Mechanism and treatment of hypertriglyceridaemia in gout

Management of Patients with Gout and Kidney Disease: A Review of Available Therapies and Common Missteps

Gout, a common form of inflammatory arthritis, is characterized by deposition of monosodium urate crystals in articular and periarticular tissues. Repeated flares of gout cause joint damage as well as significant health care utilization and decreased quality of life. Patients with CKD have a higher prevalence of gout. Treating Patients with CKD and gout is challenging because of the lack of quality data to guide management in this specific population. This often leads to suboptimal treatment of patients with gout and impaired renal function because concerns regarding the efficacy and safety of available gout therapies in this population often result in significant interphysician variability in treatment regimens and dosages. Acute gout flares are treated with various agents, including nonsteroidal anti-inflammatory drugs, colchicine, glucocorticoids, and-more recently-IL-1 inhibitors. These medications can also be used as prophylaxis if urate-lowering therapy (ULT) is initiated. While these drugs can be used in patients with gout and CKD, there are often factors that complicate treatment, such as the numerous medication interactions involving colchicine and the effect of glucocorticoids on common comorbidities, such as diabetes and hypertension. ULT is recommended to treat recurrent flares, tophaceous deposits, and patients with moderate-to-severe CKD with a serum urate goal of <6 mg/dl recommended to prevent flares. While many misconceptions exist around the risks of using urate-lowering agents in patients with CKD, there is some evidence that these medications can be used safely in Patients with renal impairment. Additional questions exist as to whether gout treatment is indicated for Patients on RRT. Furthermore, there are conflicting data on whether ULT can affect renal function and cardiovascular disease in patients. All of these factors contribute to the unique challenges physicians face when treating patients with gout and CKD.

The association between serum uric acid and hypertriglyceridemia: evidence from the national health and nutrition examination survey (2007-2018)

Background

Accumulating evidence suggests that elevated serum uric acid (SUA) may be a risk factor for hypertriglyceridemia (HTG). However, the epidemiological evidence for the association between SUA and HTG is limited. This article aimed to use the data from National Health and Nutrition Examination Survey (NHANES) (2007-2018) database to bridge the research gap.

Methods

This cross-sectional study used data from 10027 adults involved in NHANES from 2007-2018. We designed the exposure variable as SUA and the outcome variable as HTG. The covariates included demographics, questionnaires, laboratory, and examination information. Weighted logistic regression and subgroup analysis were used to explore the independent association between SUA and HTG. Furthermore, interaction tests were also carried out to evaluate the strata differences. Generalized additive models (GAM), smooth curve fittings, and threshold effect analysis were applied to examine the non-linear relationship.

Results

A total of 10027 participants were included, of which 3864 were HTG participants and 6163 were non-HTG participants. After fully adjusting for confounders, weighted multiple logistic regression models revealed a 77% increase in the risk of HTG when each unit of log2-SUA increased. There was also a positive association between elevated log2-SUA and developed risk of HTG in the quartile (Q) groups (Q1 OR: 1.00; Q2 OR: 1.17 [95%CI: 0.95,1.45]; Q3 OR: 1.43 [95%CI: 1.16,1.78]; Q4 OR: 1.68 [95%CI: 1.36,2.08]. The subgroup analysis results remained consistent across strata, with a strong positive correlation between SUA and HTG. Interaction tests showed no dependence on physical activity (PA), gender, BMI, smoking status, alcohol intake, hypertension, and diabetes for this positive association between log2-SUA and HTG (all p for interaction >0.05). The participants' age may impact the strength of the association between SUA and HTG (p for interaction <0.05).

Conclusion

There is a positive association between SUA and HTG in US adults. Considering that SUA may be a risk factor for HTG, individuals diagnosed with HTG should prioritize the daily management of SUA as part of their comprehensive care.

Comments on the updated recommendations of the American College of Rheumatology (ACR) for the treatment of gout. Lifestyle (part 2)

Updated ACR recommendations for the treatment of gout concerning lifestyle are discussed. Factors related to a lifestyle, above all food habits, for many years were of leading importance in the treatment of patients with gout, even after application of effective drugs. The authors of the updated ACR recommendations for the first time offered to reconsider the role of environmental factors in the genesis of gout and objectively assess the possibility of its non-drug treatment. On the one hand, regardless of the activity of the disease, the need for restrictions of the alcohol, purine-rich products and fructose-containing beverages, as well as the decrease of body weight in obese patients and vitamin C usage unviability are confirmed. On the other hand, these recommendations are conditional. Their new version of ACR recommendations is significantly different from both its previous version and other international and national recommendations, including recommendations on the diagnosis and treatment of gout used in the Russian Federation.

