By Hope Starkman, MD
Gout is a form of inflammatory Arthritis known to be caused by an accumulation of uric acid within the joints. It is one of the most inflammatory arthritis forms that exist. Pictures of kings from hundreds of years ago depict men with a devil pointing a pitchfork at their foot, thus suggesting the severe pain and inflammation that this condition can cause. It can be so dramatic so as to case such severe pain upon awakening that the feeling of the sheets again the affected skin can be excruciating. If enough uric acid accumulates it can cause a toothpaste like collection to accumulate around the joints. These are usually white appearing densities under the skin and over the joints, called tophi.
Gout can affect both men and women especially women after menopause. As uric acid accumulates it can form crystals in joints and also other soft tissue as well as the kidneys when the body is not able to eliminate at a pace which keeps up with production , consumption and excretion by the normal kidneys. Kidney stone formation (nephrolithiasis) may be another consequence of excessive uric acid accumulation.
Certain foods which are high protein foods, contain purines which break down into uric acids. A list of such foods can be found on many internet websites. Some of the more common ones are shellfish, organ meats, herring, asparagus, and mushrooms. Other foods like cherries may be beneficial and protective.
Certain medications such as diuretics may increase the levels of serum uric acid resulting in gout. Patients with absorption and kidney issues, and patients with kidney transplants on certain medications may be at a higher risk for hyperuricemia ( which may not need treatment), gout and tophaceous gout. It may not always be possible to cure the inciting problem, thus the gout will have to be addressed independently, at times.
The goal of treating gout is to curtail flares as soon as possible, prevent flares, prevent deformity, dissolved tophi when present. In addition the goal is to try to keep the serum uric acid (SUA) level below 6.
Several medications are available to assist in treating gout. The treatment choices must be tailored to the specific patient. NSAIDS like Ibuprofen, Indocin, Naprosyn can be used to treat the initial inflammation but must be used with caution and with physcian guidance in patients with renal insufficiency, hypertension and other medical issues. Colchys may be used as well to treat the acute process and together with other SUA lowevering agents always while being monitored by a physician. Prednisone or steroids can be used to treat acute inflammation as well, including local injections once infection hs been ruled out. Gout may occur with any changes in uric acid at all due to crystalization within the joints, whether the level declines or rises. Serum uric acid lowering drugs like Allopurinol or Uloric may be used to lower these levels but this may take some time . Therefore, often other medications, as aforemtioned, like Colchrys or sterioids must be used together with these SUA lowering drugs to prevent flare while uric acid level is being stabilized. Uloric may be better utilized in patients who are intolerant to Allopurinol or who have renal insufficiency. Finally, Pegloticase (Krystexxa, an intraveous therapy, may be used to treat refractory, difficult to treat or topahceous gout.
Hydration is of key importance in the management of gout as is diet, weight control and adherence to medical regimen. The stopping, starting, increasing or decreasing of uric acid lowering agents is never recommended in the setting of an acute gouty flare.
There are multiple and evolving therapies available to address, prevent and treat this very painful and common condition. Rheumatolgists are generally excellent at dealing with your gout head on and quickly.