Gout Is Now Equal Opportunity Pain Inflictor Posted on Tuesday, August 01, 2006
No Longer a Disease of Wealthy Old Men By Wendy J. Meyeroff THE ERICKSON TRIBUNE “For most people, their image of someone with gout is a 19th century cartoon of an aristocratic older man, with his foot swaddled in bandages and up on a stool. “For years gout was considered a disease of royalty. They were the only people who could afford to eat and drink to excess, two of the main causes of the disease,” says Leslie Brandwin, M.D., medical director of Greenspring, a community in Virginia built and managed by Erickson. That’s not true anymore, according to Brandwin. Today gout is an equal opportunity disease, affecting at least 2 million Americans. And while women can be affected (usually after menopause), men—especially older men—are at least twice as likely to face this form of arthritis. “Out of every 20 patients, 2 are women and 18 are men,” says Brandwin. Understanding Gout “Gout is caused by an excess accumulation of uric acid in the blood, which is eliminated through the kidneys. In people with gout, there is a problem with getting that uric acid out of the system. Instead, uric acid in the form of crystals deposits in certain joints,” says Brandwin. “There are actually two main reasons uric acid accumulates: either your kidneys aren’t eliminating it efficiently enough, or you are forming more uric acid than normal,” says Ira Fine, M.D., assistant professor of rheumatology at Johns Hopkins University in Maryland. “The most common place for deposits to form is the big toe, thus the old image of the swaddled foot. In a gouty foot, the pain is so intense even laying a blanket on it can be unbearable. The knee is the next most likely place for gout to develop and sometimes the elbow,” says Brandwin. Avoiding Precipitating Factors “Some foods can cause gout, especially organ meats like liver and kidneys. It is believed other meats can contribute as well. Large intakes of alcohol are another contributor,” says Brandwin. “We generally don’t restrict diet much, but one thing we do recommend modifying is alcohol intake. Remember, alcohol is a drug,” says Fine.
“Another cause is low doses of aspirin, like the kind we prescribe to prevent heart disease. Interestingly, higher doses of aspirin help spur the elimination of uric acid. If I have to choose between the low aspirin regimen and someone getting gout, I recommend lowdose aspirin, and then treat their big toe if gout flared. Anybody with gout who undergoes changes in fluid balance is at risk of an acute episode. Surgery, for example, can affect fluid balance and precipitate an acute flare-up,” says Brandwin. A Disease Unwise to Ignore There are several stages of gout. In acute gout you experience periodic flareups in which the joint becomes inflamed. “If you have a gouty episode and do nothing about it, you have a 100 percent chance of it recurring, usually within a year,” says Brandwin. Even people with asymptomatic gout (there are no immediate symptoms) would be wise to have themselves tested. Both Brandwin and Fine agree it is unwise to ignore such flare-ups. That is especially true since gout is relatively easy to treat but very destructive if ignored. “Beyond the pain gout causes, if left untreated it can destroy joints, create kidney stones, cause a problem called tophi (in which big, ugly bumps appear on the skin) and cause all sorts of internal damage, including to the heart,” says Brandwin. “If there is a family history you should definitely be tested. I also recommend it to anyone age 60 or older. It’s a simple blood test, just like checking your cholesterol level, and can be done as part of your regular physical,” says Brandwin. If you suspect you have gout or are at risk, go to your physician. “The doctor draws fluid from the inflamed joint and looks for uric acid crystals under a microscope,” says Brandwin. Treating Gout Medications are used to treat gout. The most widely prescribed is allipuronal. “It breaks down protein and prevents it from causing uric acid. Allipuronal has made a world of difference in enabling doctors to treat gout. The only problem is many people are allergic to it,” says Brandwin. For those people, doctors go back to the drugs they were using before allipuronal became available. “They are a class called uricosuric drugs which help you excrete fluids (and the uric acid) more easily. The disadvantage is you have to increase your water intake Lots of older peoplecan’t or won’t do that. For example, many in this age group think they are drinking plenty of water and they really aren’t,” says Brandwin. (See the dehydration article online at www. EricksonTribune.com) “Colchicine is used to treat the flare-ups of acute gout. It helps stop the episode, but it might have to be used quite a bit and then it causes diarrhea,” says Brandwin.
Probenecid is another option. “It increases elimination of uric acid. We are cautious in using it in many older people because it can put too much strain on their kidneys,” says Fine. Ultimately both doctors agree that there is a treatment for almost everyone. “I urge older people to get checked for this disorder. If they need treatment, they should think of it like any other chronic condition they need to control,” says Brandwin.