How much does fat mass change affect serum uric acid levels among apparently clinically healthy Korean men?

Objective:

The aim of this study was to examine the impact of fat mass alteration on serum uric acid (SUA) levels in apparently clinically healthy men.

Methods:

We evaluated 27,387 men who consecutively underwent health check ups between 2015 and 2017. We assessed the likelihood of achieving a SUA level of <0.41 mmol/L and compared the SUA levels according to fat mass changes.

Results:

Compared with those without fat mass change (the reference group), the odds ratios (95% confidence interval) of achieving a SUA level of <0.41 mmol/L for fat mass decreases of ⩾2.5, 1.5–2.5, and 0.5–1.5 kg were 1.63 (1.45–1.82), 1.19 (1.06–1.34), and 1.07 (0.97–1.18), respectively, while those for a fat mass increase of ⩾2.5, 1.5–2.5, and 0.5–1.5 kg were 0.71 (0.64–0.78), 0.87 (0.79–0.97), and 0.95 (0.86–1.04), respectively. The corresponding beta-coefficients of SUA levels (mmol/L) were –0.26 [–0.29–(–0.23)], –0.12 [–0.16–(–0.09)], and –0.09 [–0.12–(–0.06)] for fat mass decreases of ⩾2.5, 1.5–2.5, and 0.5–1.5 kg, respectively. Every 1-kg fat mass reduction was associated with 9% increased odds of achieving the target SUA level. The multivariate SUA level difference per 1-kg fat mass gain was 2.97 µmol/L. Similar levels of association persisted among the prespecified subgroups.

Conclusion:

We quantitatively demonstrated that fat mass reduction contributes to a clinically relevant decrease in SUA levels and a significant increase in the likelihood of achieving target SUA levels. Our findings may help to provide clear clinical guidance on fat mass alteration to reduce SUA levels in patients with hyperuricemia.

Serum uric acid and risk of incident hypercholesterolaemia and hypertriglyceridaemia in middle-aged and older Chinese: a 4-year prospective cohort study

PURPOSE

The aim was to investigate whether serum uric acid (SUA) was associated with incident hypercholesterolaemia and hypertriglyceridaemia in middle-aged and older Chinese.

METHODS

This prospective cohort study used data from the China Health and Retirement Longitudinal Study. A total of 6,063 participants were included, who were free of hypercholesterolaemia and hypertriglyceridaemia at baseline (2011) and were followed until 2015. Natural cubic spline models were conducted to investigate the dose-response association of SUA with incident hypercholesterolaemia and hypertriglyceridaemia. Moreover, SUA was categorized into four groups according to gender-specific quartiles. Log-binomial regression was performed to explore the association of SUA with hypercholesterolaemia and hypertriglyceridaemia, with the quartile 1 as a reference.

RESULTS

After full adjustment, we observed a positive linear dose-response relationship between SUA and hypercholesterolaemia and hypertriglyceridaemia. Compared with the quartile 1 of SUA, the adjusted risk ratios (95% confidence interval) of hypertriglyceridaemia were 1.15 (0.95-1.39), 1.23 (1.02-1.49) and 1.31 (1.08-1.59) for quartile 2-4 (p-value for trend = .004), respectively. Whereas, we failed to find SUA significantly associated with hypercholesterolaemia. Sex-stratified analyses indicated that the association of SUA with hypertriglyceridaemia was more evident in the female.

CONCLUSIONS

These findings suggest that SUA may be positively associated with incident hypertriglyceridaemia. KEY MESSAGES The natural cubic spline model showed a positive linear dose-response relationship between serum uric acid levels and hypertriglyceridaemia. Compared with the quartile 1 of SUA, the adjusted risk ratios (95% confidence interval) of hypertriglyceridaemia were 1.15 (0.95-1.39), 1.23 (1.02-1.49) and 1.31 (1.08-1.59) for quartile 2-4 (p-value for trend = .004), respectively. Sex-stratified analyses indicated that the association of serum uric acid with hypertriglyceridaemia was more evident in the female.

2020 American College of Rheumatology Guideline for the Management of Gout

OBJECTIVE

To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.

