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16-September-2008 16:20:32 - Gout Gout Classification and external resources Uric acid ICD-10 M10. ICD-9 274.0 274.1 274.8 274.9 OMIM 138900 300323 DiseasesDB 29031 eMedicine med/924 orthoped/124 emerg/221 med/1112 oph/506 radio/313 MeSH D006073 Gout also called metabolic arthritis is a disease created by a buildup of uric acid. In this condition, monosodium urate or uric acid crystals are deposited on the articular cartilage of joints, tendons and surrounding tissues due to elevated concentrations of uric acid in the bloodstream. This provokes an inflammatory reaction of these tissues. Contents 1 Signs and symptoms 2 Diagnosis 3 Pathogenesis 4 Treatment 4.1 Acute attacks 4.2 Chronic joint changes 5 Prevention 5.1 Medications 5.2 Diet 5.2.1 Reduce intake of purines 5.2.2 Increase output of uric acid 5.2.3 Other approaches 6 History 7 See also 8 References 9 External links Signs and symptoms The Gout, Cartoon by James Gillray 1799. The artist memorably illustrates the excruciating pain and swelling that are symptoms of the disease. The Gout, Cartoon by James Gillray 1799. The artist memorably illustrates the excruciating pain and swelling that are symptoms of the disease. Gout is characterized by excruciating, sudden, unexpected, burning pain, as well as swelling, redness, warmth, and stiffness in the affected joint. This occurs commonly in men in their toes but can appear in other parts of the body and affects women as well. Low-grade fever may also be present. The patient usually suffers from two sources of pain. The crystals inside the joint cause intense pain whenever the affected area is moved. The inflammation of the tissues around the joint also causes the skin to be swollen, tender and sore if it is even slightly touched. For example, a blanket or even the lightest sheet draping over the affected area could cause extreme pain. Gout usually attacks the big toe approximately 75 percent of first attacks; however, it also can affect other joints such as the ankle, heel, instep, knee, wrist, elbow, fingers, and spine. In some cases, the condition may appear in the joints of small toes that have become immobile due to impact injury earlier in life, causing poor blood circulation that leads to gout. Patients with longstanding hyperuricemia see below can have uric acid crystal deposits called tophi singular: tophus in other tissues such as the helix of the ear. Elevated levels of uric acid in the urine can lead to uric acid crystals precipitating in the kidneys or bladder, forming uric acid kidney stones. Diagnosis A definitive diagnosis of gout is from light microscopy of fluid aspirated from the joints this test may be difficult to perform to demonstrate intracellular monosodium urate crystals in synovial fluid polymorphonuclear leukocytes. The urate crystal is identified by strong negative birefringence under polarised microscopy and its needle-like morphology. A trained observer does better in distinguishing them from other crystals. Hyperuricemia is a common feature, although urate levels are not always raised.1 Hyperuricemia is defined as a plasma urate uric acid level greater than 420 μmol/L 7.0 mg/dL in males, or 380 μmol/L in females. However, a high uric acid level does not necessarily mean a person will develop gout. Urate is within the normal range in up to two-thirds of cases.2 If gout is suspected, the serum urate test should be repeated once the attack has subsided. Other blood tests commonly performed are full blood count, electrolytes, renal function, thyroid function tests and erythrocyte sedimentation rate ESR. This helps to exclude other causes of arthritis, most notably septic arthritis, and to investigate any underlying cause for the hyperuricaemia. Pathogenesis Gout occurs when mono-sodium urate crystals form on the articular cartilage of joints, on tendons, and in the surrounding tissues. Purine metabolism gives rise to uric acid, which is normally excreted in the urine. Uric acid is more likely to form into crystals when there is a hyperuricemia, although it is 10 times more common without clinical gout than with it.3 Purines can be generated by the body via breakdown of cells in normal cellular turnover, or can be ingested in purine-rich foods such as seafood. The kidneys are responsible for approximately two-third of uric acid excretion, with the gut responsible for the rest. It may be