What is Gout?
Gout is often a very painful and temporarily disabling form of arthritis. In the past, it was commonly referred to as the “Disease of Kings”. People believed that it came about as the result of a daily diet rich in meats and wine that only a king could afford. We know now however that this painful condition can affect anyone, rich or poor, and is the result of multiple risk factors. It affects more than 3 million Americans and is more common in men than women.
Causes
The causes of gout are multifactorial. The basis of the disease comes about from the deposit of microscopic needle-like crystals of uric acid that deposit within a joint space. Uric acid is a normal waste product of certain foods we consume and in its soluble form is normally filtered through the kidneys and eliminated from our body through the process of urination. Meat and seafood rich diets are high in purines that get broken down to uric acid which is then eliminated through the process of urination. When the body begins to retain high levels of uric acid then the potential for that excessive uric acid to crystalize and precipitate out into a joint causing a gouty joint flare up increases. Gout is strongly linked to obesity, high blood pressure, high cholesterol, and diabetes. Heredity and genetic factors can also predispose individuals to gout.
Symptoms
The first symptoms of a gouty flare up are usually marked by intense pain, swelling and redness in and around a joint. Typically affecting the joints in the foot and lower extremity and most commonly the big toe joint. The pain and sensitivity is so intense at times that even the slightest touch to the skin surrounding the joint is unbearable. Many individuals affected by gout relate that occurred overnight while sleeping only to be awaken by pain from just the sheets of the bed touching their foot. Occasionally lumps or nodules may form near or around a joint called “tophi” which are deposits of well organized collections of uric acid crystals. When tophi develop we refer to the chronic condition as Tophaceous Gout.
Diagnosis
Other forms of arthritis can resemble gout, so careful and proper diagnosis is key for the treatment and management of gout. Gout is suspected when a patient has joint pain, swelling and redness usually of the joints of the lower extremity. Obtaining a careful history from the individual is equally important to pick up on the clues suggestive of gout. Definitive diagnosis can be obtained by drawing fluid from the involved joint and examining it under a microscope looking for needle-shaped uric acid crystals. The presence of lumpy tophaceous nodules are clear indicators or tophaceous gout. Checking for elevated uric acid levels in the blood can be helpful in identify individuals for the potential of developing gout but can often be misleading, especially during times of an acute gouty attack. Uric acid levels may be normal or even low for a short time during attacks. X-rays and CT scans may show joint damage particularly in individuals who have had gout for a long time.
Treatment
Effective management of gout is a two fold approach that includes both the treatment of acute flare-up symptoms as well as the long term management and reduction of uric acid levels. Treatment of acute flare-ups of gout are commonly achieved using one or more of the following medications:
1. Colchicine – this medicine is often very effective if given early in the attack. However, colchicine can cause nausea, vomiting, diarrhea and other side effects. Side effects may be less frequent with low doses.
2. Nonsteroidal anti‐inflammatory drugs (NSAID’s) – are aspirin‐like medications that can decrease inflammation and pain in joints and other tissues. NSAIDs, such as Indomethacin (Indocin) and Naproxen (Naprosyn), have become the treatment choice for most acute attacks of gout.
3. Corticosteroids – are steroidal medications such as prednisone and triamcinolone
are useful options for patients who cannot take NSAIDs. They can be given orally
(by mouth) or by injection (shot) into the joint.
Treatment of chronic gout is aimed at reducing elevated uric acid levels in individuals who have repeated gout attacks, abnormally high blood uric acid levels and, tophi or kidney stone development. These medications do not help the painful flares of acute gout, so most patients should start taking them after acute attacks subside. The medications commonly used to lower uric acid blood levels are:
1. Allopurinol – works by blocking production of uric acid.
2. Uloric – also acts by blocking uric acid production.
3. Probenecid (Benemid) helps the kidneys remove uric acid. Only patients with good kidney function who do not overproduce uric acid should take probenecid.
4. Pegloticase (Krystexxa) – this drug is for patients who do not respond to other
treatments or cannot tolerate them. This medication is given by injection and
breaks down uric acid.
Treatment also can decrease the number and size of tophi. Once uric acid levels drop below 6 mg/dL (normal), crystals tend to dissolve and new deposits of crystals can be prevented. You probably will have to stay on this medicine long term to prevent gout attacks. What works well for one individual may not work as well for another. Therefore, decisions about when to start treatment and what drugs to use should be tailored for each patient. Treatment choices depend on kidney function, other health problems, personal preferences and other factors.
Prevention
What you eat can increase uric acid levels. Limit the amount of high-fructose drinks, such as sugar free soda. Also, do not drink alcohol, especially beer. Restrict eating foods that are rich in purines, compounds that break down into uric acid. These compounds are high in meat and certain types of seafood. Purines in vegetables appear to be safe, new research has found. Low‐fat dairy products may help lower uric acid levels.
Limit meat, poultry and fish. Animal proteins are high in purine. Avoid or severely limit high-purine foods, such as organ meats, red meat (beef, lamb and pork) and certain seafoods (herring, anchovies, mackerel, tuna, shrimp, lobster and scallops). Limit your intake of these protein sources to 4 to 6 ounces daily.
Cut back on fat. Saturated fat lowers the body’s ability to eliminate uric acid. Choosing plant-based protein, such as beans and legumes, and low-fat or fat-free dairy products will help you cut down the amount of saturated fat in your diet. High-fat meals also contribute to obesity, which is linked to gout.
Limit or avoid alcohol. Alcohol interferes with the elimination of uric acid from your body. Drinking beer, in particular, has been linked to gout attacks. If you’re having an attack, avoid all alcohol. However, when you’re not having an attack, drinking one or two 5-ounce servings a day of wine is not likely to increase your risk.
Limit or avoid foods sweetened with high-fructose corn syrup. Fructose is the only carbohydrate known to increase uric acid. Avoid beverages sweetened with high fructose corn syrup, such as soft drinks or juice drinks. Drinking 100% fruit juices, particularly cherry juice, seems to help reduce the production uric acid.
Choose complex carbohydrates. Eat more whole grains and fruits and vegetables and fewer refined carbohydrates, such as white bread, cakes and candy.
Choose low-fat or fat-free dairy products. Some studies have shown that low-fat dairy products can help reduce the risk of gout.
Drink plenty of water. Water helps eliminate uric acid from your body through normal kidney function. Aim for 8 to 16 glasses a day. There is also some evidence suggests that drinking 4 to 6 cups of coffee a day lowers gout risk in men.
In almost all cases, it is possible to successfully treat gout and bring a gradual end to attacks.
The Podiatrist’s Role in the Treatment of Gout
Podiatrists are well versed in the diagnosis, treatment and long term management of gout and similar arthropathies. When experiencing symptoms as described above, the sooner you seek professional help, the sooner treatment and relief can be achieved as well as active long term management and prevention of disease progression. If you feel you are suffering from gout, schedule an appointment with Dr. Bertolo today.