METHODS

Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional.

RESULTS

Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended.

CONCLUSION

Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.

2020 American College of Rheumatology Guideline for the Management of Gout

OBJECTIVE

To provide guidance for the management of gout, including indications for and optimal use of urate-lowering therapy (ULT), treatment of gout flares, and lifestyle and other medication recommendations.

METHODS

Fifty-seven population, intervention, comparator, and outcomes questions were developed, followed by a systematic literature review, including network meta-analyses with ratings of the available evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and patient input. A group consensus process was used to compose the final recommendations and grade their strength as strong or conditional.

RESULTS

Forty-two recommendations (including 16 strong recommendations) were generated. Strong recommendations included initiation of ULT for all patients with tophaceous gout, radiographic damage due to gout, or frequent gout flares; allopurinol as the preferred first-line ULT, including for those with moderate-to-severe chronic kidney disease (CKD; stage >3); using a low starting dose of allopurinol (≤100 mg/day, and lower in CKD) or febuxostat (<40 mg/day); and a treat-to-target management strategy with ULT dose titration guided by serial serum urate (SU) measurements, with an SU target of <6 mg/dl. When initiating ULT, concomitant antiinflammatory prophylaxis therapy for a duration of at least 3-6 months was strongly recommended. For management of gout flares, colchicine, nonsteroidal antiinflammatory drugs, or glucocorticoids (oral, intraarticular, or intramuscular) were strongly recommended.

CONCLUSION

Using GRADE methodology and informed by a consensus process based on evidence from the current literature and patient preferences, this guideline provides direction for clinicians and patients making decisions on the management of gout.

A population analysis of the DGAT1 inhibitor GSK3008356 and its effect on endogenous and meal-induced triglyceride turnover in healthy subjects

Non-alcoholic steatohepatitis (NASH) is a liver disease in which fatty infiltration is accompanied by liver inflammation. GSK3008356 is under development as a selective inhibitor of diacylglycerol acyltransferase 1 (DGAT1), a key enzyme involved in the formation of triglyceride (TG). Decreased DGAT1 activity can reduce circulating TG and liver TG, and therefore could potentially prevent or treat NASH. The aim of the current study was to develop a population pharmacokinetic-pharmacodynamic (PKPD) model that characterizes the PK disposition of GSK3008356 and its relation to the changes in blood TG. Drug concentrations were measured in 104 healthy adults receiving various single (SD) and repeat doses (RD) in a first time in human (FiH) study. A 30% fat meal was given at hour 2 postdose, and blood postprandial TG concentrations were measured at various time points. The population PKPD model consists of several parts including a PK model, drug effect model, meal effect model, and a turnover model. The pharmacokinetic data were described using a 3-compartment model. Drug effect was described by an inhibitory sigmoidal Emax model. Since TG levels change with the introduction of a meal, a bi-exponential meal effect model was utilized. The total change in TG was fitted using a turnover model with drug and meal effects on the TG production rate. The current analysis presents a PKPD modeling strategy of time-varying TG data coming from both endogenous and exogenous sources. In general, the presented model could be utilized in the model-based drug development of drugs that influence TG levels in blood.

Identification of Metabolite Biomarkers for Gout Using Capillary Ion Chromatography with Mass Spectrometry

Gout is a common form of inflammatory arthritis, and the detailed pathogenic mechanisms for this metabolic disorder remain largely unknown. In this study, we first profiled the salivary metabolites in 8 patients with gout, 15 patients with hyperuricaemia (HUA), and 15 healthy individuals using capillary ion chromatography (CIC) with tandem mass spectrometry (MS/MS). Forty-nine salivary metabolites were found to be significantly changed between gout patient and healthy control groups, and 26 salivary metabolites were significantly different between gout and HUA patient groups. Three metabolite biomarkers, uric acid, oxalic acid, and l-homocysteic acid (HCA), were selected for validation in the saliva samples of 30 patients with gout, 30 patients with HUA, and 30 healthy control subjects. By using commercial assay kits for the measurements, salivary uric acid and oxalic acid levels were found to be significantly higher in gout patients than healthy controls, whereas salivary HCA level was significantly higher in gout patients than both HUA patients and healthy controls. These assay measurements were in line with those obtained by CIC-MS/MS. In conclusion, we have demonstrated a new application of CIC-MS/MS for the discovery of novel metabolite biomarkers of gout. Validated biomarkers may be used for noninvasive, diagnostic and prognostic applications in gout. Future studies are warranted to investigate the clinical utility of these identified biomarkers for monitoring gout flare and/or treatment efficacy.