possible that defects in the kidney that may be genetically determined are responsible for the predisposition of individuals for developing gout. There are also different racial propensities to develop gout. Gout is high among the peoples of the Pacific Islands, and the MÄ?ori of New Zealand, but rare in the Australian aborigine despite the latter's higher mean concentration of serum uric acid.4 In the United States, gout is twice as prevalent in African American males as it is in European-Americans.5 A seasonal link also may exist, with significantly higher incidence of acute gout attacks occurring in the spring.67 Hyperuricemia is considered an aspect of metabolic syndrome, although its prominence has been reduced in recent classifications. This explains the increased prevalence of gout among obese individuals. Gout is a form of arthritis that affects mostly men between the ages of 50 and 60. The high levels of uric acid in the blood are caused by protein rich foods. Alcohol intake often causes acute attacks of gout and herary factors may contribute to the elevation of uric acid. Typically, persons with gout are obese, predisposed to diabetes and hypertension, and at higher risk of heart disease. Gout is more common in affluent societies due to a diet rich in proteins, fat, and alcohol. When it follows as a consequence of other health conditions such as renal failure, it is often regardless of the person's lifestyle.8 Lin, et al have statistical evidence linking gout to lead poisoning,9 and lead level in the body is significantly correlated with urate excretion and gout.10 It is known that lead sugar was used to sweeten wine, and that chronic lead poisoning is a cause of gout,1112 which condition is then known as saturnine gout, because of its association with alcohol and excess.13 Gout also can develop as co-morbidity of other diseases, including polycythaemia, leukaemia, intake of cytotoxics, obesity, diabetes, hypertension, renal disorders, and hemolytic anemia. This form of gout is often called secondary gout. Diuretics particularly thiazide diuretics have traditionally been blamed for precipitating attacks of gout because they compete at the same transporter, but a Dutch case-control study from 2006 appears to cast doubt on this conclusion.14 Gout with tophi on elbow and knee. Gout with tophi on elbow and knee. Treatment Acute attacks The first line of treatment should be pain relief. Once the diagnosis has been confirmed, the drugs of choice are indomethacin, other nonsteroidal anti-inflammatory drugs NSAIDs, oral glucocorticoids,15 or intra-articular glucocorticoids administered via a joint injection. Colchicine was previously the drug of choice in acute attacks of gout, as it impairs the motility of granulocytes and can prevent the inflammatory phenomena that initiate an attack. Colchicine should be taken within the first 12 hours of the attack and usually relieves the pain within 48 hours, although side effects gastrointestinal upset such as diarrhea and nausea can complicate its use. NSAIDs are the preferred form of analgesia for patients with gout. A randomized controlled trial found similar benefit from nonsteroidal anti-inflammatory drugs and oral glucocorticoids; however, less adverse drug reactions occurred in the glucocorticoids group.16 In the nonsteroidal anti-inflammatory drugs group, each patient initially received diclofenac 75 mg intramuscularly, indomethacin 50 mg orally, and acetaminophen 1 g orally. The patient was received a 5-days of indomethacin 50 mg orally every 8 hours for 2 days, followed by indomethacin 25 mg every 8 hours for 3 days, and acetaminophen 1 g every 6 hours as needed. The glucocorticoids patients received prednisolone 30 mg orally, and acetaminophen 1 g orally. The patient was then given prednisolone 30 mg orally once per day for five days. Before medical help is available, some over-the-counter medications can provide temporary relief from pain and swelling. NSAIDs such as ibuprofen can reduce the pain and inflammation slightly, although aspirin should not be used as it can worsen the condition. This is because aspirin raises plasma uric acid levels even at low doses by inhibiting uric acid secretion in the renal tubulescitation needed. Aspirin also reduces vasodilatation due to inhibition of prostaglandin PGE2 and PGI2 synthesis in the renal medulla and glomeruli respectively see mechanism of action of aspirin. This