Purine-rich foods intake and recurrent gout attacksAnn Rheum Dis 2012;71:1448–1453

Tuesday, 19th Februari 2013Ferdy Ferdian, dr

Amaylia Oehadian, dr., SpPD-KHOM

Background• Gout is a common and excruciatingly painful

inflammatory arthritis caused by monosodium crystal deposition

• Purine intake is associated with hyperuricaemia and an increased risk of incident gout

• no study to date has examined whether purine-rich food intake triggers recurrent gout attacks over a short period of time

Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453

Background• This study try to examine and quantify the

relation between purine intake and the risk of recurrent gout attacks among gout patients

Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453

Background• What is Gout?• Gout is a metabolic disorder characterized by

elevated serum uric acid levels and deposits of urate crystals in synovial fluids and surrounding tissues

Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453

increased purine synthesis, decreased

renal excretion

A high dietary intake of purine, alcohol intake

Increase uric acid in the blood (hyperuricemia)

Deposition of uric acid into the joints

GOUT

Background

Background• Who Is Likely To Develop Gout?• Genetic• Gender and age• Obesity• Alcohol• Purine rich diet• Medication (Diuretics, Salicilate, Cyclosporin, etc)

Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453

Methods• Online Case-Crossover Study• To be eligible for the study, a subject – had to report gout diagnosed by a physician– have had a gout attack within the past 12 months– be at least 18 years of age– reside in the USA– provide informed consent, and – agree to release medical records pertaining to gout

diagnosis and treatment

Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453

Methods• To confirm a diagnosis of gout, they obtained

medical records pertaining to the participant’s gout history and/or a checklist of the features listed in the American College of Rheumatology (ACR) Preliminary Classification Criteria for Gout completed by the subject’s physician

Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453

Methods• The total amount of purine intake over 2

days was divided into quintile groups• They examined the relation of total purine

intake to the risk of recurrent gout attacks using a conditional logistic regression model

Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453

MethodsQuantiles

Q1 Q2 Q3 Q4 Q5

Quantile are points taken at regular intervals from the cumulative distribution function of a random variable

Baseline

Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453

Baseline

Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453

Result• 1247 recurrent gout attacks• 92% in lower extremity• 90% were treated with colchicine, NSAIDs,

systemic corticosteroids, intra-articular corticosteroid injections or a combination of these medications

Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453

Result• Median amount of purine intake • 2-day control period : 1.66 g

~ 1.4 kg of beef ~ 2.9 kg of spinach

• 2-day hazard period : 2.03 g ~ 1.7 kg of beef ~ 3.6 kg of spinach

Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453

Result

Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453

Result

Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453

1.42 1.341.77

2.41

1.120.99

1.32 1.39

Discussion• The highest quintile of purine intake, mainly

from animal sources, over a 2-day period increases the risk of recurrent gout attacks almost by five times compared with the lowest quintile of purine intake

Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453

Discussion• Short-term impact of purine from plant sources

on the risk of gout attacks was substantially smaller than that from animal purine sources

• In a large prospective study of incident gout, the long-term, habitual consumption of purine-rich vegetables WAS NOT associated with the risk of incident gout

Discussion• The effect of purine intake on the risk

of recurrent gout attacks persisted across subgroups by sex, age, use of alcohol, diuretics, allopurinol, NSAIDs and colchicine

• Even among allopurinol users acute purine intake can increase the risk of recurrent gout attacks by more than five times.

Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453

Critical appraisal• No critical appraisal

Thank you

Preliminary criteria for the classification of the acute arthritis of primary gout ACR 1977 01. More than one attack of acute arthritis02. Maximum inflammation developed within 1 day03. Monoarthritis attack04. Redness observed over joints05. First metatarsophalangeal joint painful or swollen06. Unilateral first metatarsophalangeal joint attack07. Unilateral tarsal joint attack08. Tophus (proven or suspected)09. Hyperuricemia10. Asymmetric swelling within a joint on x ray11. Subcortical cysts without erosions on x ray12. Monosodium urate monohydrate microcrystals in joint fluid during attack13. Joint fluid culture negative for organisms during attack

Wallace SL, Robinson H, Masi AT, Decker JL, McCarty DJ, Yü T-F. Preliminary criteria for the classification of the acute arthritis of primary goutArthritis Rheum 1977;20:895---900.