Rich Man’s Disease

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Gout is a common and complex form of arthritis. It has been around since the days of ancient Egypt and has been called the “disease of kings” or “rich man’s disease.” It affects 1-2% of the population, mostly men aged 30 to 50, but can be seen in post-menopausal women. An attack causes sudden, severe joint pain, swelling, redness, and tenderness in the affected joint. Classically, it attacks the base joint of a big toe, but it can be seen in any joint in the body. Symptoms come and go. When an attack occurs, it is typically most severe the first 12 hours, after which it lessens somewhat but can last for days to weeks. Moving the joint increases the pain. It is caused by high uric acid levels in the blood. The uric acid crystallizes out of the blood in a joint as urate crystals. Under a microscope, urate crystals look like sharp, pointy spikes, or tiny toothpicks.

Purines, organic compounds found in many foods, are broken down in the body into uric acid. Uric acid is then removed from the body via the kidneys. Purines form part of the building blocks of DNA and RNA. Purines are found in many foods, but high levels are found in red meats, organ meats (i.e. liver and kidneys), fish and shellfish, beer, red wine, dark cheese, and drinks sweetened with fructose, especially high-fructose corn syrup. They are also found in many vegetables, grains, and beans but intake of purine-rich vegetables and grains is not associated with a higher risk of a gout attack. Eating low-fat dairy products lowers the risk of an attack.

Untreated gout eventually causes joint destruction and causes tophi, hard lumps of urate crystals that can be found on the hands, fingers, feet, elbows, and Achilles tendons. Risk factors for gout include a family history, diet (especially those high in meats, seafood, and beer), obesity, hypertension, diabetes, heart and kidney disease, and the use of thiazide diuretics (hydrochlorothiazide and hygroton), low-dose aspirin, and anti-rejection medications (used after an organ transplant). Ways to prevent an attack include avoidance of high-purine foods, staying well hydrated, and consuming low-fat dairy products.

Diagnosing gout can be done by draining fluid from a joint to look for crystals, a blood test for the uric acid level (however a normal uric acid level does not preclude gout), and joint X Rays. Once diagnosed, gout attacks can be treated with non-steroidal anti-inflammatory drugs (NSAIDs) like indomethacin and Celebrex, colchicine (Colcrys and Mitigare), or steroids if the above drugs cannot be used. Medications to prevent an attack include xanthine oxidases (Allopurinol and febuxostat [Uloric]), which block uric acid production, and uricosuric agents (probenecid and lesinurad) which increase kidney excretion of uric acid.

Anyone who has had a gout attack can attest to how painful they are. Sometimes even the weight of a bedsheet on an affected joint can cause excruciating pain. One would think that having once experienced an attack, most people with gout would strictly adhere to proper diet to prevent another one, but then we are, after all, only human.

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 By Peter Galvin, MD

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