A throbbing, swollen big toe on a overweight, older man’s foot: For many, that’s what comes to mind when they hear the word “gout.” However, with gout, that’s not always the picture.
Women can get gout; so can younger men. Gout attacks ankles, knees, wrist and elbows as well as the great (or big) toe. Obesity, high blood pressure and diabetes increase the risk of developing gout. Family history also plays an important role.
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Gout is an inflammatory and intensely painful type of arthritis. Uric acid, a bodily waste product, is the problem. Excessive uric acid in the blood leads to the formation of urate crystals in the joints. These sharp, needlelike crystals aren’t pretty for people experiencing gout attacks.
In gout flare-ups, joints become red and swollen, with burning or tingling sensations. Joints feel stiff, sore and vulnerable to the slightest movement or touch. Symptoms can take hours, days or even weeks to finally subside. Remissions usually follow, although some people are never symptom-free.
Gout is extremely common: More than 8 million Americans have the condition. Treatments are evolving but there is no cure. If untreated or not well-controlled, advanced gout can lead to joint deformities and disability.
While eliminating certain foods or restricting alcohol may help manage gout, most people need medication.
On July 18, the journal BMJ released its latest guidance on gout management. It advised shared decision-making between health care providers and patients regarding medication choices. The authors touched on the connection between lifestyle and gout symptoms. “Despite limited evidence, patients should be encouraged to manage their weight, increase exercise and reduce alcohol consumption,” they concluded.
Gout Surprise
“College student” and “gout” don’t seem to go together — but they can. “Back in the day, when I was 24, I first experienced a flare-up,” says Gary Ho, now a mortgage loan officer in the Austin, Texas, area. He was strolling across campus when it happened. “Just then, my foot swelled up and I thought maybe I had sprained my ankle or broken something.”
When Ho told his father about the mysterious episode, he learned gout ran in his family. However, his then-doctor dismissed the possibility of gout.
Ho says that in the past, periodic gout flares sometimes left him incapacitated. At his worst, he needed crutches and at one point, a wheelchair. Forced inactivity contributed to his gaining 50 excess pounds.
He describes nighttime agony: “I remember being in bed when a bad flare-up would happen and the simple breeze of a fan blowing across my toe would just send me into absolute pain.”
Who Gets Gout?
“Gout is a leading cause of inflammatory arthritis in men when they’re in their 30s and 40s,” says Dr. Allan Gelber, a professor of medicine in the division of rheumatology at Johns Hopkins University School of Medicine in Baltimore. However, men may develop gout much later in life.
Women also get gout, contrary to what many believe. “Not only does the frequency of gout rise with increasing age, but it also rises exponentially in postmenopausal women,” Gelber says. Younger women who have kidney problems are more vulnerable to gout, as well.
Gout is related to a constellation of health conditions that become increasingly common with age. Overweight and obesity, diabetes, high blood pressure, chronic kidney disease and high cholesterol incidence rises with each decade of life, Gelber says, and gout risk rises along with them.
A big change in understanding gout is the recognition that an individual’s likelihood of having it relates to specific genes, Gelber says. That genetic understanding is important, he says, because it’s opening the door to new gout treatments.
Measured by a simple blood test, high uric acid doesn’t necessarily mean someone has gout. However, uric levels provide a benchmark for treatment decisions and to gauge how well gout is being managed. A blood level of 6.8 milligrams per deciliter or more is defined as high uric acid, or hyperuricemia. The standard goal for gout patients is to achieve a uric acid level below 6 mg/dL.
To actually diagnose gout, clinicians draw a fluid sample from the big toe or other affected joint. Under the microscope, uric acid crystals become visible.
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Gout Medications
Certain common medications — used by many older adults — may raise uric acid levels as an unwanted side effect. Dr. Christopher Parker, chief of rheumatology at the Austin Diagnostic Clinic in Texas, says one of the first things he thinks about with new patients is whether they’re taking any medications that could safely be stopped or replaced. For example, certain diuretics used to treat high blood pressure may increase uric acid levels.
