To Reverse Metabolic Syndrome, Take Gout by the Horns

Patients presenting with hyperuricemia or gout should be evaluated for metabolic syndrome, and any recommendations regarding dietary changes and medical treatment for gout should take into consideration the potential benefits of urate reduction, according to Dr. N. Lawrence Edwards.

Both hyperuricemia and gout are independent risk factors for metabolic syndrome and its individual components, said Dr. Edwards, professor of medicine at the University of Florida, Gainesville.

In a 2007 study looking at the prevalence of metabolic syndrome in nearly 8,700 patients with hyperuricemia from the NHANES (National Health and Nutrition Examination Survey) III database, the prevalence of metabolic syndrome increased in tandem with increasing levels of serum urate, and the increase persisted across subgroups stratified by age, sex, alcohol intake, body mass index, hypertension, and diabetes (Am. J. Med. 2007;120:442-7).

The investigators found that the prevalence of metabolic syndrome (defined using both original and revised National Cholesterol Education Program Adult Treatment Panel III criteria) was 19% in those with uric acid levels less than 6 mg/dL, 36% in those with 8.0-8.9 mg/dL, 62% for 9.0-9.9 mg/dL, and 71% for levels of 10 mg/dL or greater.

Physicians should recognize that metabolic syndrome occurs frequently in patients with hyperuricemia, and should be treated to prevent serious complications, they concluded.

In a related study, the prevalence of metabolic syndrome in patients with doctor-diagnosed gout from the same NHANES population was high (nearly 63%), compared with 25% in those without a gout diagnosis. The prevalence was even higher (83%) among those with a more stringently defined gout diagnosis (specifically, those on urate-lowering therapy), Dr. Edwards noted (Arthritis Rheum. 2007;57:109-15).

As with hyperuricemia, the investigators concluded that the prevalence of metabolic syndrome is high in individuals with gout, and that, given the serious complications that can be associated with metabolic syndrome, the condition should be recognized and taken into account when clinicians plan the long-term treatment of patients with gout.

The findings of these two studies support a pathogenic overlap between metabolic syndrome and gout, and underscore the importance of evaluating gout patients for the syndrome, Dr. Edwards said.

“You see a lot of patients coming in, and they haven't had fasting glucoses performed, blood pressures may be a little out of control, and weight is certainly out of control,” he noted.

“We need to look at these patients much more seriously than if they only have gout; they need a full-court press on all of their metabolic problems and not just their uric acid.”

Dietary recommendations that consist of the standard advice to avoid foods high in purines are not sufficient. Patients will often cut out meat and shellfish, but replace those with foods high in carbohydrates and fat, which can increase insulin resistance. Therefore, it is important to advise patients to reduce intake of high-purine foods, but also to avoid high-fat foods and the wrong kinds of carbohydrates.

About 40% of their diet should be complex carbohydrates, no more than 30% should be proteins, and no more than 30% should be mono- or polyunsaturated fats, he said.

As for medical treatment considerations, it is important to keep in mind the mechanisms of hyperuricemia as it relates to insulin resistance, he added.

In patients who are hypertriglyceridemic, for example, niacin is a commonly used drug.

However, niacin can elevate uric acid levels “by quite a margin” of 1.5-2.5 mg/dL. Conversely, fenofibrate can also be used to treat hypertriglyceridemia, and can lower the levels by a similar margin.

“So just making that switch might make a pretty substantial difference,” Dr. Edwards said.

In patients who are being treated for hypertension, keep in mind that hydrochlorothiazide is associated with elevated uric acid levels, and consider switching to the angiotensin receptor blocker losartan in those in whom hydrochlorathiazide is used solely for hypertension control and not for fluid control, as losartan has uric acid lowering effects, he said.

Dr. Edwards had no disclosures relevant to his presentation.

Patients presenting with hyperuricemia or gout should be evaluated for metabolic syndrome, and any recommendations regarding dietary changes and medical treatment for gout should take into consideration the potential benefits of urate reduction, according to Dr. N. Lawrence Edwards.

Both hyperuricemia and gout are independent risk factors for metabolic syndrome and its individual components, said Dr. Edwards, professor of medicine at the University of Florida, Gainesville.

In a 2007 study looking at the prevalence of metabolic syndrome in nearly 8,700 patients with hyperuricemia from the NHANES (National Health and Nutrition Examination Survey) III database, the prevalence of metabolic syndrome increased in tandem with increasing levels of serum urate, and the increase persisted across subgroups stratified by age, sex, alcohol intake, body mass index, hypertension, and diabetes (Am. J. Med. 2007;120:442-7).

The investigators found that the prevalence of metabolic syndrome (defined using both original and revised National Cholesterol Education Program Adult Treatment Panel III criteria) was 19% in those with uric acid levels less than 6 mg/dL, 36% in those with 8.0-8.9 mg/dL, 62% for 9.0-9.9 mg/dL, and 71% for levels of 10 mg/dL or greater.

Physicians should recognize that metabolic syndrome occurs frequently in patients with hyperuricemia, and should be treated to prevent serious complications, they concluded.

In a related study, the prevalence of metabolic syndrome in patients with doctor-diagnosed gout from the same NHANES population was high (nearly 63%), compared with 25% in those without a gout diagnosis. The prevalence was even higher (83%) among those with a more stringently defined gout diagnosis (specifically, those on urate-lowering therapy), Dr. Edwards noted (Arthritis Rheum. 2007;57:109-15).

As with hyperuricemia, the investigators concluded that the prevalence of metabolic syndrome is high in individuals with gout, and that, given the serious complications that can be associated with metabolic syndrome, the condition should be recognized and taken into account when clinicians plan the long-term treatment of patients with gout.

