Vitamin C Supplements Shown to Reduce Risk of Gout

James Meschino, DC, MS, ROHP

Gout is a form of arthritis that occurs when crystals of uric acid accumulate in a joint, leading to the sudden development of pain and inflammation. Gout occurs more commonly in men (especially in their 40’s and 50’s), but also occurs in postmenopausal women. In 2009, an important study by Choi et al showed that among 47,000 men, followed for 29 years, Vitamin C supplementation between 1000-2000 mg per day was associated with up to a 45% reduction in gout episodes.

People with gout have high blood levels of uric acid. Individuals with gout either overproduce uric acid or are less efficient than other people at eliminating it. The affected joint(s) is usually red, swollen, and very tender to the touch. A low-grade fever may also be present. The joint of the big toe is the most common site to accumulate uric acid crystals, although other joints may be affected. Under normal conditions, uric acid is dissolved in the blood and passes through the kidney and into the urine for elimination. The amount of cumulated uric acid in men is about 1,200mg and in women, about 600mg. These values are increased several-fold in individuals with gout.

This abnormally high level of uric acid in the blood, called hyperuricemia, may result when a person eats too many high-purine foods such as liver, dried beans and peas, anchovies, and gravies. Several enzyme systems regulate the metabolism of purines, and a partial deficiency of one or more enzymes may be responsible for the increase in uric acid in these individuals.

Dietary and Lifestyle Factors
Restricting purine intake can reduce the risk of an attack in people susceptible to gout. Foods high in purines include anchovies, bouillon, brains, broth, consommé, dried legumes, goose, gravy, heart, herring, kidneys, liver, mackerel, meat extracts, mincemeat, mussels, partridge,  fish roe, sardines, scallops, shrimp, sweetbreads, baker’s yeast, brewer’s yeast, and yeast extracts (e.g., Marmite, Vegemite).

Avoiding alcohol, particularly beer, or limiting alcohol intake to one drink per day or less may reduce the number of attacks of gout. Studies have found an increased risk of gout with alcohol consumption. Refined sugars, including sucrose (white table sugar) and fructose (the sugar found in fruit juice), should also be restricted, because they have been reported to raise uric acid levels.

People who are overweight or have high blood pressure are at greater risk of developing gout. However, weight loss should not be rapid because severe restriction of calories can increase uric acid levels temporarily, which may aggravate the condition.

According to a 1950 study of 12 people with gout, eating one-half pound of cherries or drinking an equivalent amount of cherry juice prevented attacks of gout. Black, sweet yellow, and red sour cherries were all effective. Since that study, there have been many anecdotal reports of cherry juice as an effective treatment for the pain and inflammation of gout. The active ingredient in cherry juice remains unknown.

Supplement Considerations:

1. Vitamin C:Over the years studies have shown that vitamin C supplementation can increase the urinary excretion of uric acid and lower blood levels of uric acid. Most recently (2009) Choi et al, showed that vitamin C intake reduced risk of gout in a dose-dependent fashion and that daily vitamin C supplementation at or above 1000 mg per day were most beneficial in this regard.

– a 1976 human study first showed 4 grams of vitamin C produced increase in urinary excretion of uric acid within a few hours, and 8 grams of vitamin C per day for several days showed reduction in serum uric acid levels.

– in 2005 (Huang, 2005) showed that 500 mg vitamin C, taken twice per day resulted in significantly lower  uric acid blood levels over time

The study by Choi et al (Archives of Internal Medicine, 2009)followed almost 47,000 men for 20 years and revealed that compared to men consuming less than 250 mg per day of vitamin C:

1. Those who ingested 1500 mg vitamin C (primarily from supplementation) per day showed a 45% reduced risk of gout
2. Those who ingested 1000-1500 mg (1499 mg) (primarily from supplementation) showed a 34% reduced risk of gout
3. Those who ingested 500-1,000 mg (999 mg) (primarily from supplementation) showed a 17% reduced risk of gout

Other Supplements of Importance in Gout

2. Chinese Scullcap (Baicalein): The flavonoid Baicalein, found in the herb known as the Chinese Scullcap, is one of few bioactive agents that has been shown to inhibit the enzyme xanthine oxidase, which is responsible for the conversion of hypoxanthine to xanthine, and xanthine to uric acid, in the pathway for degradation of purines in the body.  Thus, baicalein may help to inhibit the buildup of uric acid in the body. The usual doses for therapeutic purposes ranges from 150 to 200 mg per day of Baicalein
3. Quercetin:Experimental evidence demonstrates that the flavonoid known as quercetin inhibits an enzyme (xanthine oxidase – see above) involved in the development of gout. Although human research is lacking, some doctors recommend 150–250 mg of quercetin, three times per day (taken between meals).
4. High Potency Multiple Vitamin and Mineral: Many vitamins and minerals participate in suppressing inflammatory responses in the body, especially when taken in conjunction with essential fatty acids. However, remember that high doses of niacin can aggravate gout.
5. Essential Fatty Acids – (Borage Seed, Flaxseed and Fish Oil): The combination of these sources of essential oils provides the body with the raw materials to make the anti-inflammatory hormones (prostaglandin series-1 and series-3), which are known to reduce joint inflammation in arthritic disorders.

Drugs to Treat or Prevent Gout
The following list is comprised of the drugs that are most commonly used in the treatment of gout.

1. Allopurinol is a xanthine-oxidase inhibitor, widely used in the prevention of attacks of gout, as it blocks the conversion of xanthine to uric acid in purine metabolism
2. Uricosuric drug (Probenecid) – these drugs promote the renal excretion of uric acid in the urine. These are often used to prevent tophi formation. In many cases, people are predisposed to gout because of insufficient renal excretion of uric acid. Overproduction of uric acid is less common and usually a result of another disease where rapid cellular replication occurs (e.g. hemolytic anemias, myeloproliferative and lymphoproliferative diseases, psoriasis)
3. Colchicine – one of the effects of colchicine is that it also inhibits neutrophil motility and activity, leading to a net anti-inflammatory effect.
4. Non Steroidal Anti-inflammatory Drugs –NSAID’s (other than aspirin) – drugs such as indomethacin, naproxen, and sulindac are the drugs of choice during an acute gouty attack (these are all NSAID’s). They have fewer side effects than the once popular colchicine. Note that the use of aspirin and any drugs or supplements containing aspirin (Acetylsalicylic acid) or salicylic acid (e.g. white willow extract) are contra-indicated as salicylic acid and N-acetylsalicylic acid compete with uric acid for excretion in the kidney tubules.

Recall that a Low Purine Diet Restricts:

Summary

In concert with medical management of gout, chiropractors and other health practitioners should consider educating gout-prone patients about dietary and supplementation practices that can help reduce gout incidence and severity of attacks. Most recently the research by Choi supports the use of Vitamin C supplementation of at least 1000 mg per day (up to 2000 mg per day) as a means to significantly reduce risk of gout in men.

Selected References:

1. Huang HY, et al. The effects of vitamin C supplementation on serum concentrations of uric acid: results of a randomized controlled trial. Arthritis Rheum 2005;52:1843- s.
2. Choi HK, et al. Vitamin C intake and risk of gout in men: a prospective study. Achives on Internal Medicine. 2009;169(5):502-507.
3. Pharmacology for the Primary Care Provider 2^nd edition (Editors: Edmunds MW and Mayhew MS). Publisher: Elsevier/Mosby 2004