may be a contra-indication for the use of aspirin for gout pain as well. The anti-hemorrhoidal ointment Preparation H can reduce gout-induced skin swelling temporarily. Ice may be applied for 20 to 30 minutes several times a day, and a randomized controlled trial found that patients who used ice packs had better relief of pain without side effects.17 Since gout is caused by crystals, it has been suggested that keeping very well hydrated and heating the affected joint in hot water rather than cooling with ice will promote the dissolution and clearance of the urate crystals.18 Keeping the affected area elevated above the level of the heart also may help. Professional medical care is needed for long-term management of gout. Due to swelling around affected joints for prolonged periods, shedding of skin may occur. This is particularly evident when small toes are affected and may promote fungal infection in the web region if dampness occurs, and treatment is similar to that for common athlete's foot. Some sufferers of gout report an aggravation of the condition in the knees and toes associated with long periods of immobility, such as when sitting at a computer desk for long hours. Sufferers who notice early swelling or early pain may appear to be able to arrest the aggravation when medical treatment is applied before the condition gets worse. Where this is the case, a medically prescribed anti-inflammatory oral treatment taken with food and bed rest may provide relief within 6 to 8 hours. Another possibility is acetazolamide, one of the first diuretics discovered. This drug inhibits the action of carbonic anhydrase on the proximal convoluted tubules within the kidneys, which effectively inhibits reabsorption of bicarbonate, thus alkalinizing the urine. After two to three days of usage, the diuretic effects of this drug decline because of increased downstream reabsorption of ions and water by the renal tubules; however, the alkalinization of urine persists, and this basic urine attracts weak acids such as uric acid and cystine into the urine, thus increasing their urinary excretion. Chronic joint changes For extreme cases of gout, surgery may be necessary to remove large tophi and correct joint deformity. Prevention Medications Allopurinol is a xanthine-oxidase inhibitor, widely used in the prevention of attacks of gout, and well tolerated. It is safe to use in patients with renal impairment and urate stones.19 Sulfinpyrazone is an uricosuric. It is less widely used than allupurinol, and must not be used in patients with renal impairment, or a high urate excretion rate.20 Allopurinol and azathioprine Imuran used together present a risk of a potentially fatal drug interaction, a severe risk of allopurinol use which is of importance to transplant patients being treated with azathioprine for immunosuppression.1 Febuxostat 2-3-cyano-4-isobutoxyphenyl-4-methylthiazole-5-carboxylic acid - a non-purine inhibitor of xanthine oxidase seems to be an alternative that is superior to allopurinol at reducing serum urate levels, but not at reducing attacks of gout; it is currently in Phase III trials.21 Probenecid, a uricosuric drug that promotes the excretion of uric acid in urine, is also commonly prescribed - often in conjunction with colchicine. The drug fenofibrate which is used in treating hyperlipidemia also exerts a beneficial uricosuric effect.22 As arterial hypertension quite often coexists with gout, treating it with losartan, an angiotensin II receptor antagonist, might have an additional beneficial effect on uric acid plasma levels. This way losartan can offset the negative side-effect of thiazides a group of diuretics used for high blood pressure on uric acid metabolism in patients with gout. Gout is suspected to be secondary to untreated sleep apnea in some cases, caused by the release of purines as a by-product of the breakdown of oxygen-starved cells. Treatment for apnea can therefore be effective in lessening incidence of acute gout attacks.23 A 2004 study suggests that animal flesh sources of purine such as beef and seafood greatly increase the risk of developing gout. However, high-purine vegetable sources such as asparagus, cauliflower, spinach, and green peas did not. Dairy products such as milk and cheese significantly reduced the chances of gout. The study followed over 40000 men over a period of 12 years, in which 1300 cases of gout were reported.24 