Gout

Gout - more diets, symptoms, causes, treatments

About.com: Gout and Pseudogout - Information and resources about these disorders.

Acute Gouty Arthritis - Information on acute gouty arthritis from Yahoo! Health.

Diagnosis and Management of Gout - Article from the American Family Physician.

eMedicine Health - Gout - Consumer health resource center providing an overview of gout and its causes, symptoms, and treatment.

Gout - Editorial from the British Medical Journal.

Gout - A look at this, the commonest forms of arthritis, its causes, treatment, treatment of acute attacks, how to lower uric acids and complication. Some helpful tips.

Gout - The basics about recognizing, treating and preventing this condition from the Mayo Clinic.

Gout - Doctors answers to frequently asked questions about this disorder.

Gout and Hyperuricemia - Full text article from the American Family Physician.

Gout Haters - Forums and information for people that have been diagnosed with this disease.

Gout Hater's Cookbook - Recipes for foods lower in purines, designed for persons suffering from gout.

Gout Information - Information on causes, treatment and prevention.

I Cured my Gout - Personal account from a sufferer.

MedicineNet: Gout and Hyperuricemia - Information including who is affected, risk factors, symptoms, diagnosis, treatment and future therapy.

MEDLINEplus: Gout and Pseudogout - Fact sheets and resources concerning gout and pseudogout compiled by the National Library of Medicine (NLM).

Merck Manual - Overview of the signs, symptoms, diagnosis, prognosis and treatment of gout.

A practical approach to gout - Current management of gout from Postgraduate Medicine.

Purine Metabolic Patients Association - Charity and patient support organization for those with gout and related disorders.

Questions and Answers About Gout - From the National Institutes of Health.

Seek Wellness: Gout - Information for patients, including symptoms, treatments, nutritional considerations, recovery and questions for your doctor.

UK Gout Society - Practical patient information, support, and advice about the symptoms, causes, treatment and prevention of this painful arthritic condition.

Gout Information

Gout (also called metabolic arthritis) is a disease due to an inborn uric acid metabolism. In this condition sodium urate crystals are deposited on the articular cartilage of joints and in the particular tissue like tendons. This provokes an inflammatory reaction of these tissues. These deposits often increase in size and burst through the skin to form sinuses discharging a chalky white material.

Normally, the human bloodstream only carries small amounts of uric acid. However, if the blood has an elevated concentration of uric acid, uric acid crystals are deposited in the cartilage and tissue surrounding joints. Elevated blood levels of uric acid can also result in uric kidney stones.

Signs and symptoms of gout

The classic picture is of excruciating and sudden pain, swelling, redness, warmness and stiffness in the joint. Low-grade fever may also be present. The patient usually suffers from two sources of pain. The crystals inside the joint cause intense pain whenever the affected area is moved. The inflammation of the tissues around the joint also causes the skin to be swollen, tender and sore if it is even slightly touched. For example, a blanket draping over the affected area would cause extreme pain.

Gout usually attacks the big toe (approximately 75% of first attacks), however it can also affect other joints such as the ankle, heel, instep, knee, wrist, elbow, fingers, and spine. In some cases the condition may appear in the joints of the small toes which have become immobile due to impact injury earlier in life, causing poor blood circulation that leads to gout.

Patients with longstanding hyperuricemia (see below) can have uric acid crystal deposits called tophi (singular: tophus) in other tissues e.g. the helix of the ear. Uric acid stones can form as one kind of kidney stone in some occasions.

Diagnosis

The diagnosis is generally made on a clinical basis, although tests are required to confirm the disease.

Hyperuricemia is a common feature; however, urate levels are not always raised. Hyperuricemia is defined as a plasma urate (uric acid) level greater than 420 µmol/L (7.0 mg/dL) in males ( the level is around 380 µmol/L in females ); despite the above, high uric acid level does not necessarily mean a person will develop gout. Additionally, urate falls to within the normal range in up to two-thirds of cases. If gout is suspected, the serum urate should be repeated once the attack has subsided. Other blood tests commonly performed are full blood count, electrolytes, renal function and erythrocyte sedimentation rate (ESR). This serves mainly to exclude other causes of arthritis, most notably septic arthritis.

