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Gout Dugout.Issue #072 gout help from fish | Xmas tips| lesinurad almost there
December 21, 2015

Hello and Welcome to the Winter (December) 2015, edition of the Gout Dugout newsletter. The Gout Dugout is the 10 minutes' read from that gives you useful ideas that may help with your gout. Copy and print if you prefer to read a version on paper. If you are extra busy now because it's Christmas time, you could bookmark it for later. Pass it along to friends.

Well here we are at Christmas so let’s have some good news. It’s about fish for gout.


It’s often said that gout sufferers should eat fatty fish, but also be careful of their purines. And reports this across a number of pages.

Now new recently published research (1) shows that there is a lower risk of a gout attack (flare) – among gout sufferers - if they eat fatty fish.But not that you’d never get one by simply eating fish. That would be larger than life.

In an online study, after adjusting for other gout flare triggers, the risk of a flare if fish was eaten 48 hours before an attack fell 22-23%.

The fish eaten included: anchovies, mackerel, salmon, sardines, cod, trout, herring, tuna, squid. All except squid are on our lists of the best fish for gout.

But the study did not have information on fish that are among our best fish (and fish products) for gout – real caviar, herring roe and oysters.

The other interesting finding which also echoes what is said on, is that the omega -3: omega -6 ratio in foods they tested was associated with a lower/higher risk of a gout attack. That is to say, there is more risk in foods they tested that have more omega -6 to omega -3. And less with more omega -3.This tallies with our omega 3, omega 6 findings too. High omega -3 fish, which are also high purine, might not be much of a problem.’s list of the best fish for gout is here.

The ranking is based on the least amount of created uric acid compared to the amount of omega -3 (and on another list, EPA) per 100 grams. The higher its purines and the lower the uric acid created, the higher a fish ranks. The winners were (without considering cost) real caviar, herring and mackerel.

Unlike fish, fish oil had no effect on gout flares in this study. Of course I would have liked fish oil to have shown results too, but am not bothered that it didn’t because the researchers admitted. “Study limitations included relatively few participants' reporting any supplemental omega-3 fatty acid use, possibly resulting in too few discordant pairs for precise analysis “

i.e. not enough people took fish oil, omega -3, or cod liver oil supplements to give the researchers enough to work on. Nor were there sufficient fish oil respondents for an analysis of the quality of the fish oil taken, which is very important.

Mackerel - one of the best fish for gout on our best fish tables


Whilst I have nothing new to say about dietary tips for Christmas 2015, there are new readers some of whom will want to read about do’s, don’ts, and be carefuls. If you're looking for Christmas tips and techniques, have a look at:

December 2008 Find out why you might want to be careful of mince pies and cranberry sauce.

December 2010 Say boo to a goose.

December 2011 Includes a write up about a Christmas low purine meal. And it has a list of foods to avoid at Christmas. Keep up the water drinking if you are used to it !

Find the back issue at this page FInd back issues here


The new gout drug Lesinurad, written about in this newsletter a number of times over the yearsback to the days when it was called RDEA 594, has almost made it in the US.If approved, it will be the first ever URAT1 inhibitor drug in gout treatment. In October an FDA advisory committee voted 10-4 in favour.

That score was not as good as Febuxostat in 2008 which was 12 – 0 in favour; nor Krystexxa in 2009 which was 14-1. They both made it past the approval finishing line. However, the FDA usually follows its advisory committee’s vote which was more than 2-1 in favour. They decide by 29 December this year.

The European Medicines Agency has just issued a positive opinion. Which will be reviewed by the European Commission.

How well did it do? In its two phase three trials with allopurinol just over half trialists taking it with allopurinol reached the 6.0 mg/dLtarget. Trialists were difficult gout patients, not easy ones. So the results, although not brilliant were quite good.

In a third phase three trial with febuxostat 80 mg (which alone usually reduces uric acid better than allopurinol), at 400 mg, tophi gout patients achieved statistical significance with uric acid reduction. But 400 mg will not be prescribed, because of the side effects at that amount.

Curiously Lesinurad at 200 mg daily in month 6 lesinurad and febuxostat did not achieve a statistically significant number for uric acid reduction, but in months 1-5, 8,10 and 12 they did. Again, fairly solid results. Good enough to help more difficult gout patients at tolerable risks so I think it will be approved.

How does it work? Lesinurad inhibits the kidney’s URAT1 transporter which sends uric acid back to the blood. With less sent back to the blood, more is excreted, and its uric acid level falls.

It will be used together with xanthine oxidase inhibitor drugs allopurinol or febuxostat (probably more with allopurinol because it is cheaper and more widely available). A xanthine oxidase inhibitor inhibits uric acid production so you can see this one provides an extra whammy against uric acid. A double dose like this may become the standard treatment for gout, especially for those with higher uric acid, as long as the gout patient is healthy enough to take it.

However, four members of the panel not vote for it. At 400 mg daily there were adverse reactions such as nasopharyngitis, (the common cold) arthralgia (joint pain) and respiratory tract infections. Plus cardiovcascular events and kidney related side effects.

If approved there will be a maximum dose of 200 mg daily. There were side effects at 200 mg, but not as serious as 400 mg.

Its owners, Astra Zeneca PLC, are developing another uric acid re-absorption inhibitor drug called at present RDEA 3170. They must think it is potentially better than Lesinurad otherwise they would not go through the pains-taking efforts required and the expense.

You can find references to Lesinurad by typing Lesinurad, or to find earlier references RDEA 594, in the home page search box.

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The company developing REV-002 (Bucillamine) for gout attack treatment announced positive results for its phase 2(a) trial. About half the trialists benefited from a greater than 50% reduction in a joint pain score after 72 hours (3 days). About the same per cent as those taking Colchicine. A phase 2(b) trial will follow. If it makes it, and is priced below colchicine, it could have quite a good future.

There’s also a bit of news from the company developing pegsiticase, the gout drug under development that I think is the most interesting of all of them. In a recent presentation to an audience of nano medicine specialists its Chief Scientific Officer announced it had normalized uric acid in uricase deficient mice. Humans are uricase deficient too, part of our problem with uric acid. And it prevented the antibody response in mice that is a significant problem for drugs of its type in humans.

Phase 2 studies for pegsiticase begin in 2016. Stay alert for developments of this one.


This issue marks the end of the Gout Dugout’s eighth year. Next year the publishing frequency is the same . Look out for it in your inbox towards the end of March, June, September and December.


Use's search box, located towards the bottom of the Home Page, to find site references to any word you enter into it. It is a good way to find out where and what the site has to say about any gout topic. For example, want to know more about Rasburicase? Type that in the site search box. There are currently nearly 250 pages, including all the back issues of this newsletter. It works. Use it!

Thanks for reading.An epic Christmas to all readers, and here’s wishing you a gout free 2016 !

John Mepham BA (Econ)
Makati City,

(1) Zhang M, Zhang Y, Terkeltaub R, Chen C, Neogi T. Do Omega-3 Fatty Acids Reduce Risk of Recurrent Gout Attacks? [abstract]. Arthritis Rheumatology. 2015; 67 (suppl 10).

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