Epidemiological association between uric acid concentration in plasma, lipoprotein(a), and the traditional lipid profile

BACKGROUND

Elevated levels of uric acid in serum (SUA) or plasma (PUA) are increasingly related to cardiovascular disease. It is unclear whether they are independent risk factors or simply markers, reflecting association with other traditional risk factors.

METHODS

We retrospectively assessed results of a lipid profile, including total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides, total cholesterol to HDL-C ratio (TC/HDL-C), the atherogenic index of plasma (AIP), and lipoprotein(a) (Lp[a]), in a large cohort of unselected adult outpatients.

RESULTS

Hyperuricemic men displayed significantly increased values of triglycerides and AIP when compared with men with normal PUA levels. In hyperuricemic women, significant differences were observed for HDL-C, triglycerides, TC/HDL-C, and AIP compared with women with normal PUA levels. The percentage of patients with unfavorable values was statistically higher for triglycerides and AIP in hyperuricemic men; for HDL-C, triglycerides, TC/HDL-C, and AIP in hyperuricemic women. In multivariable linear regression analysis triglycerides, AIP, and TC/HDL-C were independently associated with PUA in women, whereas no significant association was observed in men.

CONCLUSION

PUA measurement might be advisable in patients to identify those at increased risk of cardiovascular disease (CVD) who might benefit from further triage and intervention.

Endocrine and metabolic effects of consuming fructose- and glucose-sweetened beverages with meals in obese men and women: influence of insulin resistance on plasma triglyceride responses

CONTEXT

Compared with glucose-sweetened beverages, consumption of fructose-sweetened beverages with meals elevates postprandial plasma triglycerides and lowers 24-h insulin and leptin profiles in normal-weight women. The effects of fructose, compared with glucose, ingestion on metabolic profiles in obese subjects has not been studied.

OBJECTIVE

The objective of the study was to compare the effects of fructose- and glucose-sweetened beverages consumed with meals on hormones and metabolic substrates in obese subjects.

DESIGN AND SETTING

The study had a within-subject design conducted in the clinical and translational research center.

PARTICIPANTS

Participants included 17 obese men (n = 9) and women (n = 8), with a body mass index greater than 30 kg/m(2).

INTERVENTIONS

Subjects were studied under two conditions involving ingestion of mixed nutrient meals with either glucose-sweetened beverages or fructose-sweetened beverages. The beverages provided 30% of total kilocalories. Blood samples were collected over 24 h.

MAIN OUTCOME MEASURES

Area under the curve (24 h AUC) for glucose, lactate, insulin, leptin, ghrelin, uric acid, triglycerides (TGs), and free fatty acids was measured.

RESULTS

Compared with glucose-sweetened beverages, fructose consumption was associated with lower AUCs for insulin (1052.6 +/- 135.1 vs. 549.2 +/- 79.7 muU/ml per 23 h, P < 0.001) and leptin (151.9 +/- 22.7 vs. 107.0 +/- 15.0 ng/ml per 24 h, P < 0.03) and increased AUC for TG (242.3 +/- 96.8 vs. 704.3 +/- 124.4 mg/dl per 24 h, P < 0.0001). Insulin-resistant subjects exhibited larger 24-h TG profiles (P < 0.03).

CONCLUSIONS

In obese subjects, consumption of fructose-sweetened beverages with meals was associated with less insulin secretion, blunted diurnal leptin profiles, and increased postprandial TG concentrations compared with glucose consumption. Increases of TGs were augmented in obese subjects with insulin resistance, suggesting that fructose consumption may exacerbate an already adverse metabolic profile present in many obese subjects.

Apolipoprotein E phenotypes in patients with gout: relation with hypertriglyceridaemia

OBJECTIVE

To elucidate the relationship, if any, between lipid abnormalities and apolipoprotein E (apo E) polymorphism, by investigating apo E phenotype and allele frequency.

METHODS

Fasting blood samples were taken for determination of apo E phenotype and serum lipids in 221 male patients with gout and 141 control male subjects. Apo E phenotype was determined by one dimensional flat gel isoelectric focusing.

