Dr Thomas Stuttaford answers questions on gout

Asking : I've had gout attacks one or twice a year since 2000. However, in the first nine months of 2006, I had FIVE separate attacks. During a desperate search through the internet, I saw a post attributing the acidity of diet sodas - of which I was a prodigious consumer - as a major contributing factor to gout. Between that and reading the book Ultrametabolism I decided to quit my one to two litre a day diet soda habit cold turkey and I haven't had a gout attack since (18 months now)! Question: correlated, or causal?

Answering : Gout is a metabolic disorder that has a strong hereditary factor. Many different factors will increase the liability of having an acute attack of gout in those people who have this tendency. If they avoid the triggers they may remain attack free. Diet isn’t the only factor. Stress, infections, dehydration, diseases such as the leukaemias, lymphomas and even some forms of benign anaemia will trigger an attack. It is known that a high-carbohydrate diet makes gout attacks more likely in some patients but less likely in others. In my own case a sure way of inducing an attack is to go without breakfast, lunch and tea and to call in at a party on the way home and have two or three drinks. Aspirin in small quantities would then make an attack of gout even more certain.

Asking : I’m writing on behalf of my husband, A. He had a heart attack in June 2006, aged 56, and since then has suffered increasing episodes of gout, having previously only had it once or twice in his life. It goes from knee to ankle, to other knee to other ankle, and round again in an almost unbroken cycle. The latest episode was in both feet and required a home visit from his doctor as he couldn’t walk at any pace. He is waiting for a four-week break so that he can take the preventative medication. Is it possible that this is related to the medication for his heart attack? He takes: Allupurinol , dispersible Aspirin, Bisoprolol Fumarate, Furosemide, Naproxen, Olmesartan Medoxomil, Quinine Sulphate and Indometacin for the gout. A. has mentioned this to the heart Consultant who has dismissed it. However, it seems so coincidental, I’d like to find out more.

Answering : Your husband is already taking the standard preventative medication which is allupurinol . The dose is very variable and it may well be that the amount your husband is taking is inadequate. You are quite right, when someone first starts taking allupurinol the gout for a short while may seem to get worse. Similarly if the dose is inadequate it may not prevent the gout. Most patients when first starting allopurinol are given other treatment, either an NSAIDs , such as Celebrex or Arcoxia, or colchicines to cover this period. Many drugs will cause increase in symptoms of gout. This includes several types of diuretic including the furosemide that you take. Small doses of aspirin, such as the dispersable aspirin taken by patients who have suffered a heart attack, also makes gout worse. Obviously your husband needs to avoid the standard purine - rich foods such as kidneys, anchovies, game, sweetbreads etc. but it is not usually recommended that they should aim to have a totally purine-free diet.

Your husband should discuss with his own doctor his medication. Sometimes it is possible to alter the treatment by choosing alternative gout drugs , or to increase the dose of allupurinol .

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