A Bout With Gout?
By Leann (Maska) Bassing, MD
Board Eligible Rheumatologist at Yankton Medical Clinic, P.C.
It has been called ‘rheumatism of the rich’ because many years ago, people realized those who were rich were more likely to develop gout than those less well off. The wealthy with access to alcohol and excess food had more gout. Of course, there are more factors than diet contributing to the development of gouty arthritis, including a genetic predisposition and other environmental factors; however, we still counsel patients regarding the effect dietary excess can have on this disease.
Gout is a type of inflammatory arthritis. The term arthritis should be considered a very general term encompassing many different types of diseases that affect the joints. I like to think of the many different types of arthritis as fitting into two categories, one being non-inflammatory (namely, Osteoarthritis, also described as Degenerative Joint Disease or DJD), and the second category being inflammatory. Anyone who has ever experienced the typical symptoms of gout can confirm a flare is intensely inflammatory, often involving a swollen, red, warm joint such as a toe. A classic description is of a joint that is so tender, even the bed sheet resting on it is uncomfortable. These episodes of acute flares are usually separated by longer periods without symptoms.
A very important point to make is regarding the method used to make a diagnosis of gout. It would be incorrect to believe this disease can be diagnosed solely based on a blood test. It is correct, however, to understand gout is caused by an excess of uric acid in the body that can precipitate into crystals that deposit into joints and become a source for inflammation. Measuring the amount of uric acid in the blood does not confirm or reject the diagnosis of gout; it is only a clue. In fact, there are many people who have an elevated uric acid level, who do not necessarily have gout. Instead, the gold standard method to diagnose this disease is to identify the presence of monosodium urate crystals in joint fluid. Yes, this means a small needle is used to aspirate some fluid from the affected joint, then that fluid is viewed under a microscope to see the crystals. This is a simple procedure performed in the office, usually with immediate results.
Treatment is divided into two categories: treating the acute flare, and treatment to prevent further flares. Both efforts are equally important. There are a handful of medications that can be effective at calming down the intense inflammation of a “gout attack.” These include prednisone, colchicine, indomethacin or other NSAID (nonsteroid anti-inflammatory drugs), or injection of steroid directly into the affected joint. Which option is best often depends on the individual patient and their personal medical history.
The long-term treatment of gout is aimed at lowering the amount of uric acid in the body to a level that does not allow urate to physiologically precipitate into crystals. The most common medication used for this purpose is Allopurinol. Febuxostat (Uloric) can be used if someone is intolerant of Allopurinol. An even newer medication called Pegloticase, is given by intravenous route (IV) and has been shown to drop uric acid levels essentially to zero, even ‘melting away’ collections of urate in some patients who develop lump-like tophi on their fingers, elbows, or even ears. This is not often used, however, and like all medications can carry serious potential side effects. And yes, diet can make a difference. Specifically, food and drink high in purines such as beer, organ meat, and shellfish, can raise uric acid levels, and thus trigger a flare.
Lastly, I would be remiss if I did not point out the fact that patients with a diagnosis of gout are often also at higher risk for cardiovascular disease. Much research on this disease is being geared toward that fact. It is very important to treat gout not only to prevent long-term damage to joints that result from recurrent attacks, but also to limit the inflammation we know is a risk for cardiovascular disease.
Gouty arthritis is one of my favorite diseases to treat because I can often help those who suffer from it feel much better, and even help prevent further attacks. Please let me know if I can help you or a loved one who has gout or any other type of arthritis or autoimmune disease.