By Jose de Leon, MD
What is gout?
Gout is very common in Asians. It is an inherited medical disease. It is a disease of the inability to secrete excess uric acid in the urine or the inability to process foods rich in purine leading to high uric acid levels. Kidney disease or dysfunction can lead to high blood levels of uric acid. Gout is due to the accumulation of monosodium urate crystals. Pseudogout is the accumulation of calcium pyrophosphate crystals. Gout is more common.
What are gout symptoms?
Gout presents an inflammation of joints. Gout is peculiar; it occurs in areas farthest from the heart like fingers and toes, less common on ankles and wrists, less common on knees and elbows, and almost rare on hips and shoulders. Gout destroys the bone and the bone can not be replaced. Accumulation of destroyed bones is what we call tophi, which look like hard lumps on the joints. Large tophi are treated with aggressive reduction of uric acid. Usually, we do not surgically remove tophi as it can often lead to chronic non-healing wounds.
How is gout diagnosed?
Gout is diagnosed on clinical history and by physical exams. Also, your doctor can simply take a blood test to check your uric acid levels. To distinguish between gout and psuedogout, a sample of fluid from the inflamed joint needs to be taken. This is a very painful procedure and since gout is more common than psuedogout, and the treatment of the diseases is the same, most of the time we do not need to take the fluid samples.
How is gout treated?
Gout medications are directed for the reduction of uric acid, but the reduction of uric acid is also known to trigger gout attacks. Therefore, usually for six months, patients need a low dose of anti-inflammatory medicine, such as colchicine or naproxen. It is presumed that in six months, the uric acid level is low enough not to trigger frequent gout attacks. The uric acid level goal is 6.0. Pseudogout is treated with anti-inflammatory medication only and not medication intended to correct the uric acid problem.
Probenecid is another medication to decrease uric acid levels, but sometimes we worry that this may lead to the formation of uric acid stones if there is not enough hydration. Allopurinol is an old but effective medicine but is dependent on kidney function. The usual dose is one 300mg tablet daily in normal kidney function. Higher doses may be prescribed or lower doses like 100-200mg prescribed to those patients with kidney problems. A severe side effect of allopurinol is itchy skin that can turn into blisters all over the body and this can possibly lead to death. This reaction is rare, but a patient should call their physician right away if there are skin problems.
Side effects of allopurinol triggered the development of a safer medicine, febuxostat. There is cross-sensitivity to allopurinol, but it is very rare. We generally do not give this medication to patients with a history of heart attacks or are at higher risk for heart attack. The treatment goal is the same to lower the high uric acid to 6.0 to prevent triggering gout attacks.
For acute gouty attacks, some doctors use colchicine IV or colchicine tablets. Other medications include indomethacin (specifically effective in gout but has a side effect of headache), high dose steroids like methylprednisolone dosepak, or a short burst of prednisone.
Some non-gout medications surprisingly help to lower uric acid. Vitamin C leads to excretion of uric acid in the urine. Blood pressure medication losartan 50mg and a lipid medication fenofibrate 200mg also help in excreting uric acid to urine.
There are even more powerful biologic medications that are given by specialists, specifically rheumatologists, for patients with difficultly getting to the desired uric acid levels and have tophi. These biologic medications however can trigger immune-related allergies and should be used only for a limited time.
What can we do to prevent gout attacks?
We can decrease the frequency of gout attacks by avoiding some foods or at least only having them in moderation. Alcoholic beverages, particularly beer, trigger gout most of the time. The use and conversion of hops to make good beer alter uric acid. Making hard liquor uses ingredients other than hops and thus even though they can trigger gout, it is much less.
Foods that are high in uric acid can obviously cause gout attacks and should be avoided. Some food has surprisingly high uric acid, including mushrooms, some broth, roasted vegetables, leeks, green peas, brussel sprouts, sardines and anchovies, shellfish, crabs, organ meats (liver gizzards innards), turkey (chicken is a better option), cauliflower (broccoli is an option), whole milk sometimes (skim milk is a better option), tuna, haddock trout, and scallops. Certain foods, like sardines, end up with high uric acid by degradation. Other foods, like cauliflower, have a lot of individual cells that when processed yield high uric acid. Some food when barbecued produce more uric acid than boiled. Red and dark meat trigger gout more than white meat. Pork and lamb are notorious in triggering gout but duck and chicken are better substitutes.
JOSE DE LEON, MD is a private practice Internal Medicine physician in Kahili. He is a current member and past president of PMAH. He is involved in the Seafarers Free Medical Clinic.