Depending on how severe gout is, treatment options include the following medications to lower uric acid, prevent flare-ups and treat pain:
— Nonsteroidal anti-inflammatory drugs. During gout flare-ups, NSAIDs such as ibuprofen (Motrin, Advil) and naproxen (Naprosyn) reduce pain and inflammation. In some cases, prescription steroid drugs may help if over-the-counter NSAIDs aren’t enough.
— Colchicine. Colchicine in tablets (Colcrys or generic) or capsules (MItigare) is prescribed to treat gout symptoms such as joint pain and swelling.
— Allopurinol. Patients looking for a tried-and-true medication to control uric acid should ask about allopurinol first, Parker says. Allopurinol, which has been used to treat gout for about five decades, has a long track record for effectiveness, he says. Given once daily, allopurinol is generally well-tolerated by patients. However, providers and patients should be vigilant in watching for potential side effects including fever, sore throat, nausea, headaches and skin rash.
— Febuxostat. In the early 2000s, two new gout-fighting drugs came along. Febuxostat (brand name Uloric), works on the same enzyme — xanthine oxidase — as allopurinol to lower uric acid. However, Gelber explains, febuxostat, unlike allopurinol, is broken down, or metabolized, in the liver instead of the kidney — making it safer than allopurinol for patients with kidney problems. Febuxostat was reported on in the New England Journal of Medicine in 2005 and approved by the Food and Drug Administration in 2009.
— Pegloticase. For some patients at the severe end of the gout spectrum, pegloticase (brand name Krystexxa), which received FDA approval in 2010, is given by intravenous infusion. Advanced polyarticular tophaceous gout is more common in men, Gelber notes. Multiple joints are involved with this form of gout, in which soft-tissue deposits on the joints, and related bony destruction or erosions, cause irreversible deformities. These deposits, called tophi, can be now be “zapped” with this drug, he says, through abrupt, marked reductions in circulating levels of uric acid.
— IL-1 blockers. Within the past few years, drugs that block an immune-regulating protein, or cytokine, called interleukin-1 — which plays a key part in inflammation signaling during gout flare-ups — have been used off-label for some patients with severe gout. These IL-1 blockers (anakinra, canakinumab and rilonacept) are given by injections beneath the skin. These drugs “are considerations for those whose adverse health profiles preclude conventional treatment options,” Gelber says.
— Lesinurad. In 2015, the drug lesinurad (brand name Zurampic) was approved to treat gout by targeting “solute-transport carriers.” These are uric-acid transport proteins in the kidney that prevent excess uric acid from being released from the body. Lesinurad was approved for use together with one of the xanthine oxidase-inhibitor drugs. The presence of urate transporters is tied to specific genes related to gout risk, Gelber says.
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Diet may play a minor role in gout prevention. That’s related to purines, which are natural substances found in certain foods and drinks. Purine-rich foods and alcoholic beverages can contribute to uric-acid buildup. However, diet control is not a panacea.
Organ meats such as beef liver, sweetbreads, brains and kidneys; some seafood and beer are particularly high in purines. Mackerel, herring, sardines and anchovies have high purine content, as do scallops. Asparagus and mushrooms — plant foods usually thought of as healthy — are problem foods for people with gout.
Improvement Happens
About eight years ago, Ho turned his gout situation around. That’s when he sought specialized gout treatment from Dr. Parker, whom he credits for much of the improvement. Learning more about gout and the importance of keeping his uric acid levels down empowered Ho to do so. He also lost the excess weight in the process. “So at 49, I’m probably the healthiest right now as I’ve ever been,” he says.
Ho, who has not experienced a gout flare-up in years, wants others to share his success. He encourages fellow patients to see a rheumatologist, if possible, one who will really understand their condition and help keep gout management on track.
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Getting the Better of Gout originally appeared on usnews.com
