an exacerbation, the standard recommendations on what is possible and what is not are not relevant! If you experience a gouty attack, contact your doctor immediately. In nutrition, choose a one-, two-day mono-diet or exclude foods completely and drink only liquids. It can be alkaline mineral water, weak sweet herbal tea, water with lemon juice, fruit juices.

• Publication date:
  05/24/2021
• Last Modified Date:
  05/24/2021

how not to fall into a “trap”?

Author:
O. B. Yaremenko

20.04.2017

Gout – like matches: NSAIDs – extinguish fire, colchicine (prophylactically) –

keeps matches wet, xanthine oxidase inhibitors remove matches.

M.A. Becker

Gout has long been considered a “noble” disease. Outstanding personalities suffered from it – emperors, generals, philosophers. The list of famous patients includes Leonardo da Vinci, Ivan the Terrible, Charles Darwin, Oliver Cromwell and even Hippocrates himself … By the way, it was his compatriots who dubbed gout “a foot trap”. At that time, the cause of the disease was seen in a sedentary lifestyle, overeating, wine abuse against the background of significant mental stress. And only in the XVIII century. scientists for the first time discovered uric acid in kidney stones formed in patients with gout.

It is currently known that gout is associated with impaired purine metabolism, which leads to an increase in the concentration of uric acid in the blood and the accumulation of its salts – urates – in the joints and internal organs. Normally, in the human body, purines break down to uric acid, which is excreted by the kidneys. If the concentration of uric acid exceeds the threshold values, its crystals are deposited in the joints, kidneys, and soft tissues. How not to fall into this “trap”? Questions related to the prevention and treatment of gout, we addressed to the chief freelance specialist of the Ministry of Health of Ukraine in the specialty “Rheumatology”, head of the Department of Internal Diseases of the Faculty of Dentistry of the National Medical University. A. A. Bogomolets (Kyiv), Doctor of Medical Sciences, Professor Oleg Borisovich Yaremenko.

? How common are diseases such as gout and acute gouty arthritis in Ukraine and in the world?

– Gout is one of the most common inflammatory diseases of the joints. This disease is more common than rheumatoid arthritis. Gout in 80% of cases appears between the ages of 35 and 50, and men are more likely to suffer from it. This is due to the fact that they have a higher level of uric acid in their blood serum, since its products have points of biochemical contact with the synthesis of male sex hormones. Although gout can debut at a younger age, the peak incidence occurs at 40 ± 5 years, which is obviously associated with the dynamics of the activity of enzymatic systems, the decrease of which occurs after 35 years.

? What are the risk factors for gout and precipitating circumstances that can lead to the development of acute gouty arthritis?
-In the context of this question, let’s distinguish between patients with primary gout, which occurs on its own as a genetically determined disease, and patients with secondary gout, in which the increase in the concentration of uric acid in the blood is caused by some other factors. Most often, these are kidney diseases, accompanied by impaired excretory function, or taking medications, in particular diuretics. Here I would like to say that among the 20% of women suffering from gouty arthritis, a significant proportion are athletes, ballerinas, dancers who often use diuretics to reduce weight.
The reason for the development of primary gout is the genetic imperfection of the enzymatic systems that provide the synthesis and excretion of uric acid from the body (Fig. 1). Hyperuricemia, or elevated levels of uric acid in the blood, is associated with obesity and metabolic syndrome. As for the circumstances that provoke an attack of gout, two points can be distinguished. These are external factors leading to an increase in the level of uric acid, eating disorders, local and / or general cooling.

For the development of an attack of gout, uric acid must crystallize, and since the crystallization point depends on temperature and the level of uric acid, arthritis and tophi occur in those places that are most easily exposed to cold. These are, for example, auricles, peripheral joints (lower limbs) (Fig. 2). A classic example of a future patient with gout is a man who goes fishing, stands in cold water for a long time in rubber boots; Often this pastime is accompanied by the use of alcoholic beverages. An increase in the level of uric acid and hypothermia – the combination of these factors most often leads to the development of an acute gouty attack.

? What foods and medications increase uric acid levels in the blood?
– Regarding foods, I can not help but note that in the updated guidelines for gout of the European League Against Rheumatism (EULAR), published at the end of last year, their list has been noticeably updated. If all previous conciliation documents were based on research data from the 1980s, then several new tests were subsequently conducted, the results of which made it possible to significantly change and supplement this list.

