Lack of education is problem with gout
Gout is a condition of elevated uric acid depositing in the body, causing deformity, inflammation and pain. But the major problem with the condition is education, according to Rheumatologist Dr. K. Neil Parker. He says people don’t understand how to treat it, so they don’t get good results. But he says it is imminently treatable and the benefits of treatment are actually a prolonged, pain-free state. And that gout attacks can be reduced and eliminated if treated properly.
“The major barrier to treatment of gout is that patients are not aware that they have two tasks — to lower their uric acid with daily medication and prophylactic medication to keep them pain free on a daily basis, so that while they’re treated, they don’t have flare attacks of the gout, and if they have attack of the gout, their uric acid lowering agent should not be stopped. So most of the pain and uncontrolled joint damage that you see with gout is just a misunderstanding of how to properly treat and address it, and handle the different phases from the chronic hyperuricemia in the context of gout attacks to the acute attacks to the vicious cycle of pain,” said Parker. “All can be treated. You just have to understand what has to be done at every stage.”
The doctor, speaking at the most recent Doctors Hospital Distinguished Lecture Series, described gout as a condition where the body accumulates a compound called uric acid which accumulates, and in a certain segment of the population, it deposits in the tissue; the body’s response to the deposition of the crystals is what gives the clinical condition, the symptoms and signs of the disease.
Uric acid is a breakdown product of the body’s DNA that accumulates in the body. Primates, and mammals possess an enzyme that allows them to break it down; humans also possess the gene for the enzyme, but it’s not active and as a result, the uric acid accumulates in the body leading to a condition called hyperuricemia.
This accumulation of uric acid is what predisposes a person to gout. It’s necessary for the development of gout. Multiple people will have hyperuricemia, or elevations of the uric acid in their body, which the doctor says is common. But he says not everyone who has uric acid will get gout, but that a person will need to have an elevated uric acid to develop the condition.
Parker said gout is the most common inflammatory arthritis in men, affecting one to two percent of men in Western countries. He said it also affects women, but is more common in men; and that the incidence or prevalence of the condition has increased over the past several decades.
“It’s an old condition. It has been around for centuries, but it has been influenced by the ‘Western diet and lifestyle’ of which we are big partakers. Notably, only two percent of patients in the United States with gout actually are treated by rheumatologists, probably the same percentage here, and hence you get the cyclical pain, resolution, but gradual progression of the condition which is in today’s world essentially unnecessary.”
He said the conditions associated with gout — such as congestive heart failure and chronic kidney disease — are today better treated, and patients are surviving longer. And that conditions which predispose to the conditions are actually becoming more common such as hypertension and diabetes, obesity and the metabolic syndrome.
The doctor said the complex of conditions that are associative and in some instances causative, are becoming more prevalent, and the incidence of gout is increasing, along with the incidence of this condition.
Using a cup of tea as an example, the doctor spoke to making a cup and adding in two teaspoons of sugar, and stirring it, but no matter what happens he said, when you get to the bottom of the tea, sugar sediment remains. The uric acid is like that.
“Our bodies are mostly water — and uric acid, the compound that causes the gout is not very soluble. It does not dissolve well, so you can just imagine your body accumulating these crystals of uric acid overtime, and they are what cause the problem.”
The level of uric acid in a person’s body becomes problematic when it reaches 6.8 milligrams per deciliter, the level at which uric acid is insoluble and starts to come out of the solution of the blood and tissue fluids and starts to accumulate in the tissues of your body.
In men the level of uric acid accumulates after puberty. In women it starts to accumulate after menopause, which he said is why it is more common in men than women because men have the elevated levels of uric acid much longer.
People with uric acid levels of nine milligrams per deciliter or more, he said, after five years, one quarter of them will develop gout. A common abnormality, he said that translates into millions of people with gout.
Stages and diet
There are three stages of gout asymptomatic hyperuricemia, acute intermittent gout and advanced gout. In asymptomatic hyperuricemia, the level of uric acid is elevated and that’s necessary for a while before the person actually becomes symptomatic. With advanced gout the patient develops tophaceous gout. They lose any pain free periods, or the attacks become long and can last up to several weeks. Parker said it’s not a simple or benign condition in the advanced stage.
Gout is essentially a lifestyle disease.
“Some people get it because of conditions they may have, but generally speaking there are things that we do in our diet that drive the development of hyperuricemia which tips us into gout. For us in The Bahamas, this is particularly problematic because one of the things that increase the risk for hyperuricemia and gout is seafood, and we like our fish and conch (seafood on the whole), and there the problem lies.
“Red meats also increase the risk as well as organ meats like liver. As well as sugary soft drinks with high fructose corn syrups that drives gout as well, and alcohol consumption, beer and liquor having a greater
effect than wine. The good news is low fat dairy products can actually reduce the risk of developing gout, so there are things you can do that push you to or not developing gout.”
You are encouraged to avoid organ meats high in purine content such as liver, sweetbreads, kidney; red meats and seafood; high fructose corn syrup-sweetened sodas and other beverages or foods — even naturally sweetened beverages and table sugar should be limited in patients who have gout. In terms of alcohol, more than two drinks is considered overuse in men and more than one in women is overuse, and avoid any alcohol use in gout during periods of frequent gout attacks or advanced gout under poor control. Any alcohol use in gout during periods of frequent gout attacks, or advanced gout under poor control.