RESULTS

Frequencies of apo E phenotypes in gout were apo E3/3 67.9%, E4/3 18.1%, E4/4 2.3%, E4/2 1.8%, E3/2 9.5%, and E2/2 0.5%; those in control male subjects were 74.5%, 15.6%, 0%, 1.4%, 7.1%, and 1.4%, respectively. Frequencies of the e2, e3, and e4 alleles in gout were 0.061, 0.817 and 0.122, compared with the corresponding control frequencies of 0.057, 0.858 and 0.085. These differences in apo E phenotype and allele frequencies between gout and control subjects were not significant. The frequency of apo e4 allele in hyperlipidaemic gout subjects was significantly greater than that in normolipidaemic gout subjects; in contrast, its frequency was not different between hyperlipidaemic and normolipidaemic control subjects. Serum triglyceride, total cholesterol, apo B and E concentrations were significantly greater in gouty patients with the apo E4/3 phenotype than in those with gout having the apo E3/3 phenotype.

CONCLUSIONS

These data suggest that gout subjects with hyperlipidaemia (hypertriglyceridaemia, hypercholesterolaemia or both) possess the apo e4 allele with higher frequency than those with normolipidaemia. They also suggest that apo e4 may induce some susceptibility to the development of hyperlipidaemia in gout in addition to that induced by obesity or excessive alcohol consumption, and may contribute to the high prevalence of atherosclerotic diseases in gout patients.

Relationship between hypertriglyceridemia and uric acid production in primary gout

The relationship between uric acid metabolism and lipid levels was analyzed in 148 male subjects with primary gout. The subjects were divided into three groups according to their alcohol consumption: heavy drinkers, moderate drinkers, and nondrinkers or mild drinkers. There was no correlation between urinary uric acid excretion and serum triglyceride (TG) levels in the heavy group, but a marginally significant correlation was shown in the moderate group (P less than .05), and a significant correlation was observed in the nondrinker or mild group (P less than .001). This relationship in the nondrinker or mild group was also found to be significant after adjustment for BMI and age by multiple regression analysis. Serum lipoproteins were analyzed by sequential preparative ultracentrifugation in 21 patients with primary gout who neither drank alcohol nor were obese; VLDL-TG level, but not the VLDL cholesterol level, was found to be significantly correlated with 24-hour urinary uric acid excretion. These results indicate that there is a close correlation between the degree of uric acid production, as judged by 24-hour urinary uric acid excretion, and lipoprotein TG metabolism when the influence of alcohol intake is excluded.

Hypertriglyceridemia and hyperuricemia: effects of two fibric acid derivatives (bezafibrate and fenofibrate) in a double-blind, placebo-controlled trial

The effects of bezafibrate and fenofibrate on serum lipoproteins and serum urinary uric acid were compared. In a double-blind, placebo-controlled, cross-over study, each drug was administered in random order for 6 weeks followed by a 3-week drug-free phase to ten men with primary hypertriglyceridemia. Serum triglyceride and cholesterol concentrations decreased significantly with both fenofibrate and bezafibrate, although no significant change in serum apolipoprotein B, serum low density lipoprotein (LDL) cholesterol or serum high density lipoprotein (HDL) cholesterol concentrations was apparent. Serum uric acid levels, which were elevated on placebo and bezafibrate, were significantly reduced by 20% by fenofibrate. This was associated with an increase in renal uric acid clearance of 30% during fenofibrate therapy. Because it seems likely that hypertriglyceridemia and hyperuricemia are linked by a common carbohydrate inducibility, we studied the acute hyperuricemic response to orally administered fructose. Fructose (50 g) caused the anticipated rise in serum urate reaching a peak between 60 and 90 minutes, which was quantitatively greater in the men with hypertriglyceridemia than in healthy controls. The serum uric response to fructose was unaffected by bezafibrate, but was converted to normal by fenofibrate. The hyperuricemic action of fenofibrate is of sufficient magnitude to be of therapeutic value in the management of patients whose hypertriglyceridemia is associated with gout.

