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Gout

By Vivian Oputa
Gout which is a potentially disabling form of arthritis is sometimes referred to as the “Disease of Kings” because of its age old link to the overindulgence in food and wine that only the rich and powerful could afford.

The reality is that anyone can be affected and the risk factors are varied. Fortunately, this condition is treatable and the agonizing attacks can be reduced by avoiding foods that trigger them and taking advantage of treatment options available.

Initial symptoms usually include intense episodes of painful swelling with associated redness, heat and stiffness in single joints. This swelling most often affects the feet (especially the big toe) but could also affect other joints. Treatments which have to be tailored to meet individual needs are now available to treat most cases.

Gout occurs when a normal waste by_product of purine metabolism known as Uric Acid accumulates in the body and its crystals deposit in the joints and sometimes the kidneys and urinary tract. Purines naturally occur in the body and in certain foods. Gout in most cases may occur as a result of the kidneys inability to adequately remove uric acid from the body or because there is an increase in uric acid production.

Certain foods, such as red meat, shellfish and alcohol may lead to increased uric acid levels which in turn may lead to a gout attack. There are also medications that may lead to increases uric acid levels such as low_dose aspirin, diuretics such as hydrochlorthiazide and immunosuppressants such as cyclosporine and tacrolimus used in organ transplantation.

Over time, raised levels of uric acid may lead to deposits of Monosodium Urate crystals in and around the joints. These crystals attract white blood cells (cells of inflammation) leading to severe painful gout attacks. The crystals may also deposit in the urinary tract leading to kidney stones.

Other crystal deposits composed of Calcium Pyrophosphate Dihydrate cause another condition known as Pseudogout (false gout). Psuedogout is more likely to attack the larger joints such as the knees, ankles and wrists. This condition may also affect the big toe thus mimicking gout.

Gout affects about 1% of the population and men generally more often women. The occurrence of gout and its associated complications is more often seen in Men, Menopausal women and individuals with Kidney disease. During Menopause, Oestrogen levels which encourage the kidneys’ excretion of uric acid reduce drastically leading to its accumulation.

By age 60 years, the number of cases of gout in women equals that in men and by age 80 years, more women than men have gout. There a strong association between gout and Obesity, Hypertension, Diabetes and Hyperlipidaemia. There is also a hereditary factor as gout tends to run in some families.

Potential triggers of gout include Crash Diets, Sudden, severe illness, Surgery, Stress,
Chemotherapy, High blood pressure, Joint injury and Excessive exercise.

Diagnosis
Proper diagnosis is essential as several other forms of arthritis may mimic this condition. Initial gout attacks often occur at night and gout should be suspected if the patient experiences pain_free periods between attacks of joint swelling and intense pain. Blood uric acid levels may be misleading as these levels may be temporarily normal or low during attacks and individuals without gout may have elevated levels. Urine may be tested for uric acid levels.

A definitive diagnosis may depend on finding the characteristics crystals in a needle aspiration of an affected joint. Your doctor may use a needle to extract fluid from the affected joint and examine it under a microscope. These crystals may also be found as lumpy deposits under the skin (known as Tophi) commonly present around the elbows, heels or ears which are usually seen in advanced cases.

Treatment
Non_steroidal anti_inflammatory (NSAIDs) drugs are used for acute attacks of gout. These include Ibuprofen and Naproxen. These medications however have side effects such as stomach pain, ulcers and bleeding. They also have a ceiling effect which means that there is a limit to how much pain they can control so beyond a certain dosage, there are no additional benefits. Colchicine is also useful within the first 12 hours of an attack but it has associated side effects such as nausea, vomiting and diarrhoea.

People who are unable to tolerate NSAIDs may be given COX2 selective agents such as Celecoxib (this is not to be taken by individuals with impaired kidney function). For severe cases, your doctor may prescribe oral corticosteroids such as prednisone. Steroids usually provide dramatic results but may have dangerous side effects such as suppressed immunity, thinning of bones and poor wound healing.

Some doctors inject steroids directly into affected joints but this practice is limited to 3 times a year because of the associated side effects. Resting the affected joint and applying a cold compress may also help alleviate the pain.

Once an acute attack is under control, the next step is to prescribe preventive treatment to either slow the rate at which the body produces uric acid or to increase the rate at which it is excreted form the body. Allopurinol blocks the production of uric acid and is the most often prescribed agent used to normalise uric acid levels. Probenicid and Sulfinpyrazone help the kidneys eliminate uric acid.

Prevention
Keeping uric acid levels within the normal range is the goal to help prevent acute attacks. Gradual weight loss may help decrease uric acid levels but rapid drastic weight loss may temporarily raise uric acid levels.

Although medications available for the treatment of gout have reduced the need for severe dietary restrictions, some dietary changes may help reduce the severity of gout attacks.

Excessive amounts of animal protein including beef, poultry and fish should be avoided as these high protein foods increase blood uric acid levels. Organ meats such as liver, brains and kidney as well as anchovies, herring and mackerel are particularly high in purines.
Consuming too much alcohol could inhibit the excretion of uric acid which in turn can lead to gout. Drinking plenty of water and other liquids is beneficial as this helps dilute the uric acid in the blood stream.

Foods High in Purines include: All forms of alcoholic beverages, Some fish, seafood and shellfish including anchovies, sardines, mackerel, haddock, herring, mussels, codfish, scallops and trout, Some meats such as bacon, turkey, veal, venison and organ meats like liver and kidney.

Foods with Moderate Purine Content include: Meats such as beef, chicken, duck, pork and ham; Crab, oysters, lobster and shrimp; Vegetables and beans such as lentils, kidney beans, asparagus, lima beans, spinach and mushrooms.


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