A definitive diagnosis of gout is from light microscopy of joint fluid aspirated from the joint (this test may be difficult to perform) to demonstrate intracellular monosodium urate crystals in synovial fluid polymorphonuclear leukocytes. The urate crystal is identified by strong negative bi-refringence under polarised microscopy, and their needle-like morphology. A trained observer does better in distinguishing them from other crystals.

Pathogenesis

Although the exact cause of gout is not known, it is thought to be linked to defects in purine metabolism. Purine is an organic compound commonly found in the body and is metabolized by the body into uric acid. People with primary gout have either an increased production of uric acid or an impaired excretion of uric acid, or a combination of both.

There are also different racial propensities to develop gout. The prevalence of gout is high among the peoples of the Pacific Islands, and the Maori of New Zealand, but rare in the Australian aborigine despite the latter's higher mean concentration of serum uric acid.

Hyperuricemia is considered an aspect of the metabolic syndrome, although its prominence has been reduced in recent classifications. This explains the increased prevalence of gout among obese individuals.

Many still believe that gout is caused by a combination of dietary factors and "laziness". In particular, many believe that gout develops following several years of excessive alcohol consumption combined with an ongoing lack of physical activity and a diet completely lacking in purine-neutralising foods, such as berries, as well as other specific fruit and vegetables (see below). Others have refined this theory, saying that some are genetically predisposed to gout and some are not. As a result, people who are not predisposed can live over-indulgent lifestyles and not develop gout, while others who are predisposed can develop gout, despite being physically active and having a well-rounded diet. However, most in the "genetic predisposition" school of thought nonetheless believe that the condition is much more likely to develop in the predisposed if the other factors are present over several years (excess alcohol, inactivity and failure to eat purine-neutralising foods). It is known that lead sugar was used to sweeten wine, and that chronic lead poisoning is a cause of gout, which condition is then known as saturnine gout, because of its association with alcohol and excess.

Gout can also develop as co-morbidity of other diseases, including polycythaemia, leukaemia, intake of cytotoxics, obesity, diabetes, hypertension, renal disorders, and hemolytic anemia. This form of gout is often called secondary gout. Diuretics (particularly thiazide diuretics) have traditionally been blamed for precipitating attacks of gout, but a Dutch case-control study from 2006 appears to cast doubt on this.

Stages of gout

Gout has four distinct stages:

1. asymptomatic,
2. acute,
3. intercritical,
4. chronic.

In the first (asymptomatic) stage, plasma uric acid level increases, but there are no symptoms. The first attack of gout marks the second or acute stage. Mild attacks usually go away quickly, whereas severe attacks can last days or even weeks. After the initial attack, the person enters the intercritical stage or symptom-free interval that may last months or even years. Most gout patients have their second attack within 6 months to 2 years from their initial episode.

In the last or chronic stage, gout attacks become frequent and become polyarticular (affecting multiple joints at one time). Large tophi can also be found in many joints. In advanced cases of chronic gout, kidney damage, hypertension and kidney stones can also develop.

Attacks

Acutely, first line treatment should be pain relief. Once the diagnosis has been confirmed, the drugs of choice are indomethacin, other nonsteroidal anti-inflammatory drugs (NSAIDs), or intra-articular glucocorticoids, administered via a joint injection.

Colchicine was previously the drug of choice in acute attacks of gout. It impairs the motility of granulocytes and can prevent the inflammatory phenomena that initiate an attack of gout. Colchicine should be taken within the first 12 hours of the attack and usually relieves the pain within 48 hours. Its main side-effects (gastrointestinal upset) can complicate its use. NSAIDs are the preferred form of analgesia for patients with gout.

