The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by their responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.

Letter to the editor

Editor, – In his excellent article 'Management of acute gout' (Aust Prescr 2004;27:10-3) Dr McGill mentioned that 'the acute attack is also an opportunity to assess and manage associated disorders such as obesity, excessive alcohol consumption, hypertension, hyperlipidaemia and renal insufficiency'. He went on to say that 'controlling these problems may prove to be of greater long-term benefit to the patient than controlling their hyperuricaemia', but he does not mention what part a diet low in purines plays, if any, in the long-term management of gout.

Charles Dickens' Mr Pickwick suffered from gout, which was portrayed as being related to his alcohol intake, and this remains the perception of many of our patients.

John A. Comerford
General practitioner
Newstead, Qld

Author's comments

Dr Neil W. McGill, the author of the article, comments:

Although patients may attribute acute attacks to dietary indiscretions, I am not aware of any study that has shown that a particular dietary event increases the likelihood of a gouty attack. With respect to the influence of diet on the chronic management of gout, hyperuricaemia is clearly associated with alcohol intake and obesity (3.4% of people below the 20th percentile and 11.4% of people above the 80th percentile for body weight are hyperuricaemic).

The effect of purines in the diet is complex and poorly understood. A prospective study of 47 150 men showed an increased risk of gout in association with the intake of meat and seafood, and a reduced risk with low-fat dairy foods. Total protein, animal protein and purine-rich vegetable intake were not associated with the risk of gout.1 It would therefore appear sensible to recommend correction of obesity, a low alcohol intake, avoidance of high intakes of meat and seafood, and plenty of low-fat dairy products. However, it should be remembered that dietary intervention usually reduces the uric acid by a maximum of 15%, is often difficult to maintain and has never been prospectively shown to reduce the incidence of gout.

For patients with proven recurrent gout, especially those with tophi, erosions, persistent symptoms between attacks and renal impairment, encouraging lifelong compliance with hypouricaemic drug therapy is the most effective means of maintaining a healthy uric acid concentration and preventing disease progression.

References

  1. Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G. Purine-rich foods, dairy and protein intake, and the risk of gout in men. N Engl J Med 2004;350:1093-103.