Purine-rich foods: an innocent bystander of gout attacks?

The natural history of gout typically consists of three periods in a continuum: asymptomatic hyperuricaemia, episodes of acute attacks of gout with asymptomatic intervals, and chronic gouty arthritis. The last decade has seen major advances in our knowledge of acute attacks of gout with the discovery of the pivotal role of interleukin 1 (IL-1); however, the mechanisms that trigger acute flares are still poorly known. For instance, despite the incidence of gout increasing exponentially with increasing urate levels, why gout develops in only a few patients with asymptomatic hyperuricaemia is unclear. In addition, we do not know why acute attacks of gout are so sporadic in patients with established tophaceous gout, despite their massive total body urate load. In this context, the elegant report from Zhang et al published in this issue adds a piece of the puzzle to help unravel the mystery of acute attacks of gout. Indeed, this report shows for the first time, that high purine intake, in addition to being a well-known long-term risk factor of urate deposition, also increases the risk of gout attacks almost fivefold among patients with gout. The natural question resulting from this work is: How does acute purine intake trigger acute attacks of gout?