Before medical help is available, some over the counter medication can provide temporary relief to the pain and swelling. NSAIDs such as ibuprofen can reduce the pain and inflammation slightly, although aspirin should not be used as it can worsen the condition. Preparation H hemorrhoidal ointment can be applied to the swollen skin to reduce the swelling temporarily. Professional medical care is needed for long term management of gout.

Ice may be applied for 20-30 minutes several times a day. There are concerns that uric acid crystallization is accelerated by low temperature, but in a 2002 study in the Journal of Rheumatology[citation needed] patients who used ice packs had better relief of pain with no negative side effects. Keeping the affected area elevated above the level of the heart may help as well.

Due to swelling around affected joint for prolonged periods, shedding of skin may occur. This is particularly evident when small toes are affected and may promote fungal infection in the web region if dampness occurs. Treat in a similar fashion to Athlete's foot.

Prevention

Long term treatment (in frequent attacks) is antihyperuricemic therapy.

Dietary change can make a contribution to lowering the plasma urate level if a diet low in purines is maintained, because the body metabolizes purines into uric acid. Avoiding alcohol, high-purine foods, such as meat, fish, dry beans (also lentils and peas), mushrooms, spinach, asparagus, and cauliflower, as well as consuming purine-neutralizing foods, such as fresh fruits (especially cherries and strawberries) and most fresh vegetables, diluted celery juice, distilled water, and B-complex and C vitamins can help.

A strong natural cure is a berry extract supplement consisting of bilberry, blueberry or cherry extracts. The anthocyanins which give the berries their blue and purple hues, after entering the body, turn into powerful anti-inflammatories. These might be an especially preferable option to transplant patients, who frequently suffer gout due to increased toxicity and strain on the kidneys due to their immunosuppressant medication.

The mainstay of this approach, however, is the drug allopurinol, a xanthine oxidase inhibitor, which directly reduces the production of uric acid. However, allopurinol treatment should not be initiated during an attack of gout, as it can then worsen the attack. If a patient is on allopurinol during an attack, it should be continued.

The decision to use allopurinol is often a lifelong one. Patients have been known to relapse into acute arthritic gout when they stop taking their allopurinol, as the changing of their serum urate levels alone seems to cause crystal precipitation.

Allopurinol and uricosuric agents are contraindicated in patients with kidney stones and other renal conditions.

Additional measures

* Febuxostat - a novel non-purine inhibitor of xanthine oxidase seems to be an alternative that is superior to allopurinol.

* Probenecid, a uricosuric drug that promotes the excretion of uric acid in urine, is also commonly prescribed - often in conjunction with colchicine. Interestingly, the drug fenofibrate (which is used in treating hyperlipidemia) also exerts beneficial uricosuric effect.

* As arterial hypertension quite often coexists with gout, treating it with losartan, an AT receptor antagonist, might have an additional beneficial effect on uric acid plasma levels. This way losartan can offset the negative side-effect of thiazides (a group of diuretics used for high blood pressure) on uric acid metabolism in patients with gout.

* It is suspected that in many cases gout may be secondary to untreated sleep apnea, when oxygen-starved cells break down and release purines as a by-product. Treatment for apnea can be effective in lessening incidence of acute gout attacks.

* A study in 2004 suggests that animal flesh sources of purine, such as beef and seafood, greatly increase the risk of developing gout. However, high-purine vegetable sources did not. Low fat dairy products such as skim milk significantly reduced the chances of gout. The study followed over 40 thousand men over a period of years, in which 1300 cases of gout were reported.

* Puricase, a poly(ethylene glycol) ("PEG") conjugate of recombinant porcine uricase (urate oxidase), which breaks down the uric acid deposits is being studied in Phase III clinical trials for the treatment of severe, treatment-refractory gout in the United States in 2006.Pipeline

Diet

The following suggestions do not meet with universal approval among medical practitioners.

Try using a baking powder based toothpaste. This will slightly reduce the acidity and thus might reduce the chance of gout.

