One of my close family members was just diagnosed with gout, and I wanted to share information that I found on this disease. I was very confused, as the symptoms come on suddenly, and there are no other major health factors, so I thought it was more of an injury-type condition. I found out that it is a chronic disease, a type of arthritis, and wanted to learn more about it. I'm still researching answers to my questions, so please add your knowledge and experience (with any relevant health/medical links). This is a work-in-progress article...thanks for reading, and I hope this helps answer other's questions as well.
1. What is gout?
Gout is caused from excess uric acid that accumulates in the body, and the uric acid crystals are deposited in the joints. It is said to be a type of arthritis, and the excess uric acid is either caused by an increased production or because the kidneys are unable to remove the uric acid from the body adequately. Some other people may also have an enzyme defect or deficiency that interferes with the way the body breaks down purines (found in certain foods and alcohol). Lastly, there is a strong genetic component (possibly from the enzyme defect mentioned above?) to gout.
With gout, tissues of the joints are affected by uric acid crystal deposits, with symptoms of swelling and pain. When joint tissues become injured of affected by disease, with symptoms of swelling, pain and redness, this is known as joint inflammation or “arthritis”. There are 100 different types of arthritis, and gout is one of them.
2. Does this mean that there is an increased risk of arthritis, or is something wrong with kidneys if they are not removing the uric acid adequately?
- Gout is a form of arthritis, but am unclear if it causes an increased risk for other types of arthritis...still researching this.
- Gout does not necessarily indicate that there is something wrong with the kidneys; although kidney disease is a risk factor for gout.
- When individuals consume foods that are rich in purines, the excess purines cause the body to produce more uric acid. The build-up of uric acid is one possible cause of gout (explained below; high levels of uric acid in the body does not always cause gout, but rather, it is the high levels of uric acid that forms uric acid crystals that are deposited on joints and under the skin that causes gout).
- Another possible cause of gout are individuals who consume excess alcohol, as alcohol interferes with the body’s ability to get rid of excess uric acid (again, which can builds up in the bloodstream).
- There is a strong genetic factor as well, as 6-18% of individuals with gout have a family history of gout
- Persons with kidney disease are more at risk for gout, and gout is strongly associated with obesity, hypertension, hyperlipidemia and diabetes. Because of genetic factors, gout tends to run in some families.
It is important to note the differences between the words: causes, triggers, risk factors, associations. For instance, someone with kidney disease is not "predestined" to have gout, but kidney disease is a risk factor for developing gout. On the other hand, someone who has gout is not necessarily at risk for developing kidney disease. Many individuals who have a chronic disease, such as kidney disease, heart disease or diabetes, do have other risk factors that are associated with other chronic diseases; the medical term is "comorbidity" ("co-existing medical conditions").
3. I am confused between what “purine” and “uric acid” are.
- Purine is found naturally in our body’s cells. It is a chemical compound that is used when cells multiply; they use purine’s components to make new cells.
- Extra purine that is not used by the multiplying cells is filtered out by kidneys and secreted through the urine in the form of uric acid.
- If there is extra uric acid that is not filtered out by the kidneys, it builds up in the body and forms uric acid crystals
- The uric acid crystals can be deposited in the joints. Crystals may also be deposited under the skin and form a lump (this lump is usually red, painful and swollen, and can be seen and felt) called a “tophus” or multiple “tophi”.
It is important to know that some people with extra uric acid may not have crystals that form. High levels of uric acid is called “hyperuricemia”, which does not necessarily lead to gout.
4. Gout comes on suddenly, so is an acute illness. But, why is it categorized as a chronic disease?
- Symptoms of gout can attack suddenly, and this is known as “acute gout”. The uric acid gradually builds up and forms crystals that can deposit on the joints or under the skin over time.
- The presence of high levels of uric acid in the blood do not produce symptoms, and even the first symptoms of uric acid crystal deposits on the joints may go unnoticed.
- Many people with gout may have had a “first attack” that included symptoms of a slightly swollen and red big toe, but the symptoms improved after a few days, (may have been assumed to have been a bug bite or a stubbed toe).
- However, as time goes on, the "attacks" are more frequent, last longer, and will require treatment, as gout becomes extremely painful. Typically, people with gout feel the symptoms of pain, redness and swelling first in the big toe, called “podagra”. The pain, redness and swelling increases suddenly, and medication is needed.
