Gout

Gout is one of the most common causes of arthritis, accounting for approximately 5% of all cases of arthritis or 1 person in 100 in the U.S. Gout results from the deposition of uric acid crystals into the cartilage of a joint. This happens because the amount of uric acid in the person’s blood gets too high to remain in solution and precipitates into crystals, much like too much sugar in water causes crystallization of the sugar.  The deposition of these crystals into the cartilage around the joint is intensely inflammatory producing not only severe pain, but also redness, swelling and heat.  By all estimates gout is the most painful type of arthritis; the intensity of the pain has been described by sufferers as so severe that it hurts whenever someone walks into their room.

Uric acid is the byproduct of the metabolism of a class of proteins known as purines.  Normally the process of breakdown of purines involves several steps, including the metabolism of uric acid to xanthic acid.  As xanthic acid is very soluble in blood and uric acid is not, it is very important that this process proceeds or the result is the development of too much uric acid to stay in solution, resulting in precipitation into the joint cartilage.

There are two major reasons why patients develop gouty arthritis.  The first is that a certain percentage of the population has too little of the enzyme xanthine oxidase which is necessary to efficiently convert uric acid to xanthic acid.  This is a genetic predisposition that is passed on from generation to generation. 

The second major reason is that some people eat a diet that is very high in purines; thereby, overloading the front end of the process, producing excessive amounts of uric acid.  Foods such as red wine; yellow cheeses; red meats; seafood such as anchovies, sardines, scallops, prawns, crabs; organ meats such as tripe, kidney, liver, sweetbreads; and alcohol, all are on the high purine list. 

As is usually the case with medicine, there is a complex interplay of these and other causes including a sedentary lifestyle, obesity, certain blood pressure medications and male gender that play a role in causing gouty arthritis

Whatever the cause(s) in any given person, the clinical picture is usually fairly consistent and easy to diagnose during the acute phase.  Most commonly a person will have several bouts of minor to moderate discomfort followed by the acute phase.  The onset of more severe symptoms (pain, redness, swelling, heat) is usually rapid, progressing over 12 to 24 hours; and 75% of the time involves the first joint of the great toe. When gouty arthritis attacks the first joint of the great toe, it is known by the name “podagra”.

After the first acute event, patients enter an interval stage between acute attacks; however, acute attacks begin to occur more frequently,  and more often involve other joints such as the ankle, wrist, elbow, knee or fingers.  Left untreated many patients enter a chronic stage where permanent damage to the joints, precipitation of uric acid crystals into the kidney causing kidney disease and/or kidney stones, or deposition of the crystals into the subcutaneous tissues under the skin occurs.

Once the diagnosis of gout is made; treatment is two-prong – acute and chronic.  The acute treatment is aimed at reducing the profound inflammation in the joint with oral medications such as non-steroidal inflammatory drugs (e.g. ibuprofen, naproxen, indomethacin) or prednisone; occasionally direct injections of cortisone into the joint; and pain medication.  Once the acute phase has moderated, the modalities for management to prevent recurrent attacks of arthritis or other chronic conditions can be employed.  These include dietary restriction of high purine containing foods and alcohol; the addition of foods that are purported to reduce inflammation such as colored berries (blueberries, strawberries); medications such as allopurinol or probenecid , and lifestyle changes such as weight reduction and increased physical activity.

As a side note, there may be some comfort to gout sufferers to know that many famous (infamous) people who have suffered from gout – Henry VIII, Nostradamus, Queen Anne, Isaac Newton, Benjamin Franklin, Khubilai Khan, Alexander Hamilton, Karl Marx, Alfred Lord Tennyson, John Calvin, Benjamin Disraeli, and Mel Brooks have suffered from gout.

This article is intended to provide useful information, not medical advice. This information cannot, and is not meant to, replace consultation with your physician regarding your individual circumstances.