Gout

Gout

Definition

Gout is a form of acute arthritis that causes severe pain and swelling in the joints. It most commonly affects the big toe, but may also affect the heel, ankle, hand, wrist, or elbow. It affects the spine often enough to be a factor in lower back pain. Gout is often a recurring condition. An attack usually comes on suddenly and goes away after 5–10 days. Gout occurs when there are high levels of uric acid circulating in the blood, and the acid crystallizes and settles in the body. According to the National Institutes of Health (NIH), gout accounts for about 5% of all cases of arthritis reported in the United States.

Gout appears to be on the increase in the American population. According to a study published in November 2002, there was a twofold increase in the incidence of gout over the 20 years between 1977 and 1997. It is not yet known whether this increase is the result of improved diagnosis or whether it is associated with risk factors that have not yet been identified.

Description

Uric acid is formed in the bloodstream when the body breaks down waste products, mainly those containing purines. Purines can be produced naturally by the body, and they can be ingested from such high-purine foods as meat. Normally, the kidneys filter uric acid particles out of the blood and excrete it into the urine. If the body produces too much uric acid or the kidneys aren't able to filter enough of it out, there is a buildup of uric acid in the bloodstream. This condition is known as hyperuricemia.

Uric acid does not tend to remain dissolved in the bloodstream. Over the course of years, or even decades, hyperuricemia may cause deposits of crystallized uric acid throughout the body. Joints, tendons, ear tips, and kidneys are favored sites. When the immune system becomes alerted to the urate crystals, it mounts an inflammatory response that includes the pain, redness, swelling, and damage to joint tissue that are the hallmarks of an acute gout attack.

The body's uric acid production tends to increase in males during puberty. Therefore, it should come as no surprise that nine out of ten of those suffering from gout are men. Since it can take up to 20 years of hyperuricemia to have gout symptoms, men don't commonly develop gout until reaching their late 30s or early 40s. If a woman does develop gout, typically, it will be later in her life. According to some medical experts, this is because estrogen protects against hyperuricemia. It is not until estrogen levels begin to fall during menopause that urate crystals can begin to accumulate.

Hyperuricemia does not necessarily lead to gout. The tendency to accumulate urate crystals may be due to genetic factors, excess weight, or overindulgence in the wrong kinds of food. In addition, regular use of alcohol to excess, the use of diuretics, and the existence of high levels of cholesterol and triglycerides in the blood can increase the risk of developing the disease. In some cases, an underlying disease such as lymphoma, leukemia , or hemolytic anemia may also lead to gout.

Causes & symptoms

An acute episode of gout often starts without warning. The needle-like urate crystals may be present in the joints for a long time without causing symptoms. Then, there may be a triggering event such as a stubbed toe, an infection, surgery, stress, fatigue , or even a heavy drinking binge. Patients in intensive care units (ICUs) may have an acute flare-up of gout. In addition, it is now known that chronic occupational exposure to lead leads to decreased excretion of urates and an increased risk of developing gout.

In many cases, the gout attack begins in the middle of the night. There is intense pain, which usually involves only one joint. Often it is the first joint of the big toe. The inflamed skin over the joint is warm, shiny, and red or purplish, and the pain is often so excruciating that the sufferer cannot tolerate the pressure of bedcovers. The inflammation may be accompanied by a fever .

Acute symptoms of gout usually resolve in about a week, and then disappear altogether for months or years at a time. Eventually, however, the attacks may occur more frequently, last longer, and do more damage. The urate crystals may eventually settle into hard lumps under the skin around the joints, leading to joint deformity and decreased range of motion. These hard lumps, called tophi, may also develop in the kidneys and other internal organs, under the skin of the ears, or at the elbow. People with gout also face a heightened risk of kidney disease, and almost 20% of people with gout develop kidney stones . As of 2002, however, the relationship between gout and kidney stone formation is still not completely understood.

Diagnosis

Doctors can diagnose gout based on a physical examination and the patient's description of symptoms. In order to detect hyperuricemia, doctors can administer a blood test to measure serum urate levels. However, high urate levels merely point to the possibility of gout. Many people with hyperuricemia don't have urate crystal deposits. Also, it has been shown that up to 30% of gout

sufferers have normal serum urate levels, even at the time of an acute gout attack. The most definitive way to diagnose gout is to take a sample of fluid from an affected joint and test it for the presence of the urate crystals.

