Gout Treatment Guide Malaysia: Uric Acid, Diet & Medication

Gout is a form of inflammatory arthritis caused by hyperuricaemia — elevated levels of uric acid in the blood. When uric acid levels are persistently high, uric acid crystallises into needle-shaped monosodium urate crystals that deposit in joints and surrounding tissues. When these crystals provoke an immune response, the result is a gout attack: sudden, severe joint pain, swelling, redness, and warmth that can be debilitating. Uric acid is the end product of purine metabolism. Purines are compounds found naturally in many foods and also produced by the body during normal cell turnover. The kidneys normally excrete uric acid in urine, but when production exceeds excretion capacity — due to high-purine diet, reduced kidney excretion, or genetic factors — uric acid accumulates. Prevalence in Malaysia: gout affects approximately 2 to 6% of the Malaysian adult population, with much higher rates in men over 40 and among individuals of Chinese and Malay ethnicity. The condition is strongly associated with metabolic syndrome — the combination of obesity, hypertension, diabetes, and high triglycerides that is epidemic in Malaysia. Normal uric acid levels: - Men: below 420 umol/L (7 mg/dL) - Women: below 360 umol/L (6 mg/dL) Gout typically develops after years of elevated uric acid levels. Not all people with high uric acid develop gout — individual susceptibility varies.

Diet plays a significant role in gout — particularly in triggering acute attacks, even in patients on uric acid-lowering medication. Understanding which Malaysian foods are high in purines allows targeted dietary modification. Very high-purine foods to avoid or minimise: - Organ meats: hati (liver), otak (brain), buah pinggang (kidney) — extremely high in purines - Seafood: udang (prawns), ketam (crab), kerang (shellfish/cockles), ikan bilis (anchovies), sardines, and mackerel are high in purines. Other fish are lower risk. - Red meat: beef, lamb, and pork in large quantities - Alcohol: all alcohol raises uric acid, but beer is the worst (contains guanosine, a purine). Alcohol also dehydrates, concentrating uric acid. - Sugary drinks: fructose in soft drinks (especially those sweetened with high-fructose corn syrup) significantly increases uric acid production. This is an under-recognised trigger. - Gravy and meat-based broths: concentrated purines from meat cooking are a significant trigger Moderate consumption (limit but need not eliminate): - Tahu (tofu) and tempeh: moderate purines but studies show these plant purines are less likely to trigger attacks than animal purines - Spinach, mushrooms, and asparagus: contain purines but have lower gout risk than meat Beneficial foods that reduce uric acid: - Cherries and cherry juice: shown in studies to reduce gout attack frequency - Dairy products: low-fat dairy actually reduces uric acid - Vitamin C: supplementation of 500mg daily reduces uric acid - Plenty of water: staying well-hydrated promotes uric acid excretion through the kidneys. Aim for 2 to 3 litres per day.

If you have had two or more gout attacks, have tophi (uric acid crystal deposits under the skin), or have gout with kidney disease or kidney stones, long-term uric acid-lowering therapy is recommended. Allopurinol: the cornerstone of long-term gout management. It works by blocking xanthine oxidase, the enzyme that produces uric acid. The target is to reduce uric acid below 360 umol/L (6 mg/dL), and below 300 umol/L for patients with tophi. Key points about allopurinol: - Start at a low dose (50 to 100mg daily) and increase gradually every 2 to 4 weeks to minimise the risk of triggering an attack during initiation - Always take colchicine or an NSAID prophylactically for the first 3 to 6 months of allopurinol therapy to prevent attack flares during dose titration - Requires dose reduction in kidney disease — dose must be adjusted based on eGFR - A small risk of serious skin reactions (Stevens-Johnson Syndrome) exists — stop immediately if skin rash develops - HLA-B*5801 genetic testing is recommended before starting allopurinol in patients of Han Chinese, Thai, or Korean descent as this allele increases the risk of severe skin reactions Febuxostat: an alternative to allopurinol for patients who cannot tolerate allopurinol. Ongoing monitoring at Klinik Muhibbah: uric acid levels every 3 to 6 months until target achieved, then annually. Renal function monitoring is important as many gout patients also have CKD. At Klinik Muhibbah, uric acid testing and gout management are available. Contact us at +60 7-251 1162. Hours: Mon–Thu & Sat 9AM–9PM, Fri 9AM–3PM, Sun 9AM–1PM.