Gout: A Painful Problem From The Past Still Lingers On

November 29, 2022 at 9:29 p.m.


One of the nagging problems attributed to aging is gout – defined as a common and complex form of arthritis likely caused by uric acid deposition.  

It can last days to weeks if untreated;  the flares (symptoms) are inflammation, redness, tenderness and swelling, often intensely painful and debilitating. Flares can increase in frequency and severity over time. Advanced disease develops in approximately 15% of patients and is characterized by potential joint erosion and deformity.  A recent study showed that patients with gout were at a higher risk of infection and death from COVID-19. I also suffer from gout, and the symptoms seem to appear most often in both of my big toes when I am in bed trying to sleep.

Incidence    

According to a recent article in the New England Journal of Medicine, “although reports suggesting a plateauing of incidence in some geographical regions, the world wide burden of gout has grown in recent decades.”  In the United States, gout has been diagnosed in more than 10 million adults, which has contributed to increases in gout-related ambulatory visits and hospitalizations.  

Gout-related health problems are pervasive and under represented and underserved communities, notably among Black, Pacific Islander, and New Zealand Maori populations.  Other populations (e.g., Americans of Japanese descent) also have a higher incidence of gout and may have worse outcomes. As compared with men, women are less likely to receive appropriate treatment for the condition.

Uric Acid

If too much uric acid stays in the body, a condition called hyperuricemia will occur. Hyperuricemia can cause crystals of uric acid (or urate) to form. These crystals can settle in the joints and cause gout, a form of arthritis that can be very painful. They can also settle in the kidneys and form kidney stones. If untreated, high uric acid levels may eventually lead to permanent bone, joint and tissue damage, kidney disease and heart disease. Research has also shown a link between high uric acid levels and type 2 diabetes, high blood pressure and fatty liver disease.

Although hyperuricemia is a causal link factor for gout, serum urate measurement has a limited role in diagnosis owing to low specificity. Most asymptomatic patients with marked hyperuricemia were found not to have gout over 15 years of followup. Although the presence of uric acid crystals obtained for joints, bursa or trophy remains the reference standard, a clinical diagnosis of gout can be made on the basis of the presence of clinical features.

Purines

Your body produces uric acid when it breaks down purines — substances that are found naturally in your body. Purines are also found in certain foods, including red meat and organ meats, such as liver. Purine-rich seafood includes anchovies, sardines, mussels, scallops, trout and tuna. Alcoholic beverages, especially beer, and drinks sweetened with fruit sugar (fructose) promote higher levels of uric acid.

Normally, uric acid dissolves in your blood and passes through your kidneys into your urine. But sometimes either your body produces too much uric acid or your kidneys excrete too little uric acid. When this happens, uric acid can build up, forming sharp, needlelike urate crystals in a joint or surrounding tissue that cause pain, inflammation and swelling.

Treatment

In terms of drug therapy, allopurinol represents the first line of therapy to lower urate concentrations and should be administered by the physician, according to a treat-to-target approach (initial low doses followed by gradual dose elevation) to establish and maintain serum urate concentrations below 6.0 mg per deciliter.  Treatment must be individualized to account for co-existing heart and kidney conditions often overrepresented in this patient population.  Other drugs used include colchicine, probenecid, benzbromarone and corticotrophin.  

Although potentially beneficial in the management of associated conditions, dietary and lifestyle modifications alone are seldom adequate interventions for lowering urate concentrations.

My symptoms occur when I eat veal accompanied by a beer or two and relieved by taking indomethacin or naproxen. I continue to take allopurinol, available by prescription since the 1960s. It is the first-line urate lowering therapy.

Diet And Lifestyle Modifications

Modifiable lifestyle and dietary factors that adversely affect serum urate levels and flare risk include alcohol use (especially beer, dehydration, obesity and consumption of high-fructose sweeteners) (e.g. nondiet sodas) and high purine foods (meats and shellfish).  Although epidemiologic studies have linked dietary factors and obesity with gout risk, the effectiveness of dietary and lifestyle interventions in management of gout has been the subject of limited study, with available data suggesting only modest benefit.

Final Thoughts

Gout was a painful problem in the 18th and 19th century and continues today. At one time it was common to think that gout affects the rich far more than the poor, which is not difficult to explain.  It can be deduced that it is because of a diet richer in meat and strong alcohol.