- These “attacks” are actually your immune system working properly, and “attacking” the uric acid crystals that have been forming on the joints and/or under the skin over time. It is actually these “attacks” from the immune system that cause the swelling and pain.
- Gout is considered a chronic disease as it is a type of arthritis, is not curable, but the symptoms are treatable and need can be controlled with medication.
5. How can gout be prevented in the first place?
Obviously, there is nothing you can do about your family history. There are a few methods to controlling future gout symptoms, depending on what the cause is:
- Control excess purine by avoiding or limiting purine-rich foods (source: New England Journal of Medicine, NEJM), that include meat and seafood.
- Control excess uric acid by avoiding purine-rich foods, limiting alcohol intake, consuming water throughout the day to flush out uric acid from blood stream.
- According to article in the NEJM Purine-Rich Foods, Dairy and Protein Intake, and the Risk of Gout in Men, "higher level of consumption of dairy products is associated with a decreased risk [of gout], and moderate intake of purine-rich vegetables or protein is not associated with an increased risk of gout".
Once you have gout, you can take the above preventative measures, plus medications can help control uric acid from building up to excessive levels.
6. If someone does not want to make any lifestyle changes, and prefers to take the medication, what are the side effects of the drugs? How likely are the side effects?
It looks like there are two main prescription medications to control for the symptoms of repeated gout attacks (especially when tophi deposits develop):
Probenecid
- Col-Probenecid as a combination product containing Probenecid and Colchicine
-This medication forces the kidneys to excrete additional uric acid.
- Possible side effects include:
* Headache
* Appetite loss
* Nausea
* Vomiting
* Kidney disease (with prolonged use)
* Kidney stones
Allopurinol (Zyloprim, Aloprim)
- Class of medications called xanthine oxidase inhibitors
- This medication slows the development of uric acid by inhibiting the activity of certain enzymes.
- Possible side effects include:
* Rash, which may progress to a life-threatening condition
* Diarrhea
* Nausea
* Vasculitis, inflammation of blood vessels
* Bone marrow suppression
* Liver or kidney problems
- According to Medlineplus: both Probenecid and Allopurinol may increase the number of gout attacks during the first few months that you take it, although it will eventually prevent attacks. Your doctor may prescribe another medication such as colchicine to prevent gout attacks for the first few months you take probenecid or allopurinol.
Summary: one medication (Probenecid) "forces" the kidneys to excrete additional uric acid. The other medication (Allopurinol) inhibits certain enzymes to slow development of uric acid.
The “gold standard” drug, prescribed by Rheumatologists, is allopurinol.
A few other sources mentioned additional drugs:
- There is another drug that has just completed the stage III clinical trials called pegloticase (Puricase), for the most “stubborn and debilitating cases”, however, it does have serious adverse effects.
- A new drug just approved by the FDA (April 2009) called febuxosstat (Uloric), which I will continue to read up on.
For future study:
I'm not understanding the side effects for "prolonged use" if these medications are meant to be used for a prolonged period of time??
7. How does the doctor determine which medication to prescribe? How is it known if the gout is caused from kidneys or enzyme?
This is an answer I am currently trying to find the answer to!
8. What exactly is uric acid, anyways? Where does it come from? What are tophi deposits...are those the same thing?
- The uric acid crystals that build up under the skin is called tophi. They are the "lumps" you can see and feel.
- Uric acid crystals also build up around the joint
(see diagram: Gout Diagram)
9. Alternative or Complementary medicines?
There are some alternative supplements that some individuals have recommended as helping to prevent gout re-occurrence, but scientific evidence has not consistently shown these to be effective. You can read about the possible benefits of Vitamin C (500 mg daily), Folate (pterin-6-aldehyde, specifically), as well as others here.
The National Center for Alternative and Complementary Medicine (NCAAM) mentions a "tart cherry extracts called anthocyanins" that has been identified (in "unscientific reports") to reduce pain from arthritis and gout. Arthritis is a "hot topic" disease that is currently being studied, and I suspect more reports will be published about effective treatments to relieve joint inflammation and pain.
10. When is it advisable to have a second opinion; is gout ever mis-diagnosed? How would I know if I have joint damage or rheumatoid arthritis?
I am also currently researching this topic, and would love your input.
thanks!