Tell me about gout
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Gout is one of the most common forms of arthritis (joint inflammation).
It appears as an acute attack often coming on overnight. Within 12-24 hours there is severe pain and swelling in the affected joint. The skin over the joint may be red and shiny.
Gout usually affects only one or two joints at a time - most often the feet and ankles. The big toe is the most common site. Without treatment the attack subsides in a week or so and when patients first develop gout there may be intervals of many months or even years between attacks. As time goes by, these tend to become more frequent and more severe and eventually many joints may be involved. At this stage chronic joint disease may develop with progressive joint damage, disability and crippling (chronic gout). Gout affects mostly men and is very rare in women until after the menopause when it is quite often seen. Gout is particularly common in Maoris and Pacific Islanders. Some surveys have shown it to be present in up to 10% of adult males.
Uric acid is a chemical which is a natural end product of the metabolism of purines, which are substances found in certain food. The level of uric acid in the blood can be measured. Elevated blood uric acid is called hyperuricemia. When this is present the uric acid which is normally dissolved in the blood may form microscopic crystals in the joint. These crystals set up the inflammation which is called acute gouty arthritis or acute gout.
Gout develops in persons whose uric acid is consistently higher than normal. There are many causes of this. The following are some of the more common causes:
• Higher than normal levels of uric acid can be part of genetics
• High alcohol intake
• High intake of food containing purines
• Some of the drugs used to treat high blood pressure.
• Longstanding kidney disease may result in high blood levels of uric acid.
The first step wherever possible must be to correct those factors which cause high uric acid levels. Purines are substances found in food, which, produce a lot of uric acid. Therefore the following foods which are high in purines should be restricted or avoided:
• Foods such as liver, kidneys, tripe, sweetbreads and tongue.
• Excessive amounts of red meat.
• Shellfish, fish roe and scallops.
• Peas, lentils, and beans.
• Alcohol intake should be reduced. Two glasses of beer a day or less is sensible. On special occasions you can drink more.
• Weight loss may be very important.
• Medication for high blood pressure may need to be altered.
NSAIDs can be very effective. Colchicine is another medicine used for acute attacks. With effective treatment the attack may be controlled within 12-24 hours. Rest and elevation of the part involved and increased fluid intake are also important. Unfortunately, drugs used for the acute attack have no effect on reducing uric acid levels.
If the uric acid remains high and attacks continue, other drugs can be used which lower the blood uric acid. These drugs have no effect on the actual attacks of acute gout and they must be taken on a long term basis. The dose must be adjusted by repeated checks on the blood uric acid. Once the uric acid is down within normal limits(<6 mgs/dl) consistently, the patient should remain free from gout provided the drug is continued. Some drugs work by increasing elimination via the kidneys and others by blocking uric acid formation.
It is also very important for patients beginning such drugs to realize that for the first few months of treatment, gouty attacks can become more severe and frequent. This is usually controlled by taking one or two tablets a day of an additional drug for at least several months and if any acute attacks do appear they must be treated in the usual way and the long term medicines continued.
Where high uric acid has been present for a long time and acute gout has been frequent and severe, deposits of uric acid salts may appear around the affected joint and even in tissues elsewhere such as the ears. These are seen as chalk colored nodules called tophi. Their presence indicates the need for treatment with one or other of the long term uric acid lowering drugs mentioned above.
High uric acid levels and recurrent gout are often associated with high blood pressure. This combination of hyperuricemia and high blood pressure can lead to kidney damage. Gout is also associated with obesity, diabetes and elevated blood lipids. This constellation of medical conditions is called the "metabolic syndrome."
Middle-aged women who are on diuretic therapy will often develop tophi in the fingers.
Attacks not responding to oral medicines may require steroid injection.
Here are a few tips:
• Take your medicines as prescribed.
• If you think the pills make you feel worse talk to the doctor about changing the tablets but DONT STOP TAKING THEM.
• Keep your weight down.
• Ask your doctor to give you good advice about diets that will help you do this.
Avoid or cut down on the following foods:
Red meats which come from cows or sheep and include steak, chops, corned beef and larger pieces of meat usually roasted in the oven.
Brains, kidneys, liver & heart (offal).
Shellfish such as pauas, pipis, mussels, oysters and sea eggs.
Peas and beans.
Alcohol. especially beer and wine.
Medicines such as allopurinol can reduce levels of uric acid in the body as can a drug called probenecid. The choice of which drug to use depends on many factors.
Two other drugs are used. The first is febuxostat, which acts similarly to allopurinol but has fewer side effects. The second is Krystexxa (PEG uricase) which converts uric acid to allantoin, an inert ingredient. This drug is given intravenously and is particularly effective for tophaceous gout.
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