All about gout - Harvard Health

This old disease is becoming more common, but gout can be easily treated and ... But gout is still very much with us, and the number of Americans affected ... RecentBlogArticles Aconversationaboutreducingtheharmsofsocialmedia WonderingaboutCOVID-19vaccinesforchildren5to11? Menopauseandmemory:Knowthefacts Preparingfortheholidays?Don’tforgetrapidtestsforCOVID-19 Howtogetyourchildtoputawaytoys Isacommonpainrelieversafeduringpregnancy? Canvapinghelpyouquitsmoking? Gastroparesis:Aslow-emptyingstomachcancausenauseaandvomiting Canbluelight-blockingglassesimproveyoursleep? Skillschildrenneedtosucceedinlife—andgettingyoungstersstarted Allaboutgout July3,2019 Thisolddiseaseisbecomingmorecommon,butgoutcanbeeasilytreatedandthenprevented—withtherightcare. Unlessyou'veexperienceditfirsthandorknowsomeonewhohas,goutmayseemlikeamuseumpieceofadisease—aconditionthatonceafflictedcorpulentmenofmeansbutdoesn'tgetmentionedmuchthesedays.Eventhenameseemsarchaicandunscientific.Goutcomesfrom gutta,Latinfordrop,areferencetothebeliefthatitwascausedbyadrop-by-dropaccumulationofhumorsinthejoints. Butgoutisstillverymuchwithus,andthenumberofAmericansaffectedseemstobeincreasing,atleastpartlybecauseoftheobesityepidemic.Goutremainsadiseasethatmainlyaffectsmiddle-agedandoldermen,althoughpostmenopausalwomenarevulnerabletoo,perhapsbecausetheylacktheprotectiveeffectofestrogen.Thediuretics("waterpills")thatmanypeopletaketocontrolhighbloodpressureareanothercontributingfactor.Goutcanalsobeaproblemfortransplantrecipients.Thereareseveralreasonsforthisbutmedications,suchascyclosporine,takentoreducethechancesoforganrejectionandreducedkidneyfunctionaremajorcontributors. Theencouragingnewsisthatalmostallgoutcasesaretreatable.Infact,goutisoneofthefewtreatableandpreventableformsofarthritis,anumbrellatermfordozensofconditionsthatcauseinflammationinthejoints.Thechallengeismakingsurepeoplegetthegoutcaretheyneedandfollowthroughontakingmedications. Whatcausesgout? Purinesareagroupofchemicalspresentinallbodytissuesandinmanyfoods.Ourbodiesarecontinuallyprocessingpurines,breakingthemdownandrecyclingorremovingthebyproducts.Uricacidisoneofthebyproductsand,normally,anyexcessleavesintheurine.Butinsomepeople,thesystemforkeepinglevelsincheckfallsoutofkilter.Usuallyit'sbecausethekidneysaren'tkeepingupandexcretingenoughuricacid,butsometimesit'samatteroftoomuchuricacidbeingproducedorit'sacombinationofboth. Goutoccurswhensurplusuricacidcoalescesintocrystals,whichcausesinflammationinthejoints. Pain,swellingandlossofjointmotionaretypical. (Technically,thecrystalsconsistofsodiumurate,althoughforsimplicity'ssakethey'reoftenreferredtoasuricacidcrystals.)Thecrystalsappearmostofteninthejoints,buttheymayalsocollectelsewhere,includingtheouterear,intheskinnearthejoints,andthekidney. Highconcentrationsofuricacidlevelsintheblood—themedicaltermishyperuricemia—arenecessaryforthecrystalstoform.Yetmanypeoplewithhyperuricemianeverdevelopgout,andevenwhentheydo,theyoftenhavehadhighlevelsofuricacidintheirbloodforyearswithoutanysymptoms.Peoplewithhyperuricemiawithnosymptomsmightbecoachedtomakelifestylechanges—losingweightwouldoftentopthelist—buthyperuricemiabyitselfisusuallynottreated. Goutpredisposingfactors