Hyperlipoproteinaemia in primary gout: hyperlipoproteinaemic phenotype and influence of alcohol intake and obesity in Japan

Serum lipoprotein profiles were investigated in 108 male patients with primary gout before treatment to elucidate the prevalence of each individual phenotype of coexisting hyperlipoproteinaemia and pathogenic factors responsible for it. The mean serum triglyceride (TG) and total cholesterol (TC) levels in the patients with gout were 2.10 +/- 0.14 mmol/l and 5.26 +/- 0.10 mmol/l (mean +/- SEM) respectively, which were significantly higher (p less than 0.01 and p less than 0.05 respectively) than the levels in age matched controls without gout (1.30 +/- 0.07 mmol/l and 4.77 +/- 0.08 mmol/l respectively). Serum high density lipoprotein cholesterol (HDL-C) values were slightly decreased in patients with gout compared with controls (1.24 +/- 0.08 mmol/l v 1.40 +/- 0.03 mmol/l, p less than 0.05). Hyperlipoproteinaemia was seen in 61 patients (56%), of whom patients with type IIa, IIb, and IV hyperlipoproteinaemia formed 13, 15, and 69% respectively. Thus the prevalence of type IV hyperlipoproteinaemia was high in primary gout as compared with primary hyperlipoproteinaemia with primary hyperlipoproteinaemia (69% v 43%, p less than 0.01). The independent and relative influences of clinical data of the patients upon the concentrations of serum lipids were assessed by stepwise multiple regression analysis. Two major predictors of serum TG level were alcohol intake (p less than 0.01) and serum uric acid level (p less than 0.05). The most significant predictive variable was alcohol intake, but its influence was judged to be small (r2 = 0.067). None of the other variables, including obesity index, had any significant influence. The relationships between any of these variables and serum TC or HDL-C levels were not significant. In addition, serum lipid levels were investigated in patients with neither obesity (defined as 120% or more of ideal body weight) nor a history of alcohol intake. Their serum TG and TC concentrations were also significantly higher than the respective control levels. Thus hyperlipoproteinaemia in primary gout its unlikely to be secondary to excess alcohol intake or obesity, or both. Instead, it may result from genetic factors such as a combined hyperlipidaemic trait.

Hyperuricemia and hypertriglyceridemia: metabolic basis for the association

Hypertriglyceridemia has been reported frequently in patients with hyperuricemia and gout. The current studies have evaluated this relationship. To examine whether hypertriglyceridemia leads to hyperuricemia, IV intralipid was given to three gouty patients. Triglycerides increased from 169 to 700 mg/dl for three hours but caused no change in serum urate level or urine uric acid and oxypurine excretion. We next examined whether high carbohydrate intake increases serum urate and triglyceride levels. Four obese patients were placed on a 2000 kcal/d sucrose diet for seven days. The serum urate increased from 6.3 +/- 1.7 to 7.9 +/- 2.0 mg/dL. The percent uric acid clearance to creatinine clearance decreased from 5.9 +/- 1.3 to the lowest mean value of 3.7 +/- 1.2, while serum triglycerides increased from 106 +/- 33 to 252 +/- 57 mg/dL and blood lactate from 607 +/- 227 to 1167 +/- 381 mumol/L. A 3000 kcal/d glucose diet in four other obese subjects produced no change in serum urate levels but increased lactate and triglyceride levels. During an isocaloric sucrose diet in two normal men, the serum urate level increased from 5.3 and 4.0 to peak values of 9.5 and 7.4 mg/dL. The percent uric acid to creatinine clearance decreased from 5.6 and 6.6 to 2.9 and 3.3. The uric acid turnover did not increase. In three gouty patients the mean serum urate increased from 8.5 +/- 1.5 to 10.6 +/- 1.4 mg/dL following an isocaloric sucrose diet. The urine uric acid excretion increased from 0.30 and 0.25 to 0.37 and 0.38 mg/mg creatinine in two patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of smoking and physical activity on serum uric acid in a Jerusalem population sample

In 932 adult males and 531 adult females, we found large independent correlations of serum uric acid (SUA) with body mass and serum creatinine. In males, but not in females, SUA was lower in smokers than in non-smokers and in men who reported themselves to be physically active, compared to non-active men. After controlling for confounding variables by multiple regression analysis, we found that smoking remained a significant predictor of SUA in males (P = 0.003) but the effects of reported physical activity dropped to borderline significance (P = 0.056). In females, no significant relationship of SUA with reported physical activity was seen. These results, the first from an unselected free-living Israeli population, are generally in agreement with previously reported studies.

