All about gout

Waking up at night with an attack of gout gives new meaning to the phrase “rude awakening.” Your big toe is red, hot, swollen, and so tender that even the weight of a blanket on it makes you wince in pain (see drawing). Gout is a joint disorder characterized by acute inflammation commonly affecting the big toe. It can also affect other joints, including the knees, ankles, and wrists. Although many people associate the onset of gout with the excessive consumption of rich food and drink, it can actually strike any time and for no apparent reason. Fortunately, with proper treatment, a gout flare-up can be short-lived and permanent joint damages can usually be avoided.

The Trouble With Crystals

Many Filipinos have gout. In fact, we have one of the highest rates in the world as we seem to lack a certain enzyme that’s important in purine metabolism. This is something we have in common with other groups of people, like the Maoris of New Zealand.

Uric acid is formed when your body breaks down molecules called purines, which are building blocks for DNA. Purines are found in high quantities in certain foods, including anchovies, sardines, and organ meats, such as liver. But most of the uric acid produced in your body is a result of the breakdown of naturally occurring purines found in your own system. Typically, uric acid is dissolved in your blood as urate, passes through your kidneys and then is eliminated in urine. Sometimes, uric acid levels may go up (hyperuricemia) because your body either produces too much uric acid or your kidneys don’t eliminate enough. High levels of uric acid in the blood, or other triggers, can cause uric acid crystals to form in joint spaces and other tissues. The resulting inflammation, which is due to your white blood cells’ response to these crystals, is a gout attack. In some people, the crystals can form kidney stones (calculi).

Who’s At Risk And Why

Gout is more likely to affect men than women, especially men between the ages of 40 and 50. Women become more susceptible to gout after menopause. Gout appears to run in some families. A number of factors may cause the body to produce too much uric acid or deter the kidneys from eliminating enough of it. Known risk factors for gout include:

• Excess weight

• Certain medical conditions, including high blood pressure, diabetes, and elevated blood fat levels

• Excessive alcohol intake

• Excessive intake of food high in purines

• Certain medications, including some diuretics, low-dose aspirin, niacin, and the organ transplant anti-rejection drug cyclosporine

• Surgery

• Severe illness or injury

Signs And Symptoms

 Typically, gout pain comes on suddenly. The attack produces an intense pain, usually in one joint at a time, but on rare occasions, it can affect multiple joints. The affected joints often appear swollen and red. Although often associated with the large joints of the big toe, gout can also occur in other joints, including the knee, ankle, foot, hand or wrist. Gout attacks are usually short-lived. Pain and swelling in the affected joint usually go away over several days but may be stopped sooner with medications. In some people, a high load of urate crystals may build up over several years and form large deposits called tophi, in joints and nearby tissues. Tophi deposits look like lumps under the skin and typically appear near affected joints, especially on the elbows, fingers, and toes. Deposits may also develop on the outer edge of the ear.

Diagnosis And Treatment

If you experience sudden pain in a joint, contact your doctor. Gout that’s left untreated may result in increased pain and even joint damage. Gout is considered a risk factor for cardiovascular disease. To determine whether you have gout, your doctor may remove some synovial fluid from the affected joint to view it under the microscope. The presence of urate crystals in the sample can confirm a diagnosis of gout. A blood test may also be done to check for elevated uric acid levels. The earlier an acute gout is treated, the faster the pain may clear. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be prescribed. Another drug called colchicine may also be used to treat acute gout. Typically, the medications are taken until the pain subsides, usually in five days or so.

Dietary Changes

In some patients, dietary changes may help reduce the frequency of gout attacks. The first line of defense should be weight reduction for those who are overweight. A low purine diet may be advised. Purines are natural substances found in food, and are metabolized into uric acid. Some believe that people who are susceptible to gout should avoid high purines altogether. Purines are found in meats, certain types of seafood (herring, mackerel, sardines, scallops, trout), and high-fructose beverages. High-purine foods also include asparagus, anchovies, dried beans and peas, gravy, and liver. Ask your doctor if you should be limiting purines in your diet.

Here’s an example of a restricted purine diet.

Group 1. Select from these foods:

Breads

Cereals and cereal products

Cheese

Eggs

Fruits

Gelatin

Milk

Sugars and syrups

Tea and coffee

Vegetables

Group 2. Use these foods in moderation:

Fats

Fish except those listed in Group 3

Poultry

Legumes (beans, peas, lentils)

Meat

Meat soup and broth

Oatmeal

Poultry

Seafoods like crabs, oysters, eel, and shrimps

Vegetables like asparagus, spinach, mushroom, and cauliflower

Group 3. Avoid these foods:

Anchovies

Brains

Herring (tamban, tawilis, tunsoy, lapad, silinyasi)

Mackerel (alumahan, hasa-hasa, tanigue)

Mussels (tahong)

Meat extracts

Internal organs such as liver, kidney, and pancreas

Although it has nothing to do with purines, most nutritionists agree that people at any stage of gout should refrain from drinking alcohol because it can raise uric acid levels. Non-alcoholic fluids, especially water, help remove it, so drink up.

Preventing Future Attacks

It’s not uncommon for gout to recur. Preventive medications are generally recommended if you have frequent gout attacks or if you have tophi. Allopurinol (Zyloprim, generics) helps reduce the level of uric acid in your blood by slowing the rate at which it’s produced. It doesn’t relieve pain. Allopurinol can decrease the frequency of attacks and prevent long-term complications, especially if you have deposits of crystals in your joints, soft tissues or kidneys.

However, allopurinol shouldn’t be started during an acute gout attack. That’s because it works slowly over many months and may even increase the frequency of attacks for the first six months. Gouts are more likely when blood levels of uric acid are changed one way or the other. Medications such as probenecid (Benemid) or sulfinpyrazone (Anturan) may be prescribed to increase the amount of uric acid you excrete in your urine. These drugs also help dissolve tophi deposits and prevent the deposit of uric acid in joints. However, they generally aren’t prescribed for people with kidney disease or those with a history of kidney stones.

GOOD NEWS

The best news about gout is that it may be the most controllable form of arthritis. Not only are there effective medications, dietary strategies, and weight-control programs, there are also promising new drugs like infliximab and febuxostat which blocks a chemical that may play a role in reducing inflammation, and restricts the production of uric acid. The future is good for a better approach to the treatment of this common painful malady.