| Gout
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What is Gout ?
Gout has historically been considered to be a disease of the
upper class. At one time, it was considered to be so stylish that it was said that the
only thing worse than having it was to be cured! Nowadays the trend has changed and gout
has become a more common disease. It is an inflammatory arthritic condition caused by the
accumulation of uric acid crystals in the joints. Classically, it occurs in acute,
intermittent attacks of joint pain, swelling, redness and warmth. In some individuals, it
becomes a progressive, crippling chronic disease that also damages the kidneys.
Gout is twenty times more common in adult men than women
and children are rarely affected. Obesity, high blood pressure and atherosclerotic heart
disease are all often associated with gout and approximately 10% of cases have a familial
pattern.
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Known Causes
The cause of gout - Uric Acid and Hyperuricemia. Excess uric
acid is the causative agent in all cases of gout. Uric Acid is a naturally occurring
substance produced in the chemical breakdown of the purine bases that compose the genetic
material called DNA. As cells die and release DNA from their chromosomes, purines are
converted into uric acid which is promptly excreted in the urine and, to a lesser degree,
the intestinal tract. The level of uric acid dissolved in the bloodstream is directly
related to the level of uric acid production and excretion. The normal level is
approximately 2-7 mg./dl.
"Hyperuricemia" is the medical term for high
blood concentrations of uric acid. This can be caused by under-functioning kidneys,
dehydration, hormonal diseases, alcohol, a diet high in purine foods (eg. meats, poultry,
broths, gravy, anchovies, sardines, scallops, peas and beans - see diet & nutrition
section) and low doses of aspirin.
Attacks of gout are caused by the body's inflammatory
reaction to intermittent precipitation of uric acid crystals into the
joint(s). They
normally follow many years of asymptomatic hyperuricemia (ie. uric acid levels building up
without noticeable symptoms).
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Symptoms
Acute gout manifests by the rapid onset of severe joint pain,
swelling and redness. The discomfort often begins at night after the ingestion of
alcoholic beverages, uric acid-elevating medications or high-purine foods. In 90 percent
of initial episodes a single joint is involved - commonly the joint at the base of the big
toe. Podagra, gouty arthritis of the big toe, affects 90 percent of the gout patients some
time during the course of their disease. The foot, heel, ankle, knee, hands, wrists and
elbows are some of the other joints that are also frequently involved.
Episodes of gout tend to last only a few days to a few
weeks, and they respond promptly to gout medications. However, in over 90% of cases, the
gout recurs within a year. Without treatment, sufferers may develop chronic gouty
arthritis in which multiple joints are involved by a long- term destructive process. Small
nodules consisting of uric acid and inflammatory tissues known as tophi can form on the
edge of cartilage and along the course of tendons (chronic tophaceous gout).
Urinary Tract Disease: - Ultimately, kidney disease due to
hyperuricemia may be the most critical complication of gout. Uric acid crystals accumulate
within the substance of the kidney and can lead to a progressive decline in kidney
function and cause nephropathy. Alternatively, a sudden blockage of the flow of urine
through the ureters due to a precipitation of uric acid crystals can develop (acute
obstructive uropathy).
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Diagnosis
Gout is indicated whenever there is a sudden swelling and pain
in a joint -especially the big toe. However, because many other arthritic conditions and
some infections have the same symptoms, gouty arthritis should be confirmed by laboratory
testing. Analysis of joint fluid removed with a needle is the most specific method. If
uric acid crystals are seen when the fluid is examined under a special microscope, the
diagnosis is confirmed.
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Conventional
Treatment
Acute gout responds promptly to therapy with rest and heat,
and anti- inflammatory medicines (eg. colchicine, indomethacin (Indocin) and others). Once
the episode has remitted, the doctor has to make a decision about long-term preventive
treatment. Small daily doses of colchicine or indomethacin are often used with dietary
advice (see Diet & Nutrition below) Avoidance of alcohol and aspirin, and the
maintenance of proper body weight are also recommended.
Patients with recurrent attacks are candidates for therapy
to lower the blood level of uric acid. Probenecid (Benemid) and sulfinpyrazone
(Anturane)
work by increasing the urinary excretion of uric acid, while allopurinol (Zyloprim)
decreases the overall production of uric acid from purines. Sufferers should be aware that
all of these medications have side effects which include nausea, vomiting, abdominal pain,
diarrhoea, rashes, kidney damage, neuritis, hypertension, headache, vertigo and alopecia
(hair loss). (1)
No medical treatment is usually advised for asymptomatic
hyperuricemia (high uric acid levels with no symptoms) mainly because of the side effects
associated with medical treatments. Fortunately there are effective alternatives in both
the treatment and prevention of gout...
(1) British National Formulary 1986
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