Gout has often been called the "disease of kings." It was noted many years ago that gout usually affected nobility and the wealthy. This observation resulted from the richer diet available to those of means during those times. Now, most of us eat like "kings." The disease shows rare economic discrimination. It occurs when uric acid, a break-down product of normal protein degradation which is normally dissolved in the serum of the blood, crystallizes in a joint and greatly irritates its lining. The skin is often quite red over the joint during an attack. It is most common in men from ages 40 to 60. Women are rarely affected until after menopause. Multiple joints may be involved, but usually only one joint is affected at a time. The joints of the base of the big toe, knee, hip or the ankle are the most commonly involved.
It most often occurs especially in men when the kidneys are unable to get rid of uric acid as quickly as it is accumulating in the blood. In addition, this may be due to eating too much high purine protein products. Decreasing kidney function as you get older is a part of the normal aging process. When the concentration of uric acid gets high enough, some passes from the blood into joint fluid where it forms long needle-shaped crystals. The needle shape reflects what patients often experience during an attack of a million needles in the joint accompanied by terrible pain. Even the skin of the joint is usually red from the inflammation. It is most common on the days after holidays such as Thanksgiving, Christmas, and Easter due to the increase of ingested food and alcohol.
The doctor can be generally certain of the diagnosis just by listening to the patients and examining them. Many infections and other types of arthritis may look and act just like gout. Therefore, it may be necessary to withdraw some of the fluid from the involved joint. The fluid must be examined under a special microscope lens and tested to be sure of the diagnosis.
Blood tests of the concentration change of uric acid in the blood can be helpful in making the diagnosis. However, 30% or more of people experiencing an attack will have a normal serum uric acid at the time they visit the doctor's office. After the first attack, other blood and urine tests may be necessary to determine the cause of the high uric acid. Uric acid levels may change for other diseases that may lead to causing the flair, but they are not primary gout.
An attack marked by severe joint pain usually gets the patient to the doctor's office. If this is very severe, intravenous fluids are begun to start the "washing out" process. A medication that neutralizes the crystals in the joint can be given by mouth or intravenously in the most severe cases. About 80% of people do not tolerate it when orally given. Steroids (cortisone or prednisone type drugs) may be given either as an injection, by pills, or be injected directly into the joint to further calm the massive inflammation.
"Non-steroidal anti-inflammatory drugs" (NSAID's) are the mainstay of treatment of the acute attack. People who have a history of ulcer or similar stomach problems may do better with one of the newer NSAID's that are gentler on the stomach. IV medications may stop the flare-up and have you comfortably walking out of the office in an hour.
About three quarters of the people having an attack will have a second attack within 2 years if nothing is done to treat and decrease the uric acid levels. It almost never goes away without significant changes. Those who have attacks may develop chronic pain and permanently crippling changes in the joints. You and your doctor need to prevent this from happening. We must determine the exact cause of the crystallization. Other tests may be necessary to determine the exact cause of the problem, including, an intra-articular sample of fluid. Medications particularly diuretics ("water pills") are commonly used to treat high blood pressure. Medications can interfere with either the production or elimination of uric acid. Medication changes can help to prevent recurrence. High blood pressure, diabetes, low thyroid, and other disease remarkably increase the chances of getting an attack. The chance of getting another attack is greatly decreased by disease control and uric acid control. Obesity, overuse of alcohol or caffeine, dehydration or a high purine diet can all increase your likelihood of having another attack. Allopurinol and other medications can be used to lower uric acid. Medicines must be given carefully because sudden changes can actually cause an acute attack.
Review all medicines with your doctor. Identify any medications that may contribute to your attacks. Regular use of aspirin can contribute to your likelihood of getting a flare. Alcohol is the only substance that both increases production of uric acid and decreases its elimination. Decreasing or eliminating use of alcoholic beverages may, in itself, entirely prevent further attacks. Increase significant volumes of fluidyour intake of water. Beverages containing caffeine or alcohol result in dehydration, not rehydration, and thus are counter-productive. As we age, our awareness of being dehydrated decreases. By the time we feel thirsty, we are already more than "a quart low." A gout sufferer needs to make a habit of drinking replacement fluids throughout the day. Always tell your doctor about your problem. With care, the physician can avoid prescribing medication that could increase your uric acid level and precipitation of crystals.
Obesity contributes to crystallization. Fat to water ratio increases with obesity, and this results in dehydration. Fasting diets can precipitate attacks. Discuss your new diet with a nutritionist and physician. Diets high in fat and protein are usually effective for people in losing weight. High fat intake increases your likelihood of getting attacks. Liver, kidney, and sweetbreads are particularly high in uric acid. Cold-cuts (lunch meat) and processed meat products including hot dogs, sausage, and meat organs are problematic. "White meats," particularly turkey and pork, contain more of the substances that become uric acid than red meats. Occasional portions of these foods will usually not cause you to have an attack. However, a regular diet of these meats increase your chances of having crystallization. General moderation of your meat intake in combination with a well balanced diet and increased water intake are best for you. Drink lots of water.
An exercise program is an important part of a weight loss program. Over-doing it in the weight room, or taking on heavy muscle work can actually cause muscle breakdown. Over-exercise raises uric acid levels. Decreased exercise results in severe muscle soreness and dehydration. Sensible changes in your diet and lifestyle and working together with your doctor can decrease problems and save your joints from further permanent damage.