The findings of these two studies support a pathogenic overlap between metabolic syndrome and gout, and underscore the importance of evaluating gout patients for the syndrome, Dr. Edwards said.

“You see a lot of patients coming in, and they haven't had fasting glucoses performed, blood pressures may be a little out of control, and weight is certainly out of control,” he noted.

“We need to look at these patients much more seriously than if they only have gout; they need a full-court press on all of their metabolic problems and not just their uric acid.”

Dietary recommendations that consist of the standard advice to avoid foods high in purines are not sufficient. Patients will often cut out meat and shellfish, but replace those with foods high in carbohydrates and fat, which can increase insulin resistance. Therefore, it is important to advise patients to reduce intake of high-purine foods, but also to avoid high-fat foods and the wrong kinds of carbohydrates.

About 40% of their diet should be complex carbohydrates, no more than 30% should be proteins, and no more than 30% should be mono- or polyunsaturated fats, he said.

As for medical treatment considerations, it is important to keep in mind the mechanisms of hyperuricemia as it relates to insulin resistance, he added.

In patients who are hypertriglyceridemic, for example, niacin is a commonly used drug.

However, niacin can elevate uric acid levels “by quite a margin” of 1.5-2.5 mg/dL. Conversely, fenofibrate can also be used to treat hypertriglyceridemia, and can lower the levels by a similar margin.

“So just making that switch might make a pretty substantial difference,” Dr. Edwards said.

In patients who are being treated for hypertension, keep in mind that hydrochlorothiazide is associated with elevated uric acid levels, and consider switching to the angiotensin receptor blocker losartan in those in whom hydrochlorathiazide is used solely for hypertension control and not for fluid control, as losartan has uric acid lowering effects, he said.

Dr. Edwards had no disclosures relevant to his presentation.

Patients presenting with hyperuricemia or gout should be evaluated for metabolic syndrome, and any recommendations regarding dietary changes and medical treatment for gout should take into consideration the potential benefits of urate reduction, according to Dr. N. Lawrence Edwards.

Both hyperuricemia and gout are independent risk factors for metabolic syndrome and its individual components, said Dr. Edwards, professor of medicine at the University of Florida, Gainesville.

In a 2007 study looking at the prevalence of metabolic syndrome in nearly 8,700 patients with hyperuricemia from the NHANES (National Health and Nutrition Examination Survey) III database, the prevalence of metabolic syndrome increased in tandem with increasing levels of serum urate, and the increase persisted across subgroups stratified by age, sex, alcohol intake, body mass index, hypertension, and diabetes (Am. J. Med. 2007;120:442-7).

The investigators found that the prevalence of metabolic syndrome (defined using both original and revised National Cholesterol Education Program Adult Treatment Panel III criteria) was 19% in those with uric acid levels less than 6 mg/dL, 36% in those with 8.0-8.9 mg/dL, 62% for 9.0-9.9 mg/dL, and 71% for levels of 10 mg/dL or greater.

Physicians should recognize that metabolic syndrome occurs frequently in patients with hyperuricemia, and should be treated to prevent serious complications, they concluded.

In a related study, the prevalence of metabolic syndrome in patients with doctor-diagnosed gout from the same NHANES population was high (nearly 63%), compared with 25% in those without a gout diagnosis. The prevalence was even higher (83%) among those with a more stringently defined gout diagnosis (specifically, those on urate-lowering therapy), Dr. Edwards noted (Arthritis Rheum. 2007;57:109-15).

As with hyperuricemia, the investigators concluded that the prevalence of metabolic syndrome is high in individuals with gout, and that, given the serious complications that can be associated with metabolic syndrome, the condition should be recognized and taken into account when clinicians plan the long-term treatment of patients with gout.

The findings of these two studies support a pathogenic overlap between metabolic syndrome and gout, and underscore the importance of evaluating gout patients for the syndrome, Dr. Edwards said.

“You see a lot of patients coming in, and they haven't had fasting glucoses performed, blood pressures may be a little out of control, and weight is certainly out of control,” he noted.

“We need to look at these patients much more seriously than if they only have gout; they need a full-court press on all of their metabolic problems and not just their uric acid.”

Dietary recommendations that consist of the standard advice to avoid foods high in purines are not sufficient. Patients will often cut out meat and shellfish, but replace those with foods high in carbohydrates and fat, which can increase insulin resistance. Therefore, it is important to advise patients to reduce intake of high-purine foods, but also to avoid high-fat foods and the wrong kinds of carbohydrates.

About 40% of their diet should be complex carbohydrates, no more than 30% should be proteins, and no more than 30% should be mono- or polyunsaturated fats, he said.

As for medical treatment considerations, it is important to keep in mind the mechanisms of hyperuricemia as it relates to insulin resistance, he added.

In patients who are hypertriglyceridemic, for example, niacin is a commonly used drug.

However, niacin can elevate uric acid levels “by quite a margin” of 1.5-2.5 mg/dL. Conversely, fenofibrate can also be used to treat hypertriglyceridemia, and can lower the levels by a similar margin.

“So just making that switch might make a pretty substantial difference,” Dr. Edwards said.

In patients who are being treated for hypertension, keep in mind that hydrochlorothiazide is associated with elevated uric acid levels, and consider switching to the angiotensin receptor blocker losartan in those in whom hydrochlorathiazide is used solely for hypertension control and not for fluid control, as losartan has uric acid lowering effects, he said.

Dr. Edwards had no disclosures relevant to his presentation.