According to the updated recommendations, it has no effect on the level of uric acid in the blood serum and even slightly reduces its consumption of coffee and strong tea. It was previously believed that caffeine, on the contrary, increases the concentration of uric acid. Low-fat dairy products can lower uric acid levels, and drinks containing fructose, orange and apple juice can increase its concentration, which was not previously known. It has now been proven that legumes, which are high in protein and were previously restricted or considered undesirable in the diet, do not increase uric acid levels. Taking 200 ml of dry red wine per day also has no effect on this indicator and, accordingly, on the risk of developing gouty arthritis, while beer and spirits are still included in the category of highly undesirable to drink. It also includes seafood.

As far as medications are concerned, the main medications associated with an increase in serum uric acid levels are diuretics. This primarily concerns thiazide diuretics, which are part of many antihypertensive drugs / antihypertensive therapy regimens. This effect is somewhat less for indapamide, which is positioned as a metabolically neutral diuretic. However, there is still no convincing evidence that it does not increase uric acid levels.

On the other hand, and this is important information recently received and already reflected in the 2016 recommendations, there are drugs at the disposal of doctors that can reduce the level of uric acid in the blood serum. These are losartan and calcium antagonists used to treat hypertension, or a combination of both. For patients with hyperuricemia and gout who receive therapy for arterial hypertension, this is very important, since the latter can often be combined with gout, including as part of the metabolic syndrome.

Also, studies in recent years have allowed scientists to conclude that statins and fibrates have the ability to reduce the level of uric acid in the blood. Let me remind you that leflunomide, a basic drug used to treat chronic autoimmune arthropathies, also has the ability to somewhat reduce hyperuricemia.

? What manifestations of gout should be considered atypical and how often do they occur?
– Rarely, gouty arthritis can develop as acute polyarthritis. In one of the classifications, the variant “rheumatoid-like gouty polyarthritis” is highlighted. This creates some difficulties for early diagnosis. Such an atypical form – the debut in the form of rheumatoid arthritis – is more common in women.
In typical monoarthritis, in at least half of the cases, the metatarsophalangeal joints of the foot are first affected. With repeated episodes, the joints of the arch of the foot are involved, then the ankle joints, knee joints, that is, arthritis gradually rises higher.

In the literature, there are casuistic cases describing the occurrence of tophi in various parts of the spine, pelvic bones. This is somewhat strange, because the temperature there is quite high compared to that in the distal parts of the body. Nevertheless, this fact can be explained by the fact that the current state of affairs was preceded by some kind of injury or damage in these places. Often, even the traditional debut of gouty arthritis begins with the defeat of compromised joints (if any), especially in athletes. Atypical manifestations of gouty arthritis are recorded in approximately 10% of cases.

I would like to focus on one more important point. In most cases, the first attack occurs suddenly, lasts for 5-7 days and stops on its own. However, it is not uncommon for patients to turn to specialists, and they, on the basis of redness and swelling of a limb, such as a foot, diagnose “erysipelas” and prescribe antibacterial drugs to the patient. After a course of antibiotic therapy, redness and swelling disappear, although in fact, even in the absence of treatment, the effect would be similar.

I repeat: the first symptoms of gouty arthritis disappear on their own in 5-7 days and do not require therapy. Why am I focusing on this? Because such prescriptions do not just mislead the patient: due to false ideas that the drugs had a therapeutic effect, the diagnosis of gout and the start of treatment are delayed.

? Does an asymptomatic increase in the level of uric acid in the blood serum require the appointment of hypouricemic agents?

– No, it doesn’t. The EULAR recommendations state that it is necessary to start urate-lowering therapy in patients who have repeated attacks of gouty arthritis (2 times a year or more), have tophi, kidney damage (urate nephropathy – urolithiasis or interstitial gouty nephritis). In other cases, there is no evidence that medically lowering the level of uric acid in the blood can prevent the development of gout or other disorders associated with hyperuricemia. Moreover, this treatment may be accompanied by side effects, the risk of which is higher than the potential benefit in the form of lowering uric acid levels.

Not all people with elevated uric acid levels develop gouty arthritis or gouty nephropathy, so clinical symptoms should always be considered. Although a number of national recommendations, such as Japanese, as well as conciliation documents of some European countries, indicate that with a uric acid level of> 640 μmol / l, the potential negative effect on blood vessels, kidneys, and joints is significant, therefore, with asymptomatic hyperuricemia and its high concentrations, urate-lowering You still need to start therapy.

Diet therapy is suggested as the first step in all guidelines. And only if it does not provide at least a tendency to normalize the level of uric acid within 2-3 months, the question of drug achievement of its target values ​​is considered.