Low purine diet:

* To lower uric acid:
o cherries have been shown to reduce uric acid
o strawberries or blueberries (and other dark red/blue berries) are also reputed to be beneficial
o celery extracts (celery or celery seed either in capsule form or as a tea) is believed by many to reduce uric acid levels (although these are also diuretics).
o limit food high in protein such as meat, fish, poultry, or tofu to 8 ounces (226 grams) a day. Avoid entirely during a flare up.
* Food to avoid:
o foods high in purines
+ sweetbreads, kidneys, liver, brains, or other offal meats
+ sardines
+ anchovies
+ scallops, prawns, and crabs
+ alcohol. Some claim that this applies especially to beer, on the basis that *brewer's yeasts are very rich in purine. In view of the fact that most modern commercial beer contains trace amounts of yeast, this claim requires substantiation. Others claim that red wine is particularly bad for gout, though again it is difficult to find an explanation. Alcohol may also reduce the rate of uric acid excretion.
+ meat extracts, consommés, and gravies
o diet sodas (these act as diuretics in many people, causing uric acid to concentrate in the blood which can then easily precipitate)
* To avoid dehydration:
o Drink plenty of liquids, especially water, to dilute and assist excretion of urates;
o Use sparingly diuretic foods or medicines like aspirin, vitamin C, tea and alcohol.
* Folklore has it that Joe-Pye weed flushes uric acid quickly, but continued use can damage the liver or kidneys
* Another folk remedy is the use of oenomel, a drink with honey and unfermented grape juice.
* Moderate intake of purine-rich vegetables is not associated with increased gout.

Vitamins and Supplements

The following is based on information from a naturopathic physician.

* Quercetin – inhibits uric acid production
* Bromelain – anti-inflammatory
* Vitamin E
* Flaxseed oil
* Avoid high doses of vitamin C and niacin (vitamin B-3) - may increase uric acid

History of gout

Gout was traditionally viewed as a disease of the decadent and indolent, because the foods which contribute to its development were only available in quantity to the wealthy. The stereotypical victim was a lazy, obese middle-aged man who habitually overindulged in rich foods and alcohol, with port consumption often cited as a specific cause. This stereotype is especially evident when gout is referred to as "The Disease of Kings".

Perhaps due to the traditional relationship between wealth and literacy, gout is one of the most commonly-reported maladies in history.

The Roman gladiatorial surgeon Galen described gout as a discharge of the four humors of the body in unbalanced amounts into the joints. The Latin term for a drop, as a drop of discharge, is gutta -- the term gout descends from this word.

Famous people who had gout

One of the most famous sufferers of gout was Henry VIII. Others include John Calvin, Charles Spurgeon, Khubilai Khan, Nostradamus, John Milton, Queen Anne, Isaac Newton, Gottfried Leibniz, Henry Fielding, Samuel Johnson, Charles V, Holy Roman Emperor,[12] Pablo Neruda, Alfred Lord Tennyson, George IV, John Hancock, Thomas Jefferson, Karl Marx, William Pitt, 1st Earl of Chatham, Benjamin Disraeli, Kirk Reuter, David Wells, Rubens, Lennart Torstenson, Peter Gomes, Alexander Hamilton, George Mason, Benjamin Franklin, Jared Leto,Wilkie Collins, Frederick the Great.

Piero_di_Cosimo_de'_Medici was dubbed "Piero il Gottoso"; literally "Piero The Gouty".

The Roman poet Ennius wrote "numquam poetor nisi podager" — "I never write poetry unless I am suffering from gout." He used the enforced idleness caused by his arthritis to compose poetry.

The surgical treatment of his gout led Mel Brooks to create his famous persona, the 2000 Year Old Man.

According to a 1997 paper in Nature[13], also Sue, the T-Rex, could have suffered from gout.

Source: Attribition: This informational article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article Gout, which you should consult to see its full references.

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