Gout

By Chris Woolston, M.S.

What is gout?
Of all the things that can go wrong with a joint, perhaps nothing's more painful than gout.

Vinnie Campasano of San Francisco can testify to that. Campasano had his first excruciating
experience with the disease when he was 33. That night he went to bed with a slight tingling in
his big toe and woke up vaguely aware of some pain. But when his foot hit the floor, he
crumpled in agony.

"It brought tears to my eyes. It was the most painful experience I have ever had. I really thought
my toe was going to blow up," Campasano says. During that first bout, the slightest movement
was unbearable.

The excruciating pain is easy to explain. People with this condition have a build-up of needle-
sharp crystals in their joints. As if that weren't bad enough, the body's immune system starts
attacking the crystals, causing inflammation and swelling. In the past, this condition was often
crippling. But thanks to modern medicine, most patients can find quick relief and avoid future
attacks.

The crystals that cause gout are made of uric acid, a waste product that is normally expelled in
urine. People with gout have one of two basic problems: Either they produce too much uric acid
or their bodies retain more than they should. Eventually, the bloodstream is carrying more uric
acid than it can handle, and crystals settle in the spaces around the joints. Crystals of uric acid
can also form in the kidneys, causing kidney stones.

According to the Arthritis Foundation, roughly 6.1 million Americans have experienced at least
one gout attack. The disease seems to be growing more common, but serious complications have
become rare.

What causes gout?

It's not always clear why people produce too much uric acid. In some cases, diet definitely plays
a role. Certain foods are rich in purines, compounds that the body breaks down into uric acid.
Purines are especially abundant in anchovies, organ meats (such as liver), sardines, and
asparagus. Research published in the British Medical Journal also reports that soda, sugary
drinks and fructose are strongly associated with an increased risk of gout in men.
Campasano had generally been conscientious about his diet since the first bout, but shortly
before his second attack of gout, which came nearly 10 years later while he was on vacation, he
ate a series of foods tailor-made to bring on an episode. There was pizza with anchovies,
followed some days later by liver and onions, and, just before the flare-up, the final insult to his
system: shrimp cocktail, lobster, and asparagus, washed down with a little red wine. In someone
prone to gout, the uric acid in even a few of those foods can bring on an attack.
Many things can hamper the body's ability to flush out uric acid. Obesity is near the top of the
list. Other possible culprits include excessive alcohol intake, hypertension, and certain
medications including diuretics, niacin, and aspirin. Stress seems to be a factor as well. Genetics
may also play a role.

What are the symptoms of gout?

The first attack of gout usually comes on suddenly. You'll feel intense pain in a joint, most often
in the big toe. In addition to being extremely painful, the affected joint may be red, swollen, and
warm to the touch. Gout can also occur in the knees, ankles, and wrists. A few patients develop
gout in more than one joint at a time. Campasano has had it only in his foot, but that was enough
to keep him on crutches for weeks at time.

Early flare-ups of gout usually last for three to 10 days before fading away, but they can last
longer. Even without treatment, as in Campasano's case, you may not have another attack for
months or even years. But gout has a strong tendency to return. And over time, it can become
crippling. If you're having attacks and go 10 years or more without medical care, crystals can
form permanent, disfiguring lumps known as tophi. Left untreated, tophi can destroy nearby
bone.

Who is at risk for gout?

The typical patient with gout is a man in his 40s. Women can develop gout too, but it rarely
strikes before menopause. The condition sometimes runs in families. According to National
Institutes of Health estimates, up to 18 percent of people with gout have a family history of the
condition.

How is gout treated?

If you have a flare-up of gout, see a doctor right away. The sooner you get treatment, the sooner
you'll get relief. Your doctor can prescribe a strong nonsteroidal anti-inflammatory drug to ease
your pain. Some people can't take such medications, including anyone with kidney disease,
bleeding ulcers, or extremely high blood pressure. In such cases, a doctor may prescribe a steroid
to be taken orally or injected into the joint.

It's good to remember that a suddenly sore and painful joint could be gout, but at least until you
are sure of the diagnosis, it should be evaluated to be sure it's not something else -- such as a
serious joint infection that needs emergency treatment. Fever and chills are not common with
gout, so any hot, painful joint accompanied by fever and chills should be evaluated immediately
by a doctor.

How can gout be prevented?

An attack of gout is like an alarm bell. Your body is telling you that something is out of balance.

If you're overweight, you now have one more excellent reason to shed some pounds. According
to a report in Nursing Times, losing just a few pounds will provide powerful protection against
gout. As always, slow, gradual weight loss is best. Crash diets and rapid weight loss can actually
increase your risk for an attack of gout.
Here are some other tips for avoiding gout:
 Drink alcohol in moderation or not at all.
 Drink plenty of other fluids (especially water). According to the Mayo Clinic, 10 to 12 glasses
of fluid each day will help flush uric acid out of your system and greatly lower the risk of gout.
 Avoid foods high in purines, such as anchovies, asparagus, sardines, mackerel, herring,
scallops, game meats, gravy, and liver and other organ meats.
 Limit your intake of red meat.
One large-scale study, however, exonerated certain high-purine foods, including mushrooms,
beans, peas, spinach and cauliflower. Milk, once considered another food to avoid, has more
recently been associated with a decrease in gout attacks, according to the Arthritis Foundation.

If you still have frequent gout attacks, your doctor can prescribe medications for extra protection.
Options besides NSAIDs include colchicine, an anti-inflammatory that can both reduce the pain
of an acute attack and prevent flare-ups when used daily, and allopurinol (Zyloprim), a drug that
slows the production of uric acid in the body, and is best used for patients who are overproducers
of uric acid.

A drug called Uloric (febuxostat) reduces the uric acid buildup that causes painful crystals to
form in the first place. Probenecid (Benemid) increases excretion of uric acid, and is good for
patients who have trouble excreting uric acid in the urine. To decide which drug is best, your
doctor may do blood tests and a 24-hour urine test.

Gout is too painful -- and too easily treated -- to ignore. During flare-ups, Campasano takes the
medication his doctor prescribed, and he believes that avoiding foods with uric acid has helped
limit his attacks to only four in 15 years.

"It is not something that I ever want to have again," he says, "and I will do everything in my
power to avoid it."

References
Interview with Vinnie Campasano, gout sufferer
Gout Diet. Arthritis Foundation.
Mayo Clinic. Gout.
National Institute of Arthritis and Musculoskeletal and Skin Diseases. Questions and answers
about gout.
Choi HK, Curhan G. Soft drinks, fructose consumption and the risk of gout in men: prospective
cohort study. British Medical Journal, Vol. 336(7639): 285-6.
Last Updated: Jan 20, 2018

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