Not just something for the history books, gout is all too real. One in ten Americans over the age of 70 will experience at least one attack of gout, something gout patients generally describe as the worst pain imaginable.
High amounts of a molecule called uric acid can crystallize in joints, causing a very painful inflammation in the big toe or a knuckle. Over time, a knot can build, called a tophus.
While sometimes caused by severe kidney problems, cancer treatment or by some kinds of medications, blaming gout symptoms on a diet rich in meat and alcohol is not quite accurate. The causes of gout are similar to diabetes in a complex relationship of genetic factors, obesity and associated problems with sugar metabolism.
Rates of gout have been increasing worldwide, even among vegetarians, which supports the theory that body weight plays a bigger role than diet, a viewpoint that studies have consistently backed up. Gout involves more than just pain, and beginning treatment is important.
Educating doctors
At a recent rheumatology symposium, one expert stated the main problem today in the treatment of gout was education, not just patients but doctors. "As rheumatologists, gout is our disease. The cause and pathophysiology are well understood," says Robert L. Wortmann, M.D., professor of medicine at Dartmouth Medical School in Hanover, N.H.
"We can make the diagnosis with absolute certainty, and we’ve got great medicines, yet today we all see people with tophi. That’s tragic. It shouldn’t exist," Dr. Wortmann said.
"One of our biggest mistakes has been not being able to educate primary care physicians that having a tophus is bad, that it’s eroding cartilage and bone, and that it’s something we can prevent if we start urate-lowering therapy soon enough," concludes Dr. Wortmann.
Symptoms
Efforts to figure out gout were largely abandoned by medical science once effective medical treatments such as allopurinol came out in the 1960s, and investigation of the causes of uric acid buildup wasn't taken seriously by many doctors until nearly thirty years later.
Some surprising findings came out of that research, namely that fructose could also contribute to symptoms of gout. Sucrose, table sugar, contains half fructose by weight, and hundreds of products in any grocery store contain high fructose corn syrup.
Today, gout is a hard diagnosis to miss. A type of inflammatory arthritis, gout causes extreme pain in joints of the hands and feet during acute attacks, and crystallization of uric acid in the kidneys can cause kidney stone formation.
Large, disfiguring deposits of uric acid can form in the knuckles of the feet, hands, knees, and elbows. Attacks can last for days, sometimes weeks, before the symptoms mysteriously fade away.
Prevention
Although high protein diets do contain large amounts of purines, a molecule that is turned into uric acid by the body, most people's kidneys are able to compensate naturally. However, when a person with gout eats something with a lot of fructose, their liver becomes overwhelmed and uric acid levels spike, very similar to the process that occurs when people with gout consume a lot of alcohol.
Doctors now recommend that people with frequent gout symptoms avoid foods with simple sugars such as sucrose and fructose, especially soft drinks and beverages sweetened with honey, to lower their levels of uric acid and prevent attacks.
Patients with gout should avoid alcohol, and consume lower levels of seafood and meat. Some vegetables such as asparagus, beans, and mushrooms can cause attacks in patients. Several studies have shown that a diet high in dairy products lowers episodes of gout, and drinking lots of water is important to dilute the concentration of uric acid.
Studies also show that losing weight helps symptoms of gout in the long term, and similar to Type II diabetes, extensive weight loss in people who have upper body obesity can eliminate symptoms entirely in some patients.
Treatment
There are two aspects of medicating gout. Long term prevention through diet is important, but not helpful for acute attacks.
Immediate
Current recommendations for acute gout are high doses of common non-steroidal anti-inflammatory drugs (NSAIDs) such as Advil (ibuprofen) Indocin (indomethacin) and Naprosyn (naproxenn).
For some patients with severe disease, Colcrys (colchicine) may be helpful, despite the side effects, which include many medication interactions, frequent cramps, pain and diarrhea.
In the past, a shot of corticosteroid directly into the joint quickly relieved acute gout, but given the other options available today, many doctors prefer to avoid the long list of side effects involved in corticosteroid therapy.
Long Term
For long term medication to avoid the acute attacks, there are several options for gout patients. When starting these preventative drugs, acute attacks may get worse before they get better, and it’s important to drink a lot of water to protect the kidneys.
Zyloprim (allopurinol) prevents the initial formation of uric acid, which is very effective in stopping the build-up of crystals that cause the pain of acute gout attacks.
Uloric (febuxostat) also prevents the formation of uric acid and while more expensive, is used if patients experience any problems with Zyloprim.
Krystexxa (pegloticase) was developed for cases of gout where other treatments do not work, about three percent of the population. Krystexxa is given as an intravenous injection every two weeks, and it changes uric acid into another molecule that is more easily pumped out of the body by the kidneys.
Benuryl (probenecid) and Anturane (sulfinpyrazone) act by dramatically enhancing the kidney’s output of uric acid into the urine. But because these drugs act on the kidney, patients with kidney problems can't use this class of drugs.
Aspirin and ice packs should be avoided because they can make the symptoms worse, and while it may be useful for pain, extensive use of Tylenol (acetaminophen) is one of the leading causes of liver damage and therefore is not recommended.
Getting help
If you suffer from frequent attacks of gout, you will want to be under the care of a specialist - a rheumatogist. Today, you have a number of options that can help to successfully manage the disease.
