Dear Doctor Column, April 26, 2004
Treatment Available for Painful Gout
Question:
My husband has had three flare-ups of gout in his big toe over the last 6 months. Is there anyway to prevent these attacks? Does he need to be on a special diet?
Answer:
Gout is a form of arthritis caused by elevated levels of uric acid in the blood. Uric acid is a waste product of the body's metabolism that increases in the blood when the body either makes too much or the kidneys fail to excrete enough. As uric acid in the blood and body fluids increases, crystals may form in joint fluid, setting the stage for intense inflammation, causing severe pain, swelling, heat, and redness of the involved joint.
However, not everyone with an elevated uric acid level develops gout — only about 20% do. Why some people develop gouty arthritis and others do not is not clear. But, the higher the level of uric acid in the blood and the longer it remains high the more likely an acute attack of gout will develop.
Although gout most commonly attacks the big toe, the disease can affect any joint. Typically, the affected joint remains painful for several days, although a severe attack can last for weeks if left untreated.
Gout accounts for about 5% of all arthritis cases, and men aged 40 to 50 years are the most susceptible. Women rarely develop the disease before menopause, and gout is rare in children and young adults.
What happens after the first attack of gout varies from person to person. Some people never have another attack. For others, an attack may not occur for years. But for more than 60% of people, another attack will strike within months. Repeat attacks can involve either one or multiple joints, including the feet, knees, hips, hands, elbows and shoulders. A few people suffer frequent recurrent bouts of arthritis with almost constant joint pains that can lead to progressive destruction of cartilage and bone surrounding a joint.
Long-term accumulation of uric acid also may produce lumps, called tophi, just beneath the skin; common sites are the elbows and the ears. Another complication occurs when uric acid crystals deposit in the kidney, causing kidney stones. About 20% of people with gout develop kidney stones.
Today, treatment of gouty arthritis is generally effective, and recurrent attacks can be prevented. The classic treatment for acute gout is colchicine, a drug used for centuries, which can relieve a gout attack but often produces diarrhea and nausea or vomiting before completely relieving symptoms. Consequently, high doses of nonsteroidal anti-inflammatory drugs are used more often today. Aspirin should not be used as it makes an acute attack worse.
A drug to lower uric acid levels in the blood and prevent recurrent attacks is recommended for everyone with visible tophi and in those who have had two or more major attacks of gouty arthritis in a year. Two types of drugs are available to prevent future attacks; one promotes the loss of uric acid through the kidneys; the other blocks the body's production of uric acid. Lowering blood uric acid levels usually decreases the frequency of arthritis attacks, especially after a year or so of treatment. It also helps prevent the other complications crystal deposits can cause.
Gout has long had a reputation as a disease that results from eating too much rich food and drinking too much alcohol. In the past, people with the disease were advised to avoid foods containing purines, which are broken down by the body into uric acid. These foods include liver, sardines, anchovies, and dried peas.
Because of the effectiveness of new medications used to control blood uric acid levels, however, limiting foods is usually no longer essential. However, alcohol does impair the ability of the kidneys to eliminate uric acid from the blood. Therefore, physicians suggest patients with gout avoid, or severely limit, wine and other spirits.
For more information about gout, visit the Arthritis Foundation Web site.