Gout

Introduction

It usually begins at night. Your big toe is so painful, red, and swollen that even touching your legs with a sheet is unbearable. This feeling is probably not the result of an infection, but most likely a form of arthritis called gout.

Gout is one of the oldest known diseases. It was mentioned in the medical literature as early as 2000 years ago. Originally, people believed that eating a diet consisting mostly of meats and rich foods caused gout. Because of this, it was nicknamed "the disease of kings." Today we know that anyone can develop gout and overeating is not the only risk factor.

What is it?

Gout is a type of arthritis (inflammation of the joints) that mostly arises in men age 40 years and older. Women can also develop gout, although it is more likely to occur after menopause. Gout is caused by a buildup of needlelike uric acid crystals in the joints. Uric acid is a waste product in your body that comes from two sources:

  1. Normal cell metabolism
  2. Digestion of the food you eat

Under normal conditions, most uric acid is passed through the kidneys and is eventually excreted in the urine. There is a small amount of uric acid in your blood at all times, which does not cause problems. However, in patients with gout, amounts of uric acid in the blood is higher than normal, either because their body produces too much uric acid or because their kidneys are unable remove uric acid from the blood. The excess amount of uric acid in individuals with gout is stored in the joints and over a period of time may result in crystal formation. The uric acid crystals deposited in the joints are responsible for the excruciating pain of gout.

What causes it?

There are two types of gout, primary and secondary, depending on the cause of high uric acid in the blood.

Primary Gout: Primary gout is the most common. In primary gout the cause of excess uric acid is usually not known. Most scientists believe that primary gout is caused by genetics, which means that patients probably inherited this condition from someone in their family. The basic defect is either an impaired clearance of uric acid by the kidneys (also termed "underexcreter"), an increase in production of uric acid (termed "overproducer"), or a combination of both defects.

Secondary Gout: In secondary gout, the cause of excess uric acid is usually known. Most commonly, secondary gout is caused by certain medications, foods high in purine, or health conditions.

Medications that may cause secondary gout include:

  • Diuretics ("water pills"), such as chlorothiazide (Diuril), chlorthalidone (Hygroton), hydrochlorothiazide (Ezide, HCTZ), metolazone (Zaroxolyn), bumetanide (Bumex, Edecrin), ethacrynic acid, furosemide (Lasix), torsemide (Demadex)
  • Pyrazinamide (PZA)
  • Cyclosporine (Sandimmune, Gengraf, Neoral)
  • Aspirin
  • Ibuprofen (Advil, Motrin, IBU)
  • Nicotinic acid (Niacin)
  • Levodopa

Foods that contain Purine:

  • High levels: Liver, kidney, anchovies, sardines, herring, mussels, bacon, codfish, scallops, trout, haddock, veal, venison, turkey, alcoholic beverages
  • Moderate levels: Asparagus, beef, bouillon, chicken, crab, duck, ham, kidney beans, lentils, lima beans, mushrooms, lobster, oysters, pork, shrimp, spinach

Health conditions that may cause secondary gout include:

  • Alcoholism
  • Leukemia
  • Lymphoma
  • Lung cancer
  • Smoking
  • Psoriasis
  • Obesity
  • Kidney dysfunction
  • Congestive heart failure
  • Starvation
  • Anemia
  • Untreated high blood pressure
  • Diabetes
  • Severe illness or injury
  • Immobility due to bed rest
  • Down syndrome
  • Thyroid disorders

Who has it?

It is estimated by the Center for Disease Control and Prevention that three million Americans suffer from gout attacks. Gout is ten times more common in men than in women. Gout predominantly attacks males after the age of 40 years and peaks at the age of 75 years. In women, gout attacks primarily occur after menopause.

What are the risk factors?

Risk factors are characteristics that can predispose you to developing a condition. The following are key risk factors for developing gout:

  • Alcoholism (especially beer drinking)
  • Obesity and, to a minor extent, overeating
  • Certain medical conditions and medications (see section titled "What causes it?")
  • Family history of gout
  • High blood pressure
  • Age and sex: men 40 years of age and older are at higher risk

What are the symptoms?

Depending on the symptoms, gout is divided into four different stages:

  1. Asymptomatic: This is the first stage of gout in which uric acid levels in the blood are abnormally high. However, individuals usually do not have symptoms during this stage. This stage is like the "quiet before the storm."

  2. Acute gouty arthritis: In this stage, individuals experience a sudden onset of symptoms. At first, only one joint is affected (usually the big toe). Later, other joints may become involved, most commonly the ankles, knees, hands, wrists and elbows. Symptoms of this phase may include:
    • Sudden, severe, crushing pain around the affected joints
    • Swelling of the joint
    • Redness around the joint
    • Low-grade fever
    • Loss of appetite

  3. Intercritical gout: The period in between attacks is called intercritical gout. Most individuals who experience a gout attack experience it again within 1 year of the first attack, especially if untreated. Patients usually do not have any symptoms during this phase.

  4. Chronic tophaceous (pronounced: ?toe-fay-she-us?)gout: Sometimes gout can progress into a chronic condition. Symptoms of chronic gout include:
    • More frequent gout attacks (although these are often less intense than the first attack)
    • Constant mild pain and inflammation of involved joints
    • Destruction of cartilage and bone
    • Development of "tophi,"(pronounced: ?toe-fy?) --solid deposits of uric acid crystals in the joints, tendons, soft tissues, bones, and cartilage, especially on the ears, fingers, hands, forearms, knees, and elbow
    • Kidney dysfunction
    • Kidney stones

How is it treated?

Except for decreasing the amount of alcohol intake and cutting back on meats, there is little an individual can do to avoid a gout attack. Certain medications can be used to help prevent attacks. Most of the time, gout occurs unexpectedly and has to be treated with medications.

