# Lifestyle and Concurrent Medications in Gout — ACR 2020

## Dietary and Lifestyle Modifications

All lifestyle recommendations are **conditional** with low to very low certainty of evidence. While lifestyle modifications alone are unlikely to achieve target serum urate (SU) levels in most patients requiring ULT, they are recommended as adjunctive measures.

### Dietary Recommendations

| Modification | Recommendation | Certainty |
|---|---|---|
| **Limit alcohol intake** | Conditionally recommended (Conditional, Low) | Alcohol, particularly beer and spirits, increases SU and flare risk |
| **Limit purine intake** | Conditionally recommended (Conditional, Low) | High-purine foods include organ meats, red meat, shellfish |
| **Limit high-fructose corn syrup** | Conditionally recommended (Conditional, Very Low) | Fructose metabolism increases urate production |

### Weight Management

For patients who are **overweight or obese**, a structured weight loss program is conditionally recommended (Conditional, Very Low).

- Weight loss is associated with reduction in serum urate levels and gout flare frequency.
- A **structured program** is recommended rather than general dietary advice alone.

### Vitamin C Supplementation

Vitamin C supplementation is **conditionally recommended against** (Conditional, Low).

- Although small studies suggested vitamin C may modestly reduce SU, the effect is clinically insignificant and insufficient to replace pharmacological ULT.

## Concurrent Medication Management

Several commonly used medications affect serum urate levels. The ACR 2020 guideline provides conditional recommendations on managing these medications in gout patients.

### Hydrochlorothiazide (HCTZ)

For gout patients taking hydrochlorothiazide as an antihypertensive, **switching to an alternative antihypertensive agent** is conditionally recommended when feasible (Conditional, Very Low).

- Thiazide diuretics increase serum urate by reducing renal urate excretion.
- The decision to switch should consider the patient's overall cardiovascular risk and blood pressure control.

### Losartan

**Losartan is conditionally recommended as the preferred antihypertensive** for gout patients who require an angiotensin receptor blocker (Conditional, Very Low).

- Losartan has a mild uricosuric effect that lowers serum urate, unlike other ARBs.
- This property makes it a preferred choice when an antihypertensive is needed in gout patients.

### Low-Dose Aspirin

For gout patients taking low-dose aspirin for appropriate cardiovascular indications, **continuing aspirin** is conditionally recommended (Conditional, Very Low).

- Low-dose aspirin (<= 325 mg/day) modestly increases serum urate levels.
- However, the cardiovascular benefit of aspirin outweighs the small effect on urate.
- **Do not stop low-dose aspirin** solely because of gout.

### Fenofibrate

**Adding or switching to fenofibrate** specifically for urate-lowering purposes is **conditionally recommended against** (Conditional, Very Low).

- Fenofibrate has a mild uricosuric effect but is not sufficiently effective as a gout management strategy.
- If fenofibrate is already indicated for hypertriglyceridemia, it may be continued, but it should not be initiated solely for urate lowering.

## Concurrent Medication Decision Algorithm

```
Gout patient on chronic medications review
  --> On hydrochlorothiazide?
      --> Is switching to an alternative antihypertensive feasible?
          --> YES --> Switch to alternative (consider losartan if ARB appropriate)
          --> NO --> Continue HCTZ, optimize ULT to achieve SU < 6 mg/dL
  --> Needs antihypertensive therapy?
      --> Prefer losartan among ARBs (mild uricosuric effect)
  --> On low-dose aspirin for cardiovascular indication?
      --> Continue aspirin; do NOT stop for gout
  --> On fenofibrate for hypertriglyceridemia?
      --> Continue if indicated for lipid management
      --> Do NOT initiate solely for urate lowering
```

## Delivery of Care

An **augmented delivery-of-care protocol** incorporating nonphysician providers (e.g., nurse practitioners, pharmacists) for ULT management with patient education is conditionally recommended (Conditional, Moderate).

- This includes protocol-based dose titration guided by serial SU measurements.
- Shared decision-making and patient education about the chronic nature of gout and the importance of adherence to ULT are emphasized.
- Enhanced patient engagement and education improve adherence to treat-to-target strategies.

## Limitations

- All dietary and lifestyle recommendations are based on low to very low certainty evidence. Dietary modifications alone are unlikely to achieve SU < 6 mg/dL in most patients with gout.
- The recommendation to switch hydrochlorothiazide is based on very low certainty evidence and must be balanced against the patient's blood pressure management needs.
- The uricosuric effect of losartan is modest (~0.5-1 mg/dL SU reduction) and cannot substitute for dedicated ULT.
- Concurrent medication adjustments should always be coordinated with the prescribing clinician managing the underlying condition (e.g., hypertension, cardiovascular disease).