PEG-uricase, a polyethylene glycol PEG conjugate of recombinant porcine uricase urate oxidase, which breaks down the uric acid deposits is being studied in Phase III clinical trials for the treatment of severe, treatment-refractory gout in the United States in 2006.Pipeline Sodium bicarbonate baking soda is a traditional remedy,25 thought to work by raising blood pH lowering blood acidity. However, the added sodium may be inappropriate for some people. Ethylenediaminetetraacetic acid EDTA, a chelator of lead, has successfully increased uric acid excretion.26 This should be an advantageous treatment for those people whose gout was caused by lead poisoning. Care should be taken to increase intake of trace essential elements since chelation often remove these elements also. Potassium supplements should be advantageous to treat gout. Gout can be triggered by the same agents that cause potassium losses such as fasting, surgery, and potassium losing diuretics.27 A potassium deficiency can increase urate levels in the blood.28 Research from the University of British Columbia suggests long-term coffee consumption is associated with a lower risk of gout.29 Other studies extend this benefit to tea and other caffeinated foods and drinks.30 Homeopathic treatments have included extracts from the plant, Urtica Urens. Diet See Saag and Choi, 2006, an open-access review article, for detailed references and further information.31 The serum level of uric acid is the primary risk factor for gout. The serum level is the result of both intake diet and output excretion. Diet should be low fat and low protein. Reduce intake of purines The solubility threshold for uric acid is approximately 6.7 mg/dl; above this threshold crystals may form. Healthy subjects in the Normative Aging Study who had serum levels of uric acid over 9.0 mg/dl suffered a 22% incidence of gout over six years, compared to less than one percent for those with 7.0-8.9 mg/dl. The average uric acid level in men is 5.0 mg/dl, and substitution of a purine-free formula diet reduces this to 3.0 mg/dl. A purine-restricted diet lowers the level nearly as much 1-2 mg/dl. A diet low in purines reduces the serum level of uric acid, unless these levels are caused by other health conditions and not as responsive to dietary changes. For notable sources of dietary purines, see Foods to avoid section below. Protein is a crude proxy for purines; a more precise proxy is muscle. Apart from the notable dietary purines above, the main source of dietary purines is DNA and RNA, via their bases adenine and guanine. All sources of dietary protein supply some purines, but some sources provide far more purines than others. Meat particularly dark meat and seafood are high in purine because muscle cells are packed with mitochondria, which have their own DNA and RNA. In a large prospective study, high consumption of meat and seafood were found associated with an elevated risk of gout onset 41% and 50%, respectively. High consumption of dairy products, high in protein but very low in DNA and RNA, was associated with a 44% decrease in the incidence of gout. Consumption of the more purine-rich vegetables or a high protein diet per se had no significant correlation. Men who consume two or more sugary soft drinks a day have an 85% higher risk of gout compared with those who drink less than one a month.2 This is because soft drinks contain large quantities of high-fructose corn syrup HFCS, a common sweetener in soft drinks, which results in Hyperuricemia in blood.3233 Hyperuricemia, in turn predispose the body for gout.34 Consumption of beer is associated with a 49% increase in relative risk per daily 12-oz serving. By contrast, consumption of spirits was associated with only a 15% increase in relative risk, and no association at all was found with consumption of wine. Some medical drugs are purine-based. Notable among these are the purine-analog antimetabolite drugs, sometimes used as chemotherapy agents. Increase output of uric acid As mentioned above, medicines to induce uric acid output are called uricosuric drugs. Two such drugs are Probenecid and Sulfinpyrazone. Other approaches Additional dietary recommendations can be made which reduce gout indirectly, hypertension, cardiovascular disease, diabetes, and metabolic syndrome. The following suggestions do not meet with universal approval among medical practitioners. Low purine diet: To lower uric acid: