Features May 2004 Issue

Goodbye Gout

One of the most painful forms of arthritis, this lower-extremity disease can be controlled—and prevented. Here’s how.

Imagine waking up in the middle of the night with your big toe throbbing fiercely—as if someone had poked it with a hot iron. Chances are you have gout.

“Acute gout attacks are unmistakable,” says Dr. Brian Mandell, education program director of rheumatology and immunologic disease at The Cleveland Clinic. “They are excruciating episodes usually involving a joint in the lower extremities and are characterized by redness, swelling, extreme pain, and skin sensitivity.”

Gout strikes without prejudice. While the disease commonly affects men and post-menopausal women, those with kidney disease are also at risk. Genetics can also dictate who gets gout and who doesn’t. It is strongly associated with obesity, hypertension, high blood lipids, and diabetes.

The best way to prevent gout? Eat a balanced diet, maintain a healthy body weight, and, above all, avoid excessive alcohol.

What causes gout?
In the past, gout was known as “the disease of Kings,” a simplistic characterization that referred to the disease as a condition reserved for wealthy gluttons who overindulged in alcohol, a trigger for acute gout attacks.

“The idea that gout was an ailment targeting the wealthy is a common misperception,” says Dr. Mandell. “It has always been widespread in the general population. It was just more visible in the luxurious settings where intermittent alcohol use was prevalent.”

Now, a growing incidence across all social and economic levels is helping to shatter the long-held myth even further. A study by the Mayo Clinic found that the number of gout cases has more than doubled in the last two decades. Even so, the American College of Rheumatology estimates that gout afflicts only eight out of every 1,000 people. Those may be favorable odds, but if you’re among the unfortunate who fall victim to gout, that’s small consolation.

Gout, or gouty arthritis, results from an abnormal build-up of uric acid in the blood, a condition called hyperuricemia. Uric acid is a by-product of normal metabolism; the body relies on the kidneys to filter it out and excrete it in the urine. But if one of those mechanisms goes awry, the excess uric acid will continue to accumulate in the blood and may eventually crystallize in the joints, prompting very intense pain.

“Not everyone who has high levels of uric acid forms crystals. We don't know why some do and why some don’t,” says Dr. Mandell.

Keeping attacks at bay
There is no diagnostic blood test for gout. If your doctor suspects the disease, a sample of joint fluid will be taken, while you’re experiencing an attack, and examined under a microscope for crystals.

Initial gout attacks will resolve themselves in time. But in some cases, patients experience recurrent attacks that involve an increasing number of joints. Non-steroidal anti-inflammatory drugs (NSAIDs) are the preferred treatment for most acute episodes, although colchicine, in use for centuries, remains a standard as well. Corticosteroid pills or injections may also be used.

Patients who have had multiple gout attacks may be prescribed prophylactic medications, such as allopurinol or low-dose colchicine, aimed at normalizing uric acid levels in the body. With appropriate treatment, gout can be easily controlled in almost all cases.

While many Internet sites promote dietary modifications to reduce gout attacks, Dr. Mandell believes otherwise.

“Diet doesn’t help a lot, unless you've been on a fairly unusual diet of organ meats,” he admits. “What makes a big difference in controlling gout attacks is how much alcohol you consume.” Alcohol abuse is a major cause of gout—alcohol not only triggers excess uric acid production, it also halts its excretion.

And popping a few aspirin won’t heal this type of hangover.