Dr.HyonK.Choi,nowattheMassachusettsGeneralHospitalinBoston,andepidemiologistsatHarvardhaveuseddatafromtheHarvard-based,all-maleHealthProfessionalsFollow-upStudytomakeaseriesofcomparisonsbetweenthe730meninthisstudywhodevelopedgoutduringa12-yearperiodandthevastmajorityofthoseinthestudywhodidnot.Theresultisanimpressivedossierontheriskfactorsforgout,atleastastheypertaintomen. Dr.Choi'sfindingsonweightweren'tsurprisingandfitthestereotype:goutis,infact,aheavyman'sdisease.Eatinglotsofmeatandseafoodanddrinkinglotsofalcoholspellsgoutytrouble.AndtheHomerSimpsonsoftheworldaregoutcandidates:two-or-more-a-daybeerdrinkersaremorethantwiceaslikelytogetgoutasnonbeerdrinkers,whichmakessense,becausebeercontainsalotofpurines. Softdrinkfanciersmightbeinthesamegoutyboat.HighfructoseintakewaslinkedtogoutinaChoi-ledstudypublishedin2008.Uricacidisoneoftheproductsoffructosemetabolism,andthere'sgoodevidencefromcontrolledfeedingstudiesthatfructoseincreasesuricacidlevelsintheblood.Muchofthefructoseintoday'sAmericandietcomesfromthehigh-fructosecornsyrup(whichisabouthalffructoseandhalfglucose)that'susedtosweetensoftdrinksandmanyotherfoodsanddrinks. Highbloodpressureisanothermajorriskfactorforgout.Itgetscomplicated,though,becausethediureticstakentolowerhighbloodpressureincreaseuricacidlevels,sothetreatmentaswellasthediseaseisassociatedwithgout. Finally,goutdoesruninsomefamiliesandweknowthatcertaingenesincreasetheriskofgout. Goutsymptomsandcomplications Goutisnotgoutuntilsymptomsoccur.Whentheydo,theyusuallycomeonsuddenlyand,atleastinitially,affectasinglejoint.Withinhours,thatjointbecomesred,swollen,hot,andpainful—they'recalledgout attacks forareason.It'seasytomistakeagoutattackforalocalizedinfectionofajoint.Themetatarsophalangealjointatthebaseofthebigtoe(wherethetoemeetsthefoot)isoftenthesiteofthefirstattack,buttheknees,ankles,andjointsbetweenthemanysmallbonesthatformthefootarealsocommonsites.Peoplewhoalreadyhaveosteoarthritis—themostcommonformofarthritis—oftenexperiencetheirgoutattacksinthejointsofthefinger Treatingagoutattack Asistrueformanypainfulconditions,thefirst-linetreatmentforagoutattackistakingoneofthenonsteroidalanti-inflammatorydrugs(NSAIDs),suchasdiclofenac,ibuprofen,orindomethacin.Forpeoplewhocan'ttakeNSAIDs,adrugcalledcolchicineisanalternative.It'sbeenusedforcenturies—maybeevenlonger—specificallyforgout.Thetroublewithcolchicineisitssideeffects,especiallythecopiousdiarrhea.IfneitheranNSAIDnorcolchicineisanoption,thengoutattackscanbetreatedwithanoralcorticosteroid,suchasprednisone,orwithcorticosteroidinjectionsintothejoints. Preventinggoutattacks Foryears,goutpatientsweretoldtheyhadtofollowapurine-restricteddiettostaveoffattacks,butthosedietsweren'tveryeffectiveandpeoplehadadifficulttimestickingtothem.Nowtheeasier-said-than-doneadviceistoloseweight,andalsotocutbackonalcohol,especiallybeer.Bigmeatandseafoodeatersmaybetoldtocurbtheirappetitesandinsteadeatmorelow-fatdairyfoods.Diureticstendtoincreaseuricacidlevels.Ifsomeonewithgoutistakingone,adoctormightexploreloweringthedoseorswitchingtoadifferentmedication. Butthemostimportantforkintheroadforgoutsufferersiswhethertostarttakingadrugthatwilllowertheiruricacidlevels.Oncepeoplestarttakingthesedrugs,theyusuallymusttakethemfortherestoftheirlives.Goingonandoffauricacid–loweringmedicationcanprovokegoutattacks.Expertshavedifferingopinions,butmanyagreethatthecriteriaforstartingtherapyincludefrequent(say,twoorthreetimesayear)attacks,severeattacksthataredifficulttocontrol,goutwithahistoryofkidneystones,orattacksthataffectseveraljointsatatime. Guidelinesalsorecommenduricacid-loweringtreatmentifapersonwithgoutalsohaskidneydisease.  