bing cherries were reported to reduce uric acid in a small study.3536 celery extracts celery or celery seed either in capsule form or as a tisane/infusion is believed by many to reduce uric acid levels although these are also diuretics.citation needed Celery extracts have been reported to act synergistically with anti-inflammatory drugs.37 Cheese has been recommended as a low-purine food,38 and dairy products have been found to reduce the risk of gout. Carbonated beverages and sugar have also been recommended as a low-purine food,38 even though it was established that men who consume two or more sugary soft drinks a day have an 85% higher risk of gout compared with those who drink less than one a month.3 Dietary supplements Quercetin, a flavonoid, can decrease uric acid levels. Quercetin can be taken with bromelain to improve its absorption. In addition, Pantothenic acid vitamin B5 is said to help with the excretion process of uric acid. 39 Food to avoid: foods high in purines limit food high in protein such as meat, fish, poultry, or tofu to 8 ounces 226 grams a day. Avoid entirely during a flareup.citation needed Tofu has been proposed as a safe source of protein for gout patients due to its small and transient effect on plasma urate levels.40 sweetbreads, kidneys, liver, brains, or other offal meats.4142 sardines and anchovies41 seafood24 particularly shellfish such as clam, oyster, scallop, shrimp, crab, lobster, and crayfish. Asparagus. Cauliflower. Mushrooms. Spinach. Even though above says Consumption of the more purine-rich vegetables or a high protein diet per se had no significant correlation. Dry beans lentils peas. alcohol.43 Some claim that this applies especially to beer high in guanosine, on the basis that brewer's yeasts are very rich in purine. Since most modern commercial beer contains only trace amounts of yeast, this claim requires further substantiation.citation needed Formerly, port wine was sweetened with litharge, causing lead poisoning, of which gout is a complication. Ironically, red wines, particularly those produced by traditional methods,44 contain procyanidins released from grape seeds during wine making, which have been reported to lower serum uric acid levels by an indirect mechanism.45 However, withdrawal of urate-lowering therapy is associated with recurrence of acute gouty arthritis.46 meat extracts, consommés, and gravies41 Foods high in fructose, as discussed above, especially high-fructose corn syrup HFCS as main ingredient READ LABEL.34 All soft drinks non-diet, wherein HFCS is second ingredient next to water Fruit preserves, jam, jelly Syrup Candy To lesser extent, depending on fructose content, ice cream, cakes, and cookies To avoid dehydration: Drink plenty of liquids, especially water, to dilute and assist excretion of urates; Avoid diuretic foods or medicines like aspirin aspirin should be avoided by those suffering from gout, unless specified by a qualified physician, vitamin C, tea and alcohol. The role of diuretics in triggering gout has been disputed.14 Moderate intake of purine-rich vegetables is not associated with increased gout.24 History Writing ca. 30 AD, Aulus Cornelius Celsus appeared to recognize many of the features of gout, including its link with a urinary solute, late onset in women, linkage with alcohol, and perhaps even prevention by dairy products. 4 Again thick urine, the sediment from which is white, indicates that pain and disease are to be apprehended in the region of joints or viscera. and Joint troubles in the hands and feet are very frequent and persistent, such as occur in cases of podagra and cheiragra. These seldom attack eunuchs or boys before coition with a woman, or women except those in whom the menses have become suppressed. Upon the commencement of pain blood should be let; for when this is carried out at once in the first stages it ensures health, often for a year, sometimes for always. Some also, when they have washed themselves out by drinking asses' milk, evade this disease in perpetuity; some have obtained lifelong security by refraining from wine, mead and venery for a whole year; indeed this course should be adopted especially after the primary attack, even although it has subsided. The Roman gladiatorial surgeon Galen described gout as a discharge of the four humors of the body in unbalanced amounts into the joints. The Latin term for a drop, as a drop of discharge, is gutta -- the term gout descends from this word. See also Pseudogout is a very similar disease, but caused by deposition of calcium pyrophosphate, not uric acid. Arthritis Care References ^ Sturrock R 2000. Gout. Easy to misdiagnose. BMJ 320 7228: 132-3. doi:10.1136/bmj.320.7228.132. PMID 10634714. ^ Siva C, Velazquez C, Mody A, Brasington R 2003. Diagnosing acute monoarthritis in adults: a practical approach for the family physician. Am Fam Pghysician 68 1: 83-90. PMID 12887114. ^ Virsaladze DK, Tetradze LO, Dzhavashvili LV, Esaliia NG, Tananashvili DE May 2007. Levels of uric acid in serum in patients with metabolic syndrome in Russian. Georgian Med News 146: 35-7. PMID 17595458. ^ Roberts-Thomson RA, Roberts-Thomson PJ May 1999. Rheumatic disease and the Australian aborigine. Ann. Rheum. Dis. 58 5: 266-70. PMID 10225809. PMC:1752880. ^ Rheumatology Therapeutics Medical Center. What Are the Risk Factors for Gout?. Retrieved on 2007-01-26. ^ Schlesinger N, Gowin KM, Baker DG, Beutler AM, Hoffman BI, Schumacher HR February 1998. Acute gouty arthritis is seasonal. J. Rheumatol. 25 2: 342-4. PMID 9489831. ^ Gallerani M, Govoni M, Mucinelli M, Bigoni M, Trotta F, Manfredini R October 1999. Seasonal variation in the onset of acute microcrystalline arthritis. Rheumatology Oxford 38 10: 1003-6. PMID 10534553. ^ Trivieri, Larry; Ivker, Robert S.; Anderson, Robert H. 1999. The complete self-care guide to holistic medicine: treating our most common ailments. New York, N.Y: J.P. Tarcher/Putnam. ISBN 0-87477-986-3. ^ Lin JL, Tan DT, Ho HH, Yu CC November 2002. Environmental lead exposure and urate excretion in the general population. Am. J. Med. 113 7: 563-8. PMID 12459402. ^ Wright LF, Saylor RP, Cecere FA August 1984. Occult lead intoxication in patients with gout and kidney disease. J. Rheumatol. 11 4: 517-20. PMID 6434739. ^ Lin JL, Huang PT April 1994. Body lead stores and urate excretion in men with chronic renal disease. J. Rheumatol. 21 4: 705-9. PMID 8035397. ^ Shadick NA, Kim R, Weiss S, Liang MH, Sparrow D, Hu H July 2000. Effect of low level lead exposure on hyperuricemia and gout among middle aged and elderly men: the normative aging study. J. Rheumatol. 27 7: 1708-12. PMID 10914856. ^ Ball GV 1971. Two epidemics of gout. Bull Hist Med 45 5: 401-8. PMID 4947583. ^ a b Janssens HJ, van de Lisdonk EH, Janssen M, van den Hoogen HJ, Verbeek AL August 2006. Gout, not induced by diuretics? A case-control study from primary care. Ann. Rheum. Dis. 65 8: 1080-3. doi:10.1136/ard.2005.040360. PMID 16291814. ^ Janssens HJ, Janssen M, van de Lisdonk EH, van Riel PL, van Weel C May 2008. Use of oral prednisolone or naproxen for the treatment of gout arthritis: a double-blind, randomised equivalence trial. Lancet 371 9627: 1854-60. doi:10.1016/S0140-67360860799-0. PMID 18514729. ^ Man CY, Cheung IT, Cameron PA, Rainer TH 2007. Comparison of oral prednisolone/paracetamol and oral indomethacin/paracetamol combination therapy in the treatment of acute goutlike arthritis: a double-blind, randomized, controlled trial. Annals of emergency medicine 49 5: 670-7. doi:10.1016/j.annemergmed.2006.11.014. PMID 17276548. ^ Schlesinger N, Detry MA, Holland BK, et al 2002. Local ice therapy during bouts of acute gouty arthritis. J. Rheumatol. 29 2: 331-4. PMID 11838852. ^ rapid response from a GP to BMJ.com. ^ The British National Formulary website, www.bnf.org ^ Underwood M June 2006. Diagnosis and management of gout. BMJ 332 7553: 1315-9. doi:10.1136/bmj.332.7553.1315. PMID 16740561. ^ Becker MA, Schumacher HR, Wortmann RL, et al December 2005. Febuxostat compared with allopurinol in patients with hyperuricemia and gout. N. Engl. J. Med. 353 23: 2450-61. doi:10.1056/NEJMoa050373. PMID 16339094. ^ Bardin T June 2003. Fenofibrate and losartan. Ann. Rheum. Dis. 62 6: 497-8. PMID 12759281. PMC:1754575. ^ Abrams B February 2005. Gout is an indicator of sleep apnea. Sleep 28 2: 275. PMID 16171252. ^ a b c Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G March 2004. Purine-rich foods, dairy and protein intake, and the risk of gout in men PDF. N. Engl. J. Med. 350 11: 1093-103. doi:10.1056/NEJMoa035700. PMID 15014182. ^ The British Pharmaceutical Codex. Published by direction of the Council of the Pharmaceutical Society of Great Britain, 1911. Sodium ^ Lin JL, Yu CC, Lin-Tan DT, Ho HH July 2001. Lead chelation therapy and urate excretion in patients with chronic renal diseases and gout. Kidney Int. 60 1: 266-71. doi:10.1046/j.1523-1755.2001.00795.x. PMID 11422760. ^ Rodman JS 2002 Intermittent versus continuous alkaline therapy for uric acid stones and uretal stones of uncertain composition. Urology 60; 378-382. ^ Davis WH 1970 Does potassium deficiency hold a clue to metabolic disorders associated with liability to heart disease?. South African Med. Journal 44; 1297. ^ Choi HK, Willett W, Curhan G June 2007. Coffee consumption and risk of incident gout in men: a prospective study. Arthritis Rheum. 