Can you toe the line with gout?

Column by Dr. Tim Moser



Edward went to bed very happy. It was his 50th birthday, and to celebrate he had a seafood dinner and a few beers with friends at his favorite restaurant. Early in the morning, Edward awoke with right big toe pain that matched anything he had experienced in his entire life. It seemed everything made the toe hurt more - the pressure of the bed covers, trying to wriggle his toe, even looking at the toe too hard made things worse. Bearing weight was out of the question. Ed knew he had fun the night before, but he was sure he did not stub his toe, or have any recent trauma. His foot looked infected, since it was red and hot to the touch, but he did not feel feverish.

He called in sick to work that day, and the secretary suggested his symptoms could represent gout. Intrigued, Edward made an appointment for the next day, and the diagnosis of gout was confirmed. With proper medication, the pain and redness disappeared within 24 hours.

Gout is a form of arthritis that can affect any joint of the body, and typically becomes more common as we age. Men are affected more frequently than women. Dietary habits and genetics play a huge role in the risk of developing gout, and how often attacks will occur. In some cases, permanent damage can occur to the affected joints over time.

Ahh, those lovely little crystals

Gout is caused when uric acid crystals form in or near a joint. Uric acid is dissolved in everyone's blood at various concentrations that are easily measured with a non fasting blood test. The problem with uric acid is it barely stays dissolved in the bloodstream. If the level creeps too high, or if other factors are present, then uric acid crystals can form near the joints. Any joint can be the target of uric acid crystal formation, but the large toe is the most common location, followed by the knee and ankle. When a gout attack affects the big toe, it can also be called by the ancient and quaint name Podagra. If a sample of fluid is obtained from inside the affected joint and examined under a microscope with a special filter, the uric acid crystals become visible. They are quite beautiful, with a long slender profile tipped with very sharp ends. Of course, the crystals cannot be seen with the naked eye.

The pain starts here!

It is tempting to ascribe the pain of gout to the sharp ends on those crystals sticking in your joints, but alas, this is not the case. It is your own bodies' immune system that is to blame. Once the uric acid crystals are detected by the body, a mob of white blood cells arrive on the scene. Consider the white blood cells cops on the beat, looking for troublemakers in the body. When the crystals are identified, the white blood cells try to eat them - literally. Acting just like an amoeba, the crystals are engulfed by the white blood cells, and digestive enzymes are released in an attempt to rid the body of the invader. Unfortunately, the result is significant inflammation in the area, with little reduction in the amount of crystals present. A gout attack is born. Over many months, the uric acid may collect into tophi, which are lumps under the skin. If opened with a scalpel, a thick white substance is found that looks identical to toothpaste. This is composed of uric acid crystals and white blood cells.

Relief is just hours away

Treatment of gout involves treating the symptoms of pain and inflammation in the short term, and lowering the uric acid over the long term, to help reduce the chance of having a future attack. If a person's kidney function is normal, one of the preferred methods to reduce the pain from a gout attack it to use a non steroidal anti inflammatory drug, or NSAID, for short. Many NSAIDS are effective. A personal favorite for many years in the drug Indomethacin, which often provides relief within hours of the first dose. Ibuprofen (Motrin, Advil) and Naprosyn (Aleve) are also very effective.

For those that are allergic to NSAIDS, or if decreased kidney function is an issue, the steroid Prednisone can be used. This drug has many side effects when used continuously for the long term. Usually, a one or two week course will eliminate the symptoms of a gout flare.

An older medication with many side effects is Colchicine. This medication acts different from any other, but is very effective in short term use.

Prevention is the best cure

Preventing future occurrences of gout are a major priority, especially for those having the painful attacks. A good rule of thumb is to keep the blood uric acid level below 6.0 for six months or longer. Uric acid is a by product of something we eat in the diet, called purines. High purine content foods are those that are the most tasty - seafood, organ meats, and brewers yeast. An ox spleen is very high is purines, for example. Instead, eat an apple for lunch! Limiting alcohol intake and staying well hydrated can also help.

Prefer the natural route? Cherry juice has natural properties to lower uric acid levels. Drink daily and enjoy.

When medication is needed to lower uric acid levels, Allopurinol is often used. This is taken daily and can be very effective preventing gout attacks and reducing the chance of developing tophi or joint damage. Allopurinol is usually not started or stopped during an acute gout attack.

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