Max Sherman is a medical writer and pharmacist retired from the medical device industry.  His new book “Science Snippets” is available from Amazon and other book sellers. It contains a number of previously published columns.  He can be reached by email at  [email protected]

One of the nagging problems attributed to aging is gout – defined as a common and complex form of arthritis likely caused by uric acid deposition.  

It can last days to weeks if untreated;  the flares (symptoms) are inflammation, redness, tenderness and swelling, often intensely painful and debilitating. Flares can increase in frequency and severity over time. Advanced disease develops in approximately 15% of patients and is characterized by potential joint erosion and deformity.  A recent study showed that patients with gout were at a higher risk of infection and death from COVID-19. I also suffer from gout, and the symptoms seem to appear most often in both of my big toes when I am in bed trying to sleep.

Incidence    

According to a recent article in the New England Journal of Medicine, “although reports suggesting a plateauing of incidence in some geographical regions, the world wide burden of gout has grown in recent decades.”  In the United States, gout has been diagnosed in more than 10 million adults, which has contributed to increases in gout-related ambulatory visits and hospitalizations.  

Gout-related health problems are pervasive and under represented and underserved communities, notably among Black, Pacific Islander, and New Zealand Maori populations.  Other populations (e.g., Americans of Japanese descent) also have a higher incidence of gout and may have worse outcomes. As compared with men, women are less likely to receive appropriate treatment for the condition.

Uric Acid

If too much uric acid stays in the body, a condition called hyperuricemia will occur. Hyperuricemia can cause crystals of uric acid (or urate) to form. These crystals can settle in the joints and cause gout, a form of arthritis that can be very painful. They can also settle in the kidneys and form kidney stones. If untreated, high uric acid levels may eventually lead to permanent bone, joint and tissue damage, kidney disease and heart disease. Research has also shown a link between high uric acid levels and type 2 diabetes, high blood pressure and fatty liver disease.

Although hyperuricemia is a causal link factor for gout, serum urate measurement has a limited role in diagnosis owing to low specificity. Most asymptomatic patients with marked hyperuricemia were found not to have gout over 15 years of followup. Although the presence of uric acid crystals obtained for joints, bursa or trophy remains the reference standard, a clinical diagnosis of gout can be made on the basis of the presence of clinical features.

Purines

Your body produces uric acid when it breaks down purines — substances that are found naturally in your body. Purines are also found in certain foods, including red meat and organ meats, such as liver. Purine-rich seafood includes anchovies, sardines, mussels, scallops, trout and tuna. Alcoholic beverages, especially beer, and drinks sweetened with fruit sugar (fructose) promote higher levels of uric acid.

Normally, uric acid dissolves in your blood and passes through your kidneys into your urine. But sometimes either your body produces too much uric acid or your kidneys excrete too little uric acid. When this happens, uric acid can build up, forming sharp, needlelike urate crystals in a joint or surrounding tissue that cause pain, inflammation and swelling.

Treatment

In terms of drug therapy, allopurinol represents the first line of therapy to lower urate concentrations and should be administered by the physician, according to a treat-to-target approach (initial low doses followed by gradual dose elevation) to establish and maintain serum urate concentrations below 6.0 mg per deciliter.  Treatment must be individualized to account for co-existing heart and kidney conditions often overrepresented in this patient population.  Other drugs used include colchicine, probenecid, benzbromarone and corticotrophin.  

Although potentially beneficial in the management of associated conditions, dietary and lifestyle modifications alone are seldom adequate interventions for lowering urate concentrations.

My symptoms occur when I eat veal accompanied by a beer or two and relieved by taking indomethacin or naproxen. I continue to take allopurinol, available by prescription since the 1960s. It is the first-line urate lowering therapy.

Diet And Lifestyle Modifications

Modifiable lifestyle and dietary factors that adversely affect serum urate levels and flare risk include alcohol use (especially beer, dehydration, obesity and consumption of high-fructose sweeteners) (e.g. nondiet sodas) and high purine foods (meats and shellfish).  Although epidemiologic studies have linked dietary factors and obesity with gout risk, the effectiveness of dietary and lifestyle interventions in management of gout has been the subject of limited study, with available data suggesting only modest benefit.

Final Thoughts

Gout was a painful problem in the 18th and 19th century and continues today. At one time it was common to think that gout affects the rich far more than the poor, which is not difficult to explain.  It can be deduced that it is because of a diet richer in meat and strong alcohol.

Max Sherman is a medical writer and pharmacist retired from the medical device industry.  His new book “Science Snippets” is available from Amazon and other book sellers. It contains a number of previously published columns.  He can be reached by email at  [email protected]

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