56 6: 2049-55. doi:10.1002/art.22712. PMID 17530645. ^ Choi HK, Curhan G June 2007. Coffee, tea, and caffeine consumption and serum uric acid level: the third national health and nutrition examination survey. Arthritis Rheum. 57 5: 816-21. doi:10.1002/art.22762. PMID 17530681. ^ Saag KG, Choi H 2006. Epidemiology, risk factors, and lifestyle modifications for gout. Arthritis Res. Ther. 8 Suppl 1: S2. doi:10.1186/ar1907. PMID 16820041. ^ Nakagawa T, Hu H, Zharikov S, et al March 2006. A causal role for uric acid in fructose-induced metabolic syndrome. Am. J. Physiol. Renal Physiol. 290 3: F625-31. doi:10.1152/ajprenal.00140.2005. PMID 16234313. ^ Mayes PA November 1993. Intermediary metabolism of fructose. Am. J. Clin. Nutr. 58 5 Suppl: 754S-765S. PMID 8213607. ^ a b Gower, Timothy; Johnson, Richard R. 2008. The Sugar Fix: The High-Fructose Fallout That Is Making You Fat and Sick. Emmaus, Pa: Rodale Books, 304. ISBN 1-59486-665-1. ^ Jacob RA, Spinozzi GM, Simon VA, et al June 2003. Consumption of cherries lowers plasma urate in healthy women. J. Nutr. 133 6: 1826-9. PMID 12771324. ^ Blau LW 1950. Cherry diet control for gout and arthritis. Tex. Rep. Biol. Med. 8 3: 309-11. PMID 14776685. ^ Whitehouse MW, Butters DE 2003. Combination anti-inflammatory therapy: synergism in rats of NSAIDs/corticosteroids with some herbal/animal products. Inflammopharmacology 11 4: 453-64. doi:10.1163/156856003322699636. PMID 15035799. ^ a b Harris MD, Siegel LB, Alloway JA February 1999. Gout and hyperuricemia. Am Fam Physician 59 4: 925-34. PMID 10068714. ^ Gout by Zina Kroner , ^ Yamakita J, Yamamoto T, Moriwaki Y, Takahashi S, Tsutsumi Z, Higashino K 1998. Effect of Tofu bean curd ingestion and on uric acid metabolism in healthy and gouty subjects. Adv. Exp. Med. Biol. 431: 839-42. PMID 9598181. ^ a b c ROBINSON CH 1954. The low purine diet. Am. J. Clin. Nutr. 2 4: 276-7. PMID 13188851. ^ Chou P, Soong LN, Lin HY July 1993. Community-based epidemiological study on hyperuricemia in Pu-Li, Taiwan. J. Formos. Med. Assoc. 92 7: 597-602. PMID 7904493. ^ Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G April 2004. Alcohol intake and risk of incident gout in men: a prospective study. Lancet 363 9417: 1277-81. doi:10.1016/S0140-67360416000-5. PMID 15094272. ^ Corder R, Mullen W, Khan NQ, et al November 2006. Oenology: red wine procyanidins and vascular health. Nature 444 7119: 566. doi:10.1038/444566a. PMID 17136085. ^ Wang Y, Zhu JX, Kong LD, Yang C, Cheng CH, Zhang X May 2004. Administration of procyanidins from grape seeds reduces serum uric acid levels and decreases hepatic xanthine dehydrogenase/oxidase activities in oxonate-treated mice. Basic Clin. Pharmacol. Toxicol. 94 5: 232-7. doi:10.1111/j.1742-7843.2004.pto940506.x. PMID 15125693. ^ Perez-Ruiz F, Atxotegi J, Hernando I, Calabozo M, Nolla JM October 2006. Using serum urate levels to determine the period free of gouty symptoms after withdrawal of long-term urate-lowering therapy: a prospective study. Arthritis Rheum. 55 5: 786-90. doi:10.1002/art.22232. PMID 17013833. External links American College of Rheumatology March 23, 2007. Retrieved on 2007-03-23.- ACR Fact Sheet on Gout Answers and Questions on Gout. U.S. National Institutes of Health-National Institute of Arthritis and Musculoskeletal and Skin Diseases September 28, 2007. Retrieved on 2007-08-28. Diet and gout. A-Z Health Guide. webMD.com July 1, 2004. Retrieved on 2006-09-18. Coffee Consumption and Reduced Gout Risk. Drinking coffee reduces risk of gout in middle age men. U.S. National Institutes of Health. Retrieved on 2007-05-25. Purine content in food. British Dalmatian Club. Retrieved on 2006-09-18. Gout in Depth - How Stuff Works Online discussion of patients' experience of gout v d e Diseases of the musculoskeletal system and connective tissue M, 710-739 Arthropathies Arthritis Septic arthritis - Reactive arthritis - Rheumatoid arthritis - Psoriatic arthritis - Felty syndrome - Juvenile idiopathic arthritis - Still's disease - crystal Gout, Chondrocalcinosis - Osteoarthritis Heberden's node, Bouchard's nodes - Monoarthritis/Polyarthritis Specific joints shoulder Winged scapula - elbow Cubitus valgus, Cubitus varus - hand Wrist drop, Boutonniere deformity, Swan neck deformity hip Protrusio acetabuli, Coxa valga, Coxa vara - leg Foot drop, Flat feet, Club foot, Unequal leg length - patella Luxating patella, Chondromalacia patellae - foot Bunion/hallux valgus, Hallux varus, Hallux rigidus, Hammer toe general terms Valgus deformity, Varus deformity Other Hemarthrosis - Arthralgia - Osteophyte - Hypermobility Systemic CT disorders vasculitis: Arteritis Polyarteritis nodosa, Takayasu's arteritis, Temporal arteritis - arterioles/capillaries Wegener's granulomatosis, Kawasaki disease, Churg-Strauss syndrome, Microscopic polyangiitis hypersensitivity/autoimmune: Hypersensitivity vasculitis - Goodpasture's syndrome - Systemic lupus erythematosus Drug-induced - Dermatomyositis Juvenile dermatomyositis - Polymyositis - Scleroderma - Sjögren's syndrome - Behçet's disease - Polymyalgia rheumatica - Eosinophilic fasciitis Dorsopathies spinal curvature Kyphosis, Lordosis, Scoliosis - Scheuermann's disease - Spondylolysis - Torticollis - Spondylolisthesis Spondylopathies Ankylosing spondylitis, Spondylosis, Spinal stenosis - Schmorl's nodes - Degenerative disc disease - Coccydynia - Back pain Radiculopathy, Neck pain, Sciatica, Low back pain Soft tissue disorders Muscle Myositis Pyomyositis - Myositis ossificans Fibrodysplasia ossificans progressiva Synovium and tendon Synovitis/Tenosynovitis Calcific tendinitis, Stenosing tenosynovitis, Trigger finger, DeQuervain's syndrome - Irritable hip - Ganglion cyst Bursa bursitis Olecranon, Prepatellar, Trochanteric - Baker's cyst Fibroblastic disorders Dupuytren's contracture - Fasciitis Plantar fasciitis, Nodular fasciitis, Necrotizing fasciitis - Fibromatosis Shoulder lesions Adhesive capsulitis - Rotator cuff tear - Subacromial bursitis Enthesis enthesopathies Iliotibial band syndrome, Achilles tendinitis, Patellar tendinitis, Golfer's elbow, Tennis elbow, Metatarsalgia, Bone spur, Tendinitis Other, NEC Muscle weakness - Rheumatism - Myalgia - Neuralgia - Neuritis - Panniculitis - Fibromyalgia Osteopathies disorders of bone density and structure: Osteoporosis - Osteomalacia - continuity of bone Pseudarthrosis, Stress fracture - Monostotic fibrous dysplasia - Skeletal fluorosis - Aneurysmal bone cyst - Hyperostosis - Osteosclerosis Osteomyelitis - Avascular necrosis - Paget's disease of bone - Algoneurodystrophy - Osteolysis - Infantile cortical hyperostosis Chondropathies Juvenile osteochondrosis Legg-Calvé-Perthes syndrome, Osgood-Schlatter disease, Köhler disease, Sever's disease - Osteochondritis - Tietze's syndrome - Relapsing polychondritis See also congenital v d e Inborn errors of purine-pyrimidine metabolism E79, 277.2 Purine metabolism Anabolism Adenylosuccinate lyase deficiency Nucleotide salvage Lesch-Nyhan syndrome/Hyperuricemia - Adenine phosphoribosyltransferase deficiency Catabolism Adenosine deaminase deficiency - Purine nucleoside phosphorylase deficiency - Xanthinuria - Gout Pyrimidine metabolism Anabolism Orotic aciduria Catabolism Dihydropyrimidine dehydrogenase deficiency see also nucleotide metabolism, intermediates Retrieved from http://en..org/wiki/Gout Categories: Metabolic disorders | Arthritis | RheumatologyHidden categories: All articles with statements | Articles with statements since May 2008 | Articles with statements since March 2007 | Articles with statements since September 2007 Views Article Discussion this page History Personal tools Log in / create account Navigation Main page Contents Featured content Current events Random article Search Go Search Interaction Community portal Recent changes Contact Donate to Help Toolbox What links here Related changes Upload file Special pages Printable version Permanent link Cite this page Languages العربية БългарÑ?ки ÄŒesky Dansk Deutsch Ελληνικά Español Esperanto Ù?ارسی Français í•œêµì–´ Ido Bahasa Indonesia Italiano עברית Lëtzebuergesch Bahasa Melayu Nederlands 日本語 ‪Norsk bokmÃ¥l‬ Polski Português РуÑ?Ñ?кий Simple English SlovenÄ?ina СрпÑ?ки / Srpski Suomi Svenska తెలà±?à°—à±? ไทย Türkçe УкраїнÑ?ька ä¸æ–‡ This page was last modified on 16 August 2008, at 12:4
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