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Gout and Vitamin C

Effect of Vitamin C on Gout

Although most animals can make vitamin C from scratch, humans have lost the ability over the course of evolution. We must get it from food, chiefly fresh fruits and vegetables. One of this vitamin's main functions is helping the body manufacture collagen, a key protein in our connective tissues, cartilage, and tendons - particularly important for treating forms of arthritis and gout.

Vitamin C is a powerful antioxidant that neutralizes damaging natural substances called free radicals. It works in water, both inside and outside of cells. Vitamin C complements another antioxidant vitamin, vitamin E, which works in lipid (fatty) parts of the body.

Scurvy, the classic vitamin C deficiency disease, is now a rarity in the developed world, although a more subtle deficiency of vitamin C is fairly common.2-6 According to one study, 40% of Americans do not get enough vitamin C.7 In fact, vitamin C deficiency sufficient to cause bleeding problems during surgery turns out to be more common than previously thought.141

Read more details about Vitamin C.

Research Evidence on Vitamin C

In a double-blind, placebo-controlled study of 184 people without gout, use of vitamin C at a daily dose of 500 mg significantly reduced uric acid levels.7 This suggests, but falls far short of proving, that vitamin C might be helpful for preventing or treating gout.

How to Use Vitamin C

Vitamin C is an essential nutrient that must be obtained from food or supplements; the body cannot manufacture it.

Most of us think of orange juice as the quintessential source of vitamin C, but many vegetables are actually even richer sources. Red chili peppers, sweet peppers, kale, parsley, collard, and turnip greens are full of vitamin C, as are broccoli, Brussel sprouts, watercress, cauliflower, cabbage, and strawberries. (Oranges and other citrus fruits are good sources, too.)

One great advantage of getting vitamin C from foods rather than from supplements is that you will get many other potentially healthful nutrients at the same time, such as bioflavonoids and carotenes. However, vitamin C in food is partially destroyed by cooking and exposure to air, so for maximum nutritional benefit you might want to try freshly made salads rather than dishes that require a lot of cooking.

Vitamin C supplements are available in two forms: ascorbic acid and ascorbate. The latter is less intensely sour.

The official US and Canadian recommendations for daily intake are as follows:

  • Infants o 0-6 months: 40 mg o 7-12 months: 50 mg
  • Children o 1-3 years: 15 mg o 4-8 years: 25 mg o 9-13 years: 45 mg
  • Males o 14-18 years: 75 mg o 19 years and older: 90 mg
  • Females o 14-18 years: 65 mg o 19 years and older: 75 mg
  • Pregnant Women o 18 years old or younger: 80 mg o 19 years and older: 85 mg
  • Nursing Women o 18 years old or younger: 115 mg o 19 years and older: 120 mg

Note: Smoking cigarettes significantly reduces levels of vitamin C in the body.1 The recommended daily intake for smokers is 35 mg higher across all age groups.

Safety Issues

The US government has issued recommendations regarding tolerable upper intake levels (ULs) for vitamin C. The UL can be thought of as the highest daily intake over a prolonged time known to pose no risks to most members of a healthy population. The ULs for vitamin C are as follows:

  • Children
    • 1-3 years: 400 mg
    • 4-8 years: 650 mg
    • 9-13 years: 1,200 mg
  • Males and Females
    • 14-18 years: 1,800 mg
    • 19 years and older: 2,000 mg
  • Pregnant Women
    • 18 years old or younger: 1,800 mg
    • 19 years and older: 2,000 mg
  • Nursing Women
    • 18 years old or younger: 1,800 mg
    • 19 years and older: 2,000 mg

However, even within the safe intake range for vitamin C, some individuals may develop diarrhea. This side effect will likely go away with continued use of vitamin C, but you might have to cut down your dosage for a while and then gradually build up again.

Concerns have been raised that long-term vitamin C treatment can cause kidney stones . 1 However, in large-scale observational studies, individuals who consume large amounts of vitamin C have shown either no change or a decreased risk of kidney stone formation. 2 3 Still, there may be certain individuals who are particularly at risk for vitamin C-induced kidney stones. 4 People with a history of kidney stones and those with kidney failure who have a defect in vitamin C or oxalate metabolism should probably restrict vitamin C intake to approximately 100 mg daily. You should also avoid high-dose vitamin C if you have glucose-6-phosphate dehydrogenase deficiency, iron overload, or a history of intestinal surgery.

Vitamin C supplements increase absorption of iron . 5 Since it isn’t good to get more iron than you need, individuals using iron supplements shouldn’t take vitamin C at the same time except under a physician’s supervision.

One study from the 1970s suggests that very high doses of vitamin C (3 g daily) might increase the levels of acetaminophen (such as Tylenol) in the body. 6 This could potentially put you at higher risk for acetaminophen toxicity. This interaction is probably relatively unimportant when acetaminophen is taken in single doses for pain and fever, or for a few days during a cold. However, if you use acetaminophen daily or have kidney or liver problems, simultaneous use of high-dose vitamin C is probably not advisable.

Weak evidence suggests that vitamin C, when taken in high doses, might reduce the blood-thinning effects of warfarin (Coumadin) and heparin . 7 8 9 As noted above, one study found that vitamin C at a dose of 1 g daily substantially reduced blood levels of the drug indinavir, a protease inhibitor used for the treatment of HIV infection. 10 Heated disagreement exists regarding whether it is safe or appropriate to combine antioxidants such as vitamin C with standard chemotherapy drugs. The reasoning behind the concern is that some chemotherapy drugs may work in part by creating free radicals that destroy cancer cells, and antioxidants might interfere with this beneficial effect. 11 However, there is no good evidence that antioxidants actually interfere with chemotherapy drugs, but there is growing evidence that they do not. 12 The maximum safe dosages of vitamin C for people with severe liver or kidney disease have not been determined.