Allopurinolisthefirst-lineuricacid–loweringdrug. Itneedstobetakenonlyonceadayandreducesuricacidlevelsregardlessofwhethertherootproblemisoverproductionofuricacidorinadequateclearancebythekidneys.Sometimespeopledevelopamildrashwhentheystartallopurinol,althoughrarelythere'sadangerousallergicreaction.Oldguidelineswarnedagainstprescribingallopurinolforpeoplewithkidneydisease,butwithproperdosing,thedrugisusuallywelltoleratedandeffectiveevenforpeoplewithkidneydisease. Underdosinghaslongbeenaproblem.Thestandardstartingdoseis100mgperday(orlessifapersonhaskidneydisease);manydoctorsdonotincreaseitabove300milligrams(mg),butthatmightnotbeenoughtoreachthecommonlyacceptedtargetlevelforuricacidof6milligramsperdeciliter(mg/dL).Mostpeoplecantakedosesof400mgormore(ifneeded)withoutanyproblems,althoughhigherdosesdomeantakingextrapills. Anewerdrug,febuxostat(Uloric),issimilartoallopurinolinthewayitworks.Inhead-to-headtrials,febuxostatlookedtobemoreeffectivethanallopurinolatcontrollinguricacidlevels,althoughthatwaslikelybecausetheallopurinoldoseinthestudywastoolow.Asanew,brand-namedrug,febuxostatisfarmoreexpensivethanallopurinol. Probenecidisathirdchoice.Likeallopurinol,it'sbeenonthemarketfordecades,soithasalongtrackrecord.Probenecidworksbyincreasinguricacidexcretionbythekidneyssoitcantriggerthedevelopmentofkidneystonesandisnotagoodoptionforpeoplewithkidneyproblems.Anotherdrawbacktoprobenecidisthatithastobetakentwiceaday. Perhapsthebiggestproblemwiththeuricacid–loweringtherapyisstickingwithit.Anumberofstudieshavedemonstratedthatupto80%ofpeopleprescribedallopurinolweretakingitincorrectlyornotatall.Pooradherenceisunderstandable.Oncepeoplearetakinganeffectivegoutpreventionmedicine,thereareusuallynoimmediatesymptomstoremindthemtotakethepillsdaily.Andthememoryofthelastattackisboundtofade,nomatterhowexcruciatingitmighthavebeen. Manytypesofarthritiscannotbepreventedandlackmedicaltreatmentsthatreliablywork. Goutisdifferent-thetreatmentisusuallystraightforwardandhighlyeffective.  So,ifyouhavegout,askyourdoctorabouttreatmentoptions.Althoughgoutisontherise,therearenowgoodtreatmentoptionsforthisancientdisease. The HealthLetter thanksDr.RobertShmerlingforhishelpwiththisarticle.Dr.ShmerlingistheclinicalchiefoftheDivisionofRheumatologyatBethIsraelDeaconessMedicalCenterinBoston.     ShareThisPage SharethispagetoFacebook SharethispagetoTwitter SharethispageviaEmail PrintThisPage ClicktoPrint Disclaimer: Asaservicetoourreaders,HarvardHealthPublishingprovidesaccesstoourlibraryofarchivedcontent. Pleasenotethedateoflastrevieworupdateonallarticles.Nocontentonthissite,regardlessofdate, shouldeverbeusedasasubstitutefordirectmedicaladvicefromyourdoctororotherqualifiedclinician. FreeHealthbeatSignup Getthelatestinhealthnewsdeliveredtoyourinbox! SignUp Close Thanksforvisiting.Don'tmissyourFREEgift. 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