Gout is a form of arthritis that can potentially affect anyone. Its characteristic presentation is the sudden onset of severe pain, swelling, redness and tenderness of a joint, classically the joint at the base of the great toe. These attacks often awaken a person from sleep in the middle of the night with the sensation that the great toe is on fire. The effected joint is so sensitive that even the weight of a bed sheet is intolerable. Gout may occur in any joint including the ankles, knees, wrists, elbows and fingers. The pain is most intense for up to 10 – 12 hours from the onset and then may subside but some discomfort may last for several days to several weeks if left untreated. Gout attacks may spontaneously wax and wane but there are life style changes and medications that improve the symptoms and prevent recurrent attacks.
Gout can occur when a substance in the blood called uric acid becomes elevated. Uric acid enters the joint and forms urate crystals. These crystals cause joint pain that is almost equivalent to having needles in the joint.
Uric acid is a normal by-product of cellular metabolism and is produced when purine (a component of the genetic material DNA) is released during the normal break down of cells in our body. High concentrations of purine are also found in certain foods such as beef, shell fish, and organ meats such as liver. Excess amounts of purine result in higher blood levels of uric acid. Other substances that can cause high uric acid levels are alcoholic beverages, particularly beer, and drinks sweetened with the fruit sugar fructose.
Uric acid is normally carried to the kidneys where it is excreted. Sometimes, however, the uric acid becomes so high that the kidneys cannot handle it and levels increase in the blood.
Centuries ago, gout was known as the disease of Kings, because they over indulged in rich foods that only royalty could afford.
Factors that increase the risk of gout include:
· A family history of gout
· Obesity – excessive weight causes over production of uric acid
· Certain medications, most notably diuretics (water pills)
· Recent joint trauma, even though mild
The diagnosis of gout can be made with a simple blood test to measure the level of uric acid. However, if the measurement is made during an acute attack, it may be normal or falsely low. Also, some people have elevated blood uric acid and don’t get gout. A diagnosis can be definitively made by using a needle to aspirate fluid from an inflamed joint and finding urate crystals.
Prolonged elevations in uric acid can not only cause acute joint pain but can lead to chronic arthritis sometimes mistaken for osteoarthritis. Urate crystals deposited chronically in and around joints can cause nodules known as tophi which can damage joints and compromise their function. Uric acid can also be deposited in the kidneys causing kidney stones.
The goals of treatment include the following:
· Relieve inflammation and pain during an acute attack
· Prevent future attacks that might lead to permanent joint damage and deformity
· Prevent kidney stones and kidney damage
There are two types of medication used to manage gout. For acute attacks of joint inflammation and pain, there are NSAIDS (ibuprofen and naproxen), colchicine, and corticosteroids, such as prednisone. After acute flares have resolved, two drugs that inhibit the production of uric acid and prevent future attacks are allopurinol (Zyloprim) and febuxostat (Uloric). A medication that increases the excretion of uric acid by the kidneys is probenecid (Benemid). When starting these drugs, the uric acid must be reduced slowly. Rapid lowering can precipitate an acute gout attack.
It is possible to avoid a ‘Bout with Gout’ by life style changes:
· Limit consumption of foods high in purine (beef and shellfish).
· Be mindful of alcohol consumption
· Maintain an ideal body weight
· Avoid becoming dehydrated
Unfortunately, the elegant dinner of Surf and Turf (sea food and steak) with wine could represent a triple threat to cause an acute attack of gout!
Dr. Tippett is the founder of Comprehensive Quality Healthcare Providers, a concierge internal medicine practice located at 1210 Commerce Dr., Suite 106, Greensboro, Ga. 30642. He can be reached at 706-510-3659. Visit his webpage at www.drtippett.com