It’s nothing new that patients are searching the internet for answers to their health questions. This has been a phenomenon for as long as I have been in the world of pharmacy. What is new, is the quality of information available via the internet for anyone with an interest to access. There was a time when accessing niche information on particular protocols was difficult. One only found out about alternative treatments through a friend or a naturopath if funds permitted. Now, with content creation becoming a major source of business development for health care practitioners, it’s not hard to find high quality information that pertains to your condition online. Unfortunately, the majority of health care workers, myself included, find it hard to keep up with the rate of information, and often lag behind our patients, playing catch up when they see us at the pharmacy counter.
What I wish to present to you is the case of a man with an acute case of gout precipitated, I believe , by a 72 hour fast.
The scenario:
A middle aged man came into the pharmacy to fill his usual medications; rosuvastatin, ramipril and amlodipine, and asked if there was anything over the counter he could use for an acute gout attack. Upon further consult, the man told me that he knows poor diet is a factor for gout and that he’d been trying to clean up his act. In fact, he had been fasting for the past three days to try and kick start his transformation.
How I handled it in the pharmacy:
Without time to go and look up the connection between fasting and acute gout I suggested to the man that the timing of this attack was not a coincidence and I felt that the fast had brought on this attack. I suggested that instead of doing a 72 hour fast, he could switch to intermittent fasting which should have lower consequences. My theory was that the fasting had caused a breakdown of amino acids which would result in a higher level of uric acid in the blood, hence an attack of acute gout.
A more likely scenario.
Upon review, gout can indeed be precipitated by a fast, but the mechanism is actually related to the kidneys. It’s not a greater production of uric acid that is to blame, but rather a reduction in excretion. Fasting causes both a reduction in glomerular filtration rate, and a competition for excretion between uric acid and ketone bodies, produced when the body switches into ketosis to fuel itself in the absence of glucose. Indeed, in an article from 1969, the author reports that a history of gout has historically been considered a contraindication to fasting in obese patients. (source: https://pmj.bmj.com/content/postgradmedj/45/522/251.full.pdf).
The take-away
As the most accessible component of the healthcare team, pharmacists need to understand the complex connection between diet and different disease states. At the very least we need to be able to counsel patients on the effect of diet on the medications they take and the diseases they live with. In the case of gout, this man had a sore toe to deal with. In other patients there are more severe consequences like over medication with anti-hypertensives and a risk of falling. Ideally, pharmacists have an opportunity to recognize the power of diet in managing disease and helping to get patients off of unnecessary medications, spending less time at the pharmacy counter and more time living their lives.