HYDERABAD: Gout is a painful and potentially disabling form of arthritis that has been around since ancient times. It is sometimes referred to as the “disease of kings,” because people long have incorrectly linked it to the kind of overindulgence in food and wine only the rich and powerful could afford. In fact, gout can affect anyone, and its risk factors vary.
The first symptoms usually are intense episodes of painful swelling in single joints, most often in the feet, especially the big toe. The swollen site may be red and warm. Fifty percent of first episodes occur in the big toe, but any joint can be involved. Fortunately, it is possible to treat gout and reduce its very painful attacks by avoiding food and medication triggers and by taking medicines that can help. However, diagnosing gout can be hard, and treatment plans often must be tailored for each person.
What causes gout?
Gout occurs when excess uric acid (a normal waste product) collects in the body, and needle-like urate crystals deposit in the joints. This may happen because either uric acid production increases or, more often, the kidneys cannot remove uric acid from the body well enough. Certain foods and drugs may raise uric acid levels and lead to gout attacks. These include:
Some medications, such as:
Low-dose aspirin (but because it can help protect against heart attacks and strokes, we do not recommend that people with gout stop taking low-dose aspirin)
Certain diuretics (“water pills”) such as hydrochlorothiazide and Lasix Over time, increased uric acid levels in the blood may lead to deposits of urate crystals in and around the joints. These crystals can attract white blood cells, leading to severe, painful gout attacks and chronic arthritis. Uric acid also can deposit in the urinary tract, causing kidney stones.
Who gets gout?
This condition and its complications occur more often in middle aged men, women after menopause, and people with kidney disease. Gout is strongly linked to obesity, hypertension (high blood pressure), hyperlipidemia (high cholesterol and triglycerides) and diabetes. Because of genetic factors, gout tends to run in some families. Gout rarely affects children.
How is gout diagnosed?
Some other kinds of arthritis can mimic gout, so proper diagnosis (detection) is key. Health care providers suspect gout when a patient has joint swelling and intense pain in one or two joints at first, followed by pain-free times between attacks. Early gout attacks often start at night.
Uric acid levels in the blood are important to measure but can sometimes be misleading, especially if measured at the time of an acute attack. Levels may be normal for a short time or even low during attacks. Even people who do not have gout can have increased uric acid levels.
X-rays may show joint damage in gout of long duration. Ultrasound and dual energy computed tomography (commonly called dual energy CT) can show early features of gouty joint involvement. These imaging techniques also can help suggest the diagnosis Gout also can be diagnosed by aspirating fluid from the joint and examining it under microscope for uric acid crystals .
How is gout treated?
Treatment of acute attacks:
To treat acute attacks generally NSAIDS (Pain killers) are given for short duration . And Colchicine can be added if attacks are recurrent and can be continued for few months to prevent gout attacks . In some cases where pain killers cannot be given due to kidney or heart disease , Injections can be given into the the affected joint which can reduce the symptoms .
Treatment to remove excess uric acid
Patients who have repeated gout flares, abnormally high levels of blood uric acid, or tophi or kidney stones should strongly consider medicines to lower blood uric acid levels. These medications do not help the painful flares of acute gout, so most patients should start taking them after acute attacks subside. The drug most often used to return blood levels of uric acid to normal is allopurinol . It blocks production of uric acid. Another option, febuxostat , also acts by blocking uric acid production.
If you are taking a uric acid-lowering drug, your doctor should slowly raise the dose and keep checking your blood uric acid levels. Once your uric acid levels drop below 6 mg/dL (normal), crystals tend to dissolve and new deposits of crystals can be prevented. You probably will have to stay on this medicine long term to prevent gout attacks.
What works well for one person may not work as well for another. Therefore, decisions about when to start treatment and what drugs to use should be tailored for each patient. Treatment choices depend on kidney function, other health problems, personal preferences and other factors.
What you eat can increase uric acid levels. Limit the amount of high-fructose drinks, such as non-diet soda. Also, do not drink alcohol, especially beer. Restrict eating foods that are rich in purines, compounds that break down into uric acid. These compounds are high in meat and certain types of seafood. New research has found purines in vegetables appear to be safe. Low-fat dairy products may help lower uric acid levels.
In almost all cases, it is possible to successfully treat gout and bring a gradual end to attacks.
Gout often is associated with high blood pressure, heart and kidney disease, or the use of medications that increase uric acid levels. Therefore, health care providers should test for these related health problems.
Living with gout
Gout affects quality of life by both the intermittent attacks and the potential for chronic (lasting) arthritis. Compliance with your treatment plan is critical. Lifestyle changes may make it easier to manage this lifelong disease. Suggestions include gradual weight loss, avoidance of alcohol and reduced consumption of fructose-containing drinks and foods high in purines.
(The author is a Sr Rheumatologist, Star Hospitals)
Summary
Intensely painful, swelling joints (most often in the big toe or other part of the foot) and/or bouts of arthritis that come and go may indicate gout.
Gout treatments exist, but therapy should be tailored for each person. Treatment choices depend on kidney function, other health problems, personal preferences and other factors.
Patients may need medications to lower their elevated blood uric acid levels that predispose to gout. The goal is a uric acid level less than 6 (mg/dL).
There are two types of medicine for gout. For control of acute attacks of joint pain, there are NSAIDs, colchicine and corticosteroids. After gout flares have resolved, there are medications that can lower the level of uric acid over time in order to prevent or lessen attacks.
Lifestyle changes such as controlling weight, limiting alcohol intake and limiting meals with meats and fish rich in purines also can help control gout.