? In clinical practice, mistakes are often made by both patients themselves, having read about gout on the Internet, and doctors who are little familiar with this pathology. In particular, this concerns questions about when to start urate-lowering therapy, what drugs to treat, and what are the target levels of uric acid in the blood serum. Could you clarify these points for our readers?

– The most common mistake is to start taking urate-lowering drugs during a flare-up. This leads to the fact that the attack is delayed or becomes recurrent. This phenomenon is observed in 30-40% of patients, so the general rule is to start prescribing urate-lowering therapy no earlier than 3-4 weeks after the end of the last attack of arthritis. Moreover, in the European and American recommendations of 2016, in the first 6 months of treatment with any urate-lowering drug, it is recommended to prevent gouty arthritis medically using NSAIDs in medium doses or colchicine at a dose of 0.5-1 mg / day. This tactic has demonstrated effectiveness in preventing exacerbation of the articular syndrome provoked by the initiation of hypouricemic therapy.

Which drugs should be used for urate-lowering therapy? In most cases, allopurinol is used for this purpose, a well-known drug that is well tolerated and makes it possible to achieve target levels of uric acid. If there are contraindications or restrictions (allergic reactions, gastrointestinal intolerance, a significant decrease in glomerular filtration rate), febuxostat or its combination with uricosuric agents, such as benzbromarone, is recommended. By stepping up the dose, this approach can achieve a target uric acid level that is <360 µmol/L for individuals without kidney disease and tophi, and <300 µmol/L for patients with severe gouty arthropathy, tophi or kidney disease. Thus, there is a clear corridor of values ​​that provide an optimal clinical result.

It is important to educate the patient that the use of these medications should be lifelong. At the same time, a long-term decrease in the level of uric acid <240 µmol / l is undesirable. There is evidence from several studies showing that such low concentrations of uric acid increase the risk of developing neurodegenerative diseases such as Alzheimer's disease, Parkinson's disease and amyotrophic lateral sclerosis. This is logical, since uric acid plays an important role in a number of metabolic processes that ensure the normal functioning of the nervous system.

Let me emphasize once again: the level of uric acid is of strategic importance in the management of patients with gout, and the doctor needs to convey this to the patient’s mind. In the first 3 months from the start of hypouricemic therapy, the patient should check this indicator every 3-4 weeks, then hypouricemic drugs are titrated until the target corridor is reached. In the future, the concentration of uric acid should be determined (and, if necessary, hypouricemic therapy should be corrected) once every 3 months.

? What is the treatment for arterial hypertension associated with gout?

– Secondary gouty arterial hypertension is mediated by disorders of the kidneys. If there are kidney lesions associated with hyperuricemia in the form of interstitial nephritis or urolithiasis, then the same drugs are used to treat hypertension as in hypertension. In this case, the appointment of diuretics should be avoided, and medicines that can further reduce the level of uric acid in the blood, that is, losartan and calcium antagonists, will be preferred.

? What is the algorithm for diagnosing gouty nephropathy (gouty kidney)?

– The first stage of diagnosis is a general urine test. In a significant part of patients with gout, especially in those with gouty nephropathy, urates are determined in the urinary sediment, which most often consist of renal calculi. The next step is to conduct an ultrasound examination of the kidneys for all patients with hyperuricemia to detect urolithiasis.
Interstitial nephritis associated with hyperuricemia is somewhat more difficult to diagnose. As the first step in the diagnostic search, a general urinalysis is also performed (typical changes are a decrease in specific gravity, confirmed using the Zimnitsky test, and erythrocyturia). At later stages of interstitial nephritis, the glomerular filtration rate decreases, which is determined by the calculation method.
Evaluation of the daily excretion of uric acid in the urine is of no value in the diagnosis of gouty nephropathy. To a greater extent, it is used to determine the type of disorders that provoked hyperuricemia (altered excretion or hyperproduction), which affects the choice of drug therapy (drugs that accelerate excretion or inhibitors of uric acid synthesis are prescribed, respectively).

? How should nephroprotection be carried out in case of gout?

– A rational approach to nephroprotection involves maintaining the level of uric acid in the optimal range of values ​​using diet or its combination with drug support. There are currently no other methods available.

? What means are optimal for quick relief of an attack of acute gouty arthritis?

– The longer an attack of gouty arthritis lasts, the more likely are morphological and functional changes in the affected joint. The updated EULAR recommendations, like previous versions of the document, state that an attack of gouty arthritis should be stopped as soon as possible, and treatment should be started in the first hours of its development and continued until the symptoms disappear completely.