Alcohol consumption in arthritic patients: clinical and laboratory studies

In popular belief patients with chronic arthritis take alcohol for its analgesic effect. To test this we studied by validated questionnaire the past and present alcohol consumption of 103 patients with primary osteoarthritis of the hip (OA), 95 patients with rheumatoid arthritis (RA), and 90 orthopaedic non-arthritic controls. OA men were most likely and RA men least likely to have been heavy drinkers at any time of their lives. Mean red corpuscular volume (MCV), gamma-glutamyltransferase (GGT), and serum uric acid (SUA) levels did not correlate with reported alcohol consumption. Two of 93 OA femoral heads examined had avascular change; both were from heavy drinkers. The abstemiousness of RA men compared with their OA counterparts was due to a striking increase in joint pain after drinking alcohol (p = 0.004), fear of adverse drug reactions with alcohol, and a widespread belief not expressed by OA men that 'alcohol and arthritis do not mix'.

Serum lipids and lipoproteins in patients with primary gout

Serum lipid and lipoprotein values of 32 male patients suffering from gout were quantitated and compared with corresponding values of a random control group which did not differ significantly with regard to age, body weight index and socio-economic status. All patients were on therapy with allopurinol which lasted on average for 6 years. The most striking differences between patients and controls were the increased triglyceride and apo B values and the decreased HDL-cholesterol (HDL-C) and HDL-phospholipid (HDL-PL) values in the patient group. The values of total cholesterol, LDL-cholesterol, apo A-I and Lp (a) were not significantly different between patients and controls. The great differences in the ratios of apo B/LDL-C, apo A-I/HDL-C and apo A-I/HDL-PL values suggest that gout is connected with changes in the chemical composition of the major lipoprotein classes. In three normolipemic individuals who were treated for 3 weeks with allopurinol no changes in lipoproteins and apolipoproteins were apparent. The results are discussed in view of the atherosclerosis risk of patients suffering from gout.

A controlled study of diet in patients with gout

To determine whether patients with gout have a diet which is distinctive in quality or quantity a careful dietary questionnaire was posed over 7 days to 61 men with gout and 52 control subjects. The average daily intake of most nutrients, including total purine nitrogen, was similar except that the patients with gout drank significantly more alcohol. Beer was the most popular beverage, and 25 (41%) of those with gout consumed more than 60 g alcohol daily (equivalent to 2 . 5 litres of beer). The heavy drinkers had a significantly higher intake of purine nitrogen, half of which was derived from beer. Though the effect of ingested purine on the blood uric acid is difficult to estimate, it probably was sufficient to have a clinical effect, augmenting the hyperuricaemic effect of alcohol itself.

Family study of lipid and purine levels in gout patients

A family study was performed to determine whether the hypertriglyceridaemia associated with gout is present in families of gout patients or due to the life style of the patient himself. The study revealed the expected hypertriglyceridaemia in gout patients; this was reflected by elevated serum levels of prebetalipoproteins and with reduction in the proportion of beta-lipoprotein. None of these abnormalities were seen in the first-degree relatives. Furthermore, the proportion of high-density lipoproteins was not significantly raised in gout patients.

Allopurinol treatment and its effect on renal function in gout: a controlled study

Fifty-nine patients with primary gout were treated with either a combination of colchicine and allopurinol or colchicine alone. Assessments of renal function over 2 years revealed a statistically significant fall of glomerular filtration rate an urine concentrating ability in those receiving only colchicine. The renal function of patients given allopurinol did not change. Treatment with allopurinol resulted ina significant reduction of ammonium excretion, a phenomenon which could not be readily explained. Urate clearance also declined during allopurinol treatment, and the impaired urate clearance associated with gout became more evident. The most important observation was that allopurinol retarded an apparent decline of renal function. Presumably this was achieved through its hypouricaemic effect and implies that the hyperuricaemia of gouty patients is deleterious to the kidneys.

Family study of lipid and purine levels in gout patients and analysis of mortality

A family study was performed to determine whether the hypertriglyceridaemia associated with gout is present in families of gout patients or simply due to their life-style. The study revealed hypertriglyceridaemia in gout patients, reflected by hyperprebetalipoproteinaemia and with reciprocal reduction in the proportion of beta-lipoprotein. These abnormalities were not seen in first-degree relatives. No definite increase in mortality was found from coronary or cerebrovascular disease in male gout patients after presentation to hospital or in their relatives. Families of hyperlipidaemic gout patients did reveal a slight increase in male coronary deaths although the significance of this finding was doubtful since some hypercholesterolaemia was found in these hyperlipidaemic families.