Treatment

The symptoms of gout will stop completely a week or so after an acute attack without any intervention. It is important, however, to be diagnosed and treated by a health care practitioner in order to avoid attacks of increasing severity in the future and to prevent permanent damage to the joints, kidneys, and other organs. During an acute attack, treatment should focus on relieving pain and inflammation. On an ongoing basis, the focus is on maintaining normal uric acid levels, repairing tissue damage, and promoting tissue healing.

Diet

Generally, gout is unheard of in vegetarians. It is a condition that responds favorably to improvements in diet and nutrition . Recurrent attacks can be avoided by maintaining a healthy weight and limiting the intake of purinerich foods. A diet high in fiber and low in fat is also recommended. Processed foods should be replaced by complex carbohydrates, such as whole grains. Protein intake should be limited to under 0.8g/kg of body weight per day.

Nutritional supplements

Vitamin E and selenium are recommended to decrease the inflammation and tissue damage caused by the accumulation of urates.

Folic acid has been shown to inhibit xanthine oxidase, the main enzyme in uric acid production. The drug allopurinol (see below) is used for this same purpose in the treatment of gout. The therapeutic use of folic acid for this condition should be prescribed and monitored under the supervision of a heath care practitioner. The recommended dosage range is 400–800 micrograms per day.

The amino acids alanine, aspartic acid, glutamic acid, and glycine taken daily improve the kidneys' ability to excrete uric acid. Bromelain , an enzyme found in pineapples, is an effective anti-inflammatory. It can be used as an alternative to NSAIDs and other prescription anti-inflammatory drugs. It should be taken between meals at a dosage of 200–300 mg, three times per day.

The bioflavonoid quercetin helps the body absorb bromelain. It also helps decrease uric acid production and prevents the inflammation that leads to the acute symptoms of gout and the resulting tissue destruction. Quercetin should be taken at the same time and dosage as bromelain: 200–400 mg, between meals at a three times per day.

Herbs

Dark reddish-blue berries such as cherries, blackberries, hawthorn berries, and elderberries are very good sources of flavonoid compounds that have been found to help lower uric acid levels in the body. Flavonoids are effective in decreasing inflammation and preventing and repairing the destruction of joint tissue. An amount of the fresh, frozen, dried, juiced, or otherwise extracted berries equal to half a pound (about 1 cup) fresh should be consumed daily.

Devil's claw , Harpagophytum procumbens, has been shown to be of benefit. It can be used to reduce uric acid levels and to relieve joint pain.

Gout represents a serious strain on the kidneys. The dried leaves of nettles, Urtica dioica, can be made into a pleasant tea and consumed throughout the day to increase fluid intake and to support kidney functions. However, some people are allergic to nettles.

Therapy

Colchicum is a general homeopathic remedy that can be used for pain relief during a gout attack. It is formulated from the same plant, Autumn crocus, as the drug colchicine, used in the conventional treatment of gout. Gout may be improved by having a constitutional remedy prescribed that is based on the tendency to develop the disease and its symptoms.

During the acute phase of gout, acupuncture can be helpful with pain relief.

Applications of ice or cold water can reduce pain and inflammation during acute attacks.

Allopathic treatment

Standard medical treatment of acute attacks of gout includes nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen sodium (Aleve), ibuprofen (Advil), or indomethacin (Indocin). Daily doses until the symptoms have subsided are recommended. Colchicine (Colbenemid), is also used. Corticosteroids such as prednisone (Deltasone, prednisolone, and corticotropin [ACTH]) may be given orally or may be injected directly into the joint for a more concentrated effect. Because these drugs can cause undesirable side effects, they are used for only about 48 hours so as not to cause major problems. Aspirin and other salicylates should be avoided, because they can impair uric acid excretion and may interfere with the actions of other gout medications.

Once an acute attack has been successfully treated, doctors try to prevent future attacks of gout and long-term joint damage by lowering uric acid levels in the blood. Colchicine is the drug of choice to deter recurrence. This medication can be very hard on the vascular system and the kidneys, however, and it is incompatible with a number of antidepressants, tranquilizers, and antihistamines. It should be avoided by pregnant women and the elderly.