For this purpose, non-steroidal anti-inflammatory drugs (NSAIDs) are most often used in a therapeutic dose. Indomethacin is one of the most effective, however, when it is used, a high incidence of side effects from the gastrointestinal tract (GIT) and the nervous system is noted. Diclofenac, nimesulide and etoricoxib also demonstrate high performance. It does not matter what the route of their administration will be: oral or parenteral. Compliance with an adequate dosing regimen (taking the full therapeutic dosage in case of oral use) was recognized as a key aspect. For example, for an adult, the dose of diclofenac should be at least 150-200 mg / day.

If there are contraindications to taking NSAIDs or they have shown insufficient effect, colchicine, which is in the first position in the EULAR recommendations, can be an alternative. Treatment with colchicine should be started within the first 12 hours from the moment an attack of gouty arthritis develops, using first 1 mg, and then 0.5 mg every hour until the attack is completely relieved. The total dose should not exceed 4-5 mg due to the risk of side effects from the gastrointestinal tract. In Ukraine, colchicine is not registered, so our doctors need to focus on NSAIDs or glucocorticoids. A reasonable and effective alternative is the introduction of long-acting glucocorticoids into the affected joint. As a rule, this is resorted to in the absence of the desired effect against the background of the use of NSAIDs for several days.

Inhibitors of interleukin-1, which plays a key role in the pathogenesis of inflammatory arthropathy, are used abroad, in particular canakinumab. However, the cost of this group of drugs is high, so they can hardly be considered as an alternative in domestic realities.

A rapid and pronounced anti-inflammatory effect is provided by intravenous administration of pegloticase, but so far in Ukraine it can only be used theoretically and in exceptional cases.

? Local therapy and physiotherapy for gout. How necessary are they, and if so, what methods should be used?

– Physiotherapy for gout is not indicated, since the effect in this disease must be achieved quickly, and this can only be done through drug therapy. In the vast majority of cases, the drug arsenal is enough to stop an attack of gouty arthritis (including severe, protracted, recurrent). Moreover, physiotherapeutic procedures for gout, as with any active inflammatory processes, are not only not recommended, but are even contraindicated due to the possible intensification of the process.

Local cooling may be used as topical therapy. This method is often resorted to by patients themselves, standing barefoot on a cold floor, doing cold wraps or applying ice. These are the most acceptable methods of local action in the treatment of gouty arthritis.

? Please list the features of the course of gout and, accordingly, its therapy in elderly patients.

– No fundamental features. It should be taken into account that with age, the glomerular filtration rate decreases and the frequency of chronic nephropathies of various origins (diabetic, hypertensive, etc.) increases. Elderly people often have atherosclerosis and its complications in the form of myocardial infarctions and strokes. Patients who have experienced atherothrombotic events are not recommended to prescribe NSAIDs, the only exception is naproxen. The use of glucocorticoids, especially long-term and non-articular, may be limited by the presence of diabetes mellitus. In patients with reduced glomerular filtration rate, it is not recommended to use colchicine and NSAIDs in medium or high doses, since these drugs aggravate renal dysfunction. The same applies to allopurinol: its doses (and this is indicated in the instructions for medical use) should be lower in individuals with reduced glomerular filtration.

Thus, if we talk about urate-lowering therapy, then in elderly people one has to resort to the use of febuxostat, which does not require dose adjustment for renal dysfunction.

? If a patient with gout comes to the family doctor / therapist, what are the important points to pay attention to?

– If this is a patient with hyperuricemia without target organ damage, then referral to a rheumatologist is not necessary. The task of the family doctor is to:

• convince the patient of the expediency of following a hypouricemic diet and provide him with relevant information materials;
• to determine if this patient is at risk of developing joint, kidney or cardiovascular lesions associated with hyperuricemia.

If the patient has obesity, diabetes mellitus, arterial hypertension, kidney or joint damage, then urate-lowering therapy is most likely to be appropriate. In the absence of disorders from the target organs, one can limit the recommendation of dietary measures. A patient with gouty arthropathy should be referred to a rheumatologist in order to determine a treatment strategy, taking into account risk factors and features of the functioning of various organs and systems. In the future, such a patient may be under the supervision of a family doctor.

Prepared by Elvira Sabadash

Medical newspaper “Health of Ukraine 21 stories” No. 6 (403), birch 2017

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• Medical newspaper “Health of Ukraine 21 stories” No. 6 (403), birch 2017

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