1. Purine-rich foods intake and
recurrent gout attacks
Ann Rheum Dis 2012;71:1448–1453
Tuesday, 19th Februari 2013
Ferdy Ferdian, dr
Amaylia Oehadian, dr., SpPD-KHOM
2. 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
3. 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
4. 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
5. A high dietary intake of
purine, alcohol intake
Background
increased purine
synthesis, decreased
renal excretion
Increase uric acid in the
blood (hyperuricemia)
Deposition of uric acid
into the joints
GOUT
6. 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
7. 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
8. 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
9. 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
10. Methods
Quantiles
Q1 Q2 Q3 Q4 Q5
Quantile are points taken at regular intervals
from the cumulative distribution function
of a random variable
11. Baseline
Zhang et al. Purine-rich foods
intake and recurrent gout
attacks. Ann Rheum Dis
2012;71:1448–1453
12. Baseline
Zhang et al. Purine-rich foods
intake and recurrent gout
attacks. Ann Rheum Dis
2012;71:1448–1453
13. 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
14. 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
15. Result
Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453
16. Result
2.41
1.77
1.42 1.34
1.32 1.39
1.12
0.99
Zhang et al. Purine-rich foods intake and recurrent gout attacks. Ann Rheum Dis 2012;71:1448–1453
17. 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
18. 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
19. 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
23. Preliminary criteria for the classification of the acute arthritis
of primary gout ACR 1977
01. More than one attack of acute arthritis
02. Maximum inflammation developed within 1 day
03. Monoarthritis attack
04. Redness observed over joints
05. First metatarsophalangeal joint painful or swollen
06. Unilateral first metatarsophalangeal joint attack
07. Unilateral tarsal joint attack
08. Tophus (proven or suspected)
09. Hyperuricemia
10. Asymmetric swelling within a joint on x ray
11. Subcortical cysts without erosions on x ray
12. Monosodium urate monohydrate microcrystals in joint fluid during attack
13. 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 gout
Arthritis Rheum 1977;20:895---900.