There are two types of drugs used for lowering uric acid levels. Sometimes these drugs resolve the problem completely. However, the use of low-level amounts may be required for a lifetime. Uricosuric drugs, such as probenecid (Benemid) and sulfinpyrazone (Anturane), decrease urates in the blood by increasing their excretion. These drugs may also promote the formation of kidney stones, and they are contraindicated for patients with kidney disease. Xanthine oxidase inhibitors block the production of urates in the body. They can dissolve kidney stones as well as treat gout. Allopurinol is the drug most used in this respect. Its adverse effects include reactions with other medications, and the aggravation of existing skin, vascular, kidney, and liver dysfunction.

Expected results

Gout cannot be cured, but it can be managed successfully. Prompt attention to diet and reducing uric acid levels will rectify many of the problems associated with gout. Kidney problems can also be reversed or improved. Tophi can be dissolved or surgically removed, and with the tophi gone, joint mobility generally improves. Gout is generally more severe in those whose initial symptoms appear before age 30. The coexistence of hypertension , diabetes, or kidney disease can make for a much more serious condition.

Prevention

For centuries, gout has been known as the "rich man's disease," a disease of overindulgence in food and drink. While this view is perhaps oversimplified, lifestyle factors clearly influence a person's risk of developing gout. For example, losing weight and limiting alcohol intake can help ward off gout. Since purines are broken down into urates by the body, consumption of foods high in purine should be limited. Foods that are especially high in purines are red meat, organ meats, meat gravies, shellfish, sardines, anchovies, mushrooms, cooked spinach, rhubarb, yeast, asparagus, beer, and wine.

Dehydration promotes the formation of urate crystals, so people taking diuretics, or "water pills," may be better off switching to another type of blood pressure medication. Increased intake of fluids will dilute the urine and encourage excretion of uric acid. Therefore, six to eight glasses of water should be consumed daily, along with plenty of herbal teas and diluted fruit juices.

Consumption of saturated fats impedes uric acid excretion, and consumption of refined carbohydrates, such as sugar and white bread and pasta, increases uric acid production. Both should be seriously limited.

The use of vitamin C should be avoided by people with gout, due to the high levels of acidity.

Resources

BOOKS

Parker, James N., M.D., and Philip M. Parker, Ph. D. The 2002 Official Patient's Sourcebook on Gout. San Diego, CA: ICON Health Publications, 2002.

PERIODICALS

Arromdee, E., C. J. Michet, C. S. Crowson, et al. "Epidemiology of Gout: Is the Incidence Rising?" Journal of Rheumatology 29 (November 2002): 2403–2406.

Conos, Juan J., and Robert Kalish. "Gout: Effective Drug Therapy for Acute Attacks and for the Long Term." Consultant (August 1996): 1752–55.

Emmerson, Bryan T. "The Management of Gout." New England Journal of Medicine (February 15, 1996): 445–451.

Hsu, C. Y., T. T. Shih, K. M. Huang, et al. "Tophaceous Gout of the Spine: MR Imaging Features." Clinical Radiology 57 (October 2002): 919–925.

Lin, J. L., D. T. Tan, H. H. Ho, and C. C. Yu. "Environmental Lead Exposure and Urate Excretion in the General Population." American Journal of Medicine 113 (November 2002): 563–568.

Perez-Ruiz, F., M. Calabozo, G. G. Erauskin, et al. "Renal Underexcretion of Uric Acid is Present in Patients with Apparent High Urinary Uric Acid Output." Arthritis and Rheumatism 47 (December 15, 2002): 610–613.

Raj, J. M., S. Sudhakar, K. Sems, and R. W. Carlson. "Arthritis in the Intensive Care Unit." Critical Care Clinics 18 (October 2002): 767–780.

Shekarriz, B., and M. L. Stoller. "Uric Acid Nephrolithiasis: Current Concepts and Controversies." Journal of Urology 168 (October 2002) (4 Pt 1): 1307–1314.

ORGANIZATIONS

Arthritis Foundation. 1330 W. Peachtree Street, P.O. Box 7669, Atlanta, GA 30357-0669. (800) 283-7800. http://www.arthritis.org.

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). National Institutes of Health (NIH), 1 AMS Circle, Bethesda, MD 20892-3675. <www.niams.nih/gov>.

OTHER

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Questions and Answers About Gout. Bethesda, MD: NIAMS, 2002. NIH Publication No. 02-5027. <www.niams.nih.gov/hi/topics/gout/gout/htm>.

Patience Paradox

Rebecca J. Frey, PhD