Limiting serving sizes of beef, lamb, pork, seafood with high purine content such as sardines and shellfish; naturally sweet fruit juices, table sugar, and sweetened beverages and desserts, and table salt including in sauces and gravies; alcohol, particularly beer, but also wine and spirits in all gout patients is encouraged.
The consumption of low-fat or non-dairy fat products and vegetables is encouraged.
Parker said people should be aware that certain common medications also increase the level of uric acid — such as those taking low-dose aspirin for risk factors for heart disease. The aspirin he said increases a person’s uric acid.
“Lots of patients with heart trouble, or fluid retention for various reasons and are on diuretics (water tablets), which also drives up the uric acid; and laxative abuse could also do it. So some of the medical conditions ironically which on their own, increase the risk of gout, the treatment of those increases the risk of gout, so in these patients we see a high occurrence of gout, and it’s not uncommon for a patient to be admitted to hospital with heart failure.
According to Parker, gout is probably one of, if not one of the most painful inflammatory arthritis. He said it usually starts in one joint, classically the big toe joint overnight, and rapidly in a day becomes so painful that even a sheet dragging over it would drive the person insane with pain.
While gout usually starts off in the big toe, he said it is also common in other joints of the lower limb —instep of the foot, ankle, heel, knee, wrists, fingers and elbow as well, but initial attacks are in the lower limb. It can also accumulate in tissues like an infection and present like cellulitis; patients can develop gout in their soft tissue.
He said gout attacks often occur usually during the night or early morning when the blood is coolest, and the joint is furthest from the heart, so it presents the perfect set up for a person who has a high level of uric acid in their body to develop the crystals that come out of the solution and cause the gout attacks.
Gout attacks, the doctor says usually last anywhere from three to 10 days, and even if not treated, tend to go away on their own. However, he said treatment shortens the duration of the attack.
Attacks usually follow years of asymptomatic hyperuricemia and people usually develop their first attack in their 30s and 40s in men and post-menopause in women.
Diagnosis and treatment
The ideal way to diagnose gout, Parker said, is to actually look at the fluid under a microscope. With that now always possible, or the attack sometimes already resolved, by the time a person goes to the doctor, he said the American College of Rheumatology and the European League Against Rheumatism in 2015 developed classification criteria to help medical practitioners characterize typical gout attacks and see if they can classify patients as having gout.
In treatment, he said lifestyle modification is important.
“What we want to do is lifestyle modification, and risk factors for diabetes and hypertension, that have to be taken into account. You want to eliminate possible causes, and manage the risk.”
And that gout is best treated early which means the more effective treatment is going to be and the shorter the duration of an attack.
“If you treat it within the first 24 hours, regardless of which method you use, you are better off. You get a better result. The more effectively you treat the uric acid, the lower the frequency of gout attacks you will have.”
Parker said doctors don’t actually treat uric acid just because it’s high, the reason being that most people won’t develop gout. For those people that do develop gout, he said most people who have a gout attack, will have another attack in a year or two. And after they are hyperuricemic for years, the attacks become more frequent. He said it basically becomes a cycle.
“Patients generally from my experience get an attack, they treat the attack, and because the attacks aren’t frequent initially, they don’t seek care. They don’t seek to manage the gout properly, and what happens is they get into a cycle, and by the time they’re looking for treatment, they have what’s called advanced gout, where they have multiple attacks, or there is no pain free intervals between attacks. They’re constantly painful, or they have so much uric acid accumulating in their body it begins to give them deformities and they start to look like patients that have rheumatoid arthritis.”
In gout, Parker said there is a difference between treating a patient’s uric acid level and treating their pain. That he said provides the discord, and the difficulty arises in treatment, because the patient doesn’t understand the difference between treating their uric acid level and treating their pain. He said that lack of understanding could cause multiple problems.
“The treatment of the uric acid, and using the medications that can bring the uric acid down can cause the flares, and so patients will in frustration start to take the medication for lowering their uric acid thinking that will treat their gout and end up with horrific and prolonged gout attacks because they are not using the treatment properly.”
The two arms of the treatment of gout Parker said are the necessary and essential pain control, but that it doesn’t treat the uric acid level, which is separate and apart from treating the underlying problem which is the elevated uric acid.
“Once you develop the elevated uric acid, we then need to bring the elevated uric acid down with uric acid lowering agents. We want to bring the uric acid level down while keeping the patient as pain free as possible. But when you treat the uric acid level, you’re going to potentially increase the patient’s risk of having attacks, because when you lower the uric acid level, the crystals begin to dissolve, and what happens is during that process you can actually end up with gout attacks. So when treating uric acid, you want to have the patient on prophylaxis which means you give them medication daily in addition to the medication that lowers the uric acid, so that you minimize their risk of having a gout attack while you treat the uric acid.”
But there is good news. Parker said a patient with advanced gout can get good results and have their deforming masses resolved if treated properly.