Question: I
enjoyed your recent article on shingles and found it to be
well explained and easily understood. I have similar
questions regarding gout, how you get it, the symptoms and
what you can do to cure it or alleviate the symptoms.
Rudy Childs, Rockland, MA
Answer: Gout is a type of arthritis. It was first
described centuries ago and it is just as common today. It
is estimated that about one in 125 people in the U.S. suffer
from gout. It can cause tremendous pain and debility, and,
in its severest form, can cause renal failure and even
death.
An excess of a compound called uric acid in the bloodstream
causes gout. Uric acid results from the breakdown of
proteins in the body, either ingested proteins (like meat
and fish) or body tissue proteins (like muscle and white
blood cells). This uric acid needs to be excreted along with
other waste and it is the kidney’s job to get rid of most of
it. If the kidney can’t keep up with the amount of uric acid
circulating in the blood, uric acid crystals may form. These
crystals can then become lodged in parts of the body,
especially in the joints.
When uric acid crystals become lodged in a joint, this is
known as an acute gouty arthritis. The joint becomes
intensely painful and inflamed, as the body’s immune system
reacts to the uric acid crystals. Any joint may be affected,
but the most common joint is the first metatarsophalangeal
joint. This is where the big toe joins the foot. Acute
arthritis of the big toe is so typical of patients with gout
that it has its own name: podagra. However, no joint is safe
from gout; it also commonly affects the knee, ankle, elbow
and shoulder.
An attack of gouty arthritis usually occurs suddenly and
reaches maximum intensity within 24 hours. Without
treatment, most attacks will resolve within two to three
days, but severe attacks can last weeks. Fortunately, we
have treatments for gouty arthritis that can improve the
pain and shorten the attack’s duration.
One of the most commonly used classes of medication for gout
is the non-steroidal anti-inflammatories (NSAIDS). NSAIDS
include ibuprofen (otherwise known as Motrin or Advil),
naproxen (Naprosyn or Aleve), feldene, iodine, indocin and
mobic. NSAIDS are very effective at relieving the pain and
inflammation of an attack and are usually the first line of
therapy, especially in seniors. However, NSAIDS can have
serious side effects, including ulcers and gastrointestinal
bleeding. If you have a history of ulcers, use caution when
taking these medications, and do so under the care of your
doctor.
Another family of medications used for gout is the COX-2
inhibitors, including celebrex and bextra (another member,
vioxx, was recently taken off the market). These medications
are “cousins” to NSAIDS and reduce inflammation and pain.
They are somewhat safer for the stomach than NSAIDS, but
recent concerns about their safety have prompted doctors to
use them very cautiously and sparingly. Your doctor may
prescribe celebrex or bextra for an acute attack of gouty
arthritis, since the medication is usually very short-term.
Although aspirin is a cousin to NSAIDS and COX-2 inhibitors,
it is rarely used for gout, since it can decrease the
kidney’s ability to excrete uric acid, worsening the
situation.
If NSAIDS and COX-2 inhibitors are too risky, your doctor
may use a medication called colchicine. This is a powerful
anti-inflammatory used specifically for acute gouty
arthritis. It is usually quite effective, but has
potentially serious side effects including profuse diarrhea
and GI upset. It definitely should be used in low doses in
seniors.
Occasionally, gout is so severe and limiting that it needs
to be treated with cortisone-like medications (steroids)
such as prednisone, which needs to be given in a tapered
fashion – an initial big dose followed by smaller and
smaller doses. Steroids can seriously suppress the immune
system and are a last resort for gout. To minimize these
side effects, the steroid may be given as an injection into
the affected joint. This decreases the risk of side effects
from the medication, but is painful and carries a risk of
infection and bleeding.
It may seem discouraging that the treatments for this
painful condition are risky, but if you work with your
doctor, you should be able to find a medication that can
safely be used to treat the arthritis.
Once the acute arthritis has resolved, anti-inflammatory
medications can be stopped. However, the gout is not cured,
and unless a preventative medication is begun, the arthritis
may flare up again. Additionally, uric acid in the blood
that is not being properly excreted can do other, more
silent damage to the body. The crystals may be deposited in
the skin, causing raised lesions called tophi. These are not
necessarily painful, but they are unsightly and are a
reminder that the uric acid problem is not solved. Uric acid
crystals may coalesce in the urine, causing renal stones,
which are extremely painful and could lead to severe urinary
infections. Most seriously, uric acid crystals may
permanently damage the kidneys, leading to impaired
excretion of toxins, and possibly to renal failure.
Untreated gout can progress to renal failure in less than 10
years.
That is why gout should be treated with preventative
medicine even if no acute attacks have occurred or the
attack has resolved.
The most commonly used medication to prevent uric acid
buildup is call allopurinol (zyloprim). Allopurinol prevents
the formation of uric acid from its components. It is
necessary to take it every day if you are diagnosed with
gout, whether or not you notice any symptoms. Interestingly,
starting allopurinol may precipitate an acute gouty
arthritis attack, so a few days of an NSAID or colchicine is
needed to successfully start taking allopurinol. It is very
important to continue taking the medication, however,
usually for life.
There are non-medical treatments for gout as well. Uric acid
is made from the breakdown of proteins and is increased by
alcohol, so a healthy low-protein diet and abstinence from
alcohol will help prevent gouty attacks. When early
physicians first described gout, the “typical” patient was a
wealthy, overweight male who ate and drank more than was
good for him! These patients were put on a strict diet,
since no medications were available.
However, we now know that dietary indiscretions alone do not
cause gout. Most people also have a genetic predisposition
to gout, usually an inability to properly metabolize uric
acid.
For gout patients, diet is not enough, unfortunately, to
ensure that the kidneys are not damaged, but it will help
the body to require less allopurinol to control uric acid.
Also, avoiding dehydration helps to prevent gouty attacks –
the kidneys do a better job of excreting everything when
well-hydrated.
Gout is a disease that has afflicted mankind since the
beginning of time. Before the development of today’s
effective medications, especially allopurinol, gout led to
frequent painful attacks of arthritis and kidney stones and
often led to disability and death from renal failure.
Fortunately, we can now treat and control gout, but it must
be properly diagnosed and not taken for granted if its most
serious effects are to be avoided! |