  1. Acute Gout: The goal of therapy for acute gout is to decrease the excruciating pain and inflammation of the joints. The medications used include:
    • Non-steroidal Anti-Inflammatory Drugs (NSAIDs) such as indomethacin (Indocin), ketoprofen (Orudis), oxaprozin (Daypro), diclofenac (Voltaren), ibuprofen (Motrin, Advil), etodolac (Lodine), naproxen (Naprelan, Naprosyn, Aleve), sulindac (Clinoril) and others. Non-steroidal anti-inflammatory drugs (NSAIDs) are considered to be the best treatment available, which means that they are preferred over any other medication in acute gout. NSAIDs block prostaglandins, the substance that dilates blood vessels and causes inflammation and pain of gout. NSAIDs are generally taken by mouth three or four times daily, usually for as long as the afflicted individual has gout symptoms.

    • Colchicine has been used to treat gout for years. Colchicine works well to eliminate the pain of gout; however, many individuals cannot tolerate its side effects, which include diarrhea, nausea, vomiting, and abdominal cramps. For this reason, colchicine is regarded as a second line therapy for acute gout and is only used in persons who have contraindication to NSAIDs.

    • Corticosteroids, such as prednisone, prednisolone, and triamcinolone. Some steroids can be injected directly into the joint or a muscle to relieve the pain locally. Steroids are not used very often in acute gout because they do not work as well as NSAIDs or colchicine. They are the "last resort" therapy, used only in persons who cannot take NSAIDs or colchicine (as determined by a physician).

  2. Chronic Gout: The goal of therapy for chronic gout is to prevent an acute gout attack from recurring. People who have more than 2 gout attacks a year, have a presence of tophi, or have renal (kidney) insufficiency are generally recommended to receive gout prophylactic treatment. This is sometimes accomplished by decreasing the uric acid levels. The following medications are used:

    • Xanthine Oxidase Inhibitors, such as allopurinol work by decreasing the amount of uric acid produced by the body. Allopurinol is usually prescribed for persons who produce excessive amounts of uric acid in their body ("overproducers").

    • Uricosuric Agents, such as probenecid or sulfinpyrazone, work by helping the kidneys get rid of the excess uric acid produced in the body. Uricosuric agents are usually prescribed for people whose kidneys cannot eliminate uric acid from the body ("underexcreters").

Helping Yourself

Some things you can do to decrease the amount of uric acid in your body and help prevent gout attacks include:

  • Avoid alcohol. Heavy drinking, especially binge drinking of beer can cause excessive production of uric acid in the body.

  • Avoid overeating. Diets high in protein, especially meats, yeast products, oatmeal, spinach, cauliflower, and lentils can increase uric acid in the body.

  • Lose excess weight. Careful, supervised weight-loss can help decrease the amount of uric acid in the body. On the other hand, avoid crash dieting and other quick weight changes, since these can increase the amount of uric acid in the body.

  • Drink 6 pints of fluid a day to stay hydrated. Natural spring water has been recommended. Drinking plenty of fluids can help remove the uric acid crystals from the body, decreasing the chances of gout attack.

What is on the horizon?

PEG-uricase is a mammalian derived enzyme which may be useful in decreasing uric acid in patients with gout. This drug is currently being tested for its safety and efficacy. If the trials are favorable, then we may see PEG-uricase as a new therapy for gout.

Additionally, Lumiracoxib, a Cox-2 inhibitor like Celebrex, is currently in the late stages of testing. If trials go well we may see this drug utilized more often with gout.

Studies are being conducted with the use of low frequency sound waves to help relieve pain associated with gout. However, these studies are preliminary.

References

American academy of family physician home page. Available at: http://www.aafp.org/afp/990215ap/925.html. Accessed April 2006, April 12, 2007, and June 4, 2008.

Discovery health home page. Available at: http://health.discovery.com/encyclopedias/illnesses.html?article=663. Accessed April 12, 2007, and June 4, 2008.

Hawkins DW, Rahn DW. Gout and hyperuricemia. In Dipiro JT, Talbert RL, Yee GC, and others, eds: Pharmacotherapy: A Pathophysiologic Approach. 6th ed. New York: McGraw-Hill; 2005: 1705-1711.

Health world online. Available at: http://www.healthy.net/asp/templates/article.asp-PageType=article&ID=1653. Accessed April 2006, April 12, 2007, and June 4, 2008.

MSN health home page. Gout. Available at http://health.msn.com/encyclopedia/healthtopics/articlepage.aspx?cp-documentid=100071771: Accessed April 12, 2007.

Reginato AJ. Gout and other crystal arthropathies. In Braunwald E, Fauci AS, Kasper D, and others, eds: Harrison's Principals of Internal Medicine. 15th ed. New York: McGraw-Hill; 2001:1994-1998.

Palmer T, Toombs J. Managing joint pain in primary care. J Am Board Fam Pract. 2004;17:s32-42.

Efficacy and Safety of Lumiracoxib 400mg Once Daily in Acute Flares of Gout. ClinicalTrials.gov. http://clinicaltrials.gov/ct/show/NCT00170781?order =2. Accessed April 2006, April 12, 2007, and June 5, 2008.

Pegylated Recombinant Mammalian Uricase (PEG-Uricase) as Treatment for Refractory Gout. ClinicalTrials.gov. http://clinicaltrials.gov/ct/show/NCT00111657?order =1. Accessed April 2006, April 12, 2007, and June 5, 2008.

Center for Disease Control and Prevention. Arthritis types-gout. Available at: http://www.cdc.gov/arthritis/arthritis/gout.htm. Accessed June 5, 2008.

Gout Health Condition Last Updated: June 2008

Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.

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