Interactions You Should Know About

If you are taking:

  • Aspirin , other anti-inflammatory drugs, or oral contraceptives : You may need more vitamin C.
  • Acetaminophen (eg, Tylenol) : The risk of liver damage from high doses of acetaminophen may be increased if you also take large doses of vitamin C.
  • Warfarin (Coumadin) or heparin : High-dose vitamin C might reduce their effectiveness.
  • Iron supplements: High-dose vitamin C can cause you to absorb too much iron. This is especially a problem for people with diseases that cause them to store too much iron.
  • Medications in the nitrate family: Vitamin C may help maintain their effectiveness. Note: Angina is too serious a disease for self-treatment. If you have angina, do not take vitamin C (or any other supplement) except on a physician’s advice.
  • Protease inhibitors for HIV: High-dose vitamin C may reduce their effectiveness.
  • Cancer chemotherapy : Do not use vitamin C except on physician’s advice.

References

  1. Auer BL, Auer D, Rodgers AL. Relative hyperoxaluria, crystalluria, and hematuria after mega-dose ingestion of vitamin C. Eur J Clin Invest. 1998;28:695-700.
  2. Curhan GC, Willett WC, Speizer FE, et al. Intake of vitamins B 6 and C and the risk of kidney stones in women. Am Soc Nephrol. 1999;10:840-845.
  3. Curhan GC. A prospective study of the intake of vitamin C and vitamin B 6 and the risk of kidney stones in men. J Urol. 1996;155:1847-1851.
  4. Auer BL, Auer D, Rodgers AL. Relative hyperoxaluria, crystalluria, and hematuria after mega-dose ingestion of vitamin C. Eur J Clin Invest. 1998;28:695-700.
  5. Maskos Z, Koppenol WH. Oxyradicals and multivitamin tablets. Free Radic Biol Med. 11(6):609-10.
  6. Houston JB, Levy G. Drug biotransformation interactions in man VI: acetaminophen and ascorbic acid. J Pharm Sci. 65(8):1218-21.
  7. Owen CA Jr, Tyce GM, Flock EV, McCall JT. Heparin-ascorbic acid antagonism. Mayo Clin Proc. 45(2):140-5.
  8. Rosenthal G. Interaction of ascorbic acid and warfarin [letter]. JAMA. 1971;215:1671.
  9. Harris JE. Interaction of dietary factors with oral anticoagulants: review and applications. J Am Diet Assoc. 95(5):580-4.
  10. Slain D, Ansden J, Khakoo R, et al. Effects of high-dose vitamin C on the steady state pharmacokinetics of the protease inhibitor Indinavir in healthy volunteers. Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) Meeting; Sept 13-17, 2003; Chicago, IL. Poster A-1610.
  11. Labriola D, Livingston R. Possible interactions between dietary antioxidants and chemotherapy. Oncology. 1999;13:1003-1012.
  12. Weijl NI, Cleton FJ, Osanto S. Free radicals and antioxidants in chemotherapy-induced toxicity. Cancer Treat Rev. 23(4):209-40.
  1. Lykkesfeldt J, Christen S, Wallock LM, et al. Ascorbate is depleted by smoking and repleted by moderate supplementation: a study in male smokers and nonsmokers with matched dietary antioxidant intakes. Am J Clin Nutr. 2000;71:530-536.
  1. Hercberg S, Preziosi P, Galan P, et al. Vitamin status of a healthy French population: Dietary intakes and biochemical markers. Int J Vitam Nutr Res. 1994;64:220-232.
  1. Lowik MR, Wedel M, Kistemaker C, et al. Assessment of the adequacy of vitamin C intake in the Netherlands [abstract]. J Am Coll Nutr. 1991;10:544.
  1. US Department of Agriculture. National Food Consumption Survey. 1985.
  1. Baker B. Vitamin C deficiency common in hospitalized. Fam Pract News. March 1995:25.
  1. Taylor CA, Hampl JS, Johnston CS. Low intakes of vegetables and fruits, especially citrus fruits, lead to inadequate vitamin C intakes among adults. Eur J Clin Nutr. 2000;54:573-578.
  1. Huang HY, Appel LJ, Choi MJ, et al. The effects of vitamin C supplementation on serum concentrations of uric acid: results of a randomized controlled trial. Arthritis Rheum. 2005 June 2. [Epub ahead of print]
  1. Coffey G, Wilson SW. Letter: Ascorbic acid deficiency and aspirin-induced haematemesis. Br Med J. 1975;1:208.
  1. Das N, Nebioglu S. Vitamin C aspirin interactions in laboratory animals. J Clin Pharm Ther. 1992;17:343-346.
  1. Molloy TP, Wilson CW. Protein-binding of ascorbic acid. 2. Interaction with acetylsalicylic acid. Int J Vit Nutr Res. 1980;50:387-392.
  1. Rivers JM, Devine MM. Plasma ascorbic acid concentrations and oral contraceptives. Am J Clin Nutr. 1972;25:684-689.
  1. Webb JL. Nutritional effects of oral contraceptive use: a review. J Reprod Med. 1980;25:150-156.
  1. Larsson-Cohn U. Oral contraceptives and vitamins: a review. Am J Obstet Gynecol. 1975;121:84-90.
  1. Wynn V. Vitamins and oral contraceptive use. Lancet. 1975;1:561-564.
  1. Briggs M, Briggs M. Vitamin C requirements and oral contraceptives [letter]. Nature. 1972;238:277.
  1. Blee TH, Cogbill TH, Lambert PJ. Hemorrhage associated with vitamin C deficiency in surgical patients. Surgery. 2002;131:408-412.

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