"Dirty Dish" Hypothesis May Hold Water for Gout

Management of hyperuricemia in gout with a 2-stage approach based on the "dirty dish" hypothesis could be effective. The first stage would consist of a period of crystal depletion, with the target serum urate level far below the threshold for saturation of urate (lower than 6 mg/dL) to completely dissolve formed crystals; the second stage would involve a preventive treatment period in which the target is a serum urate level just below that threshold for saturation of urate to avoid new crystal formation.

Perez-Ruiz and colleagues conducted a prospective cohort study of 211 patients. Serum urate levels were measured at baseline and at the time of urate-lowering therapy withdrawal. Recurrence and several variables were analyzed.

Serum urate levels during urate-lowering treatment and after its withdrawal were independently related to gout recurrence; they were 8.8 ± 1.3 mg/dL, 4.9 ± 0.9 mg/dL, and 8.5 ± 1.4 mg/dL at baseline, during urate-lowering therapy, and after withdrawal of urate-lowering therapy, respectively. There was no crystal-proven recurrence of gout in the patients who had average serum urate levels lower than 7 mg/dL after urate-lowering therapy withdrawal.

The authors made an analogy with the cleaning of a dirty dish: more is required to get it clean than to keep it clean.