What is Gout?
Gout is a disease of the joints in which an acute arthritis occurs as a result of urate crystals being deposited in the joint spaces, setting up irritation. Left untreated, recurring bouts of acute pain may occur, with the formation of aggregations of crystals called tophi, and gradual destruction of the joint. But this is often in association with other more widespread disorders of body metabolism, which can affect the kidneys, and allow the formation of stones with the detrimental effects these produce.
However, modern therapy can now almost totally eliminate attacks of gout, and sensible patients following routine medication can live normal lives uninterrupted by the excruciating pain of gout. The exact and immediate cause of the gout attack is an increase of uric acid in the blood. When this exceeds the upper arbitrary level of 0.42 mmol per liter, then gout is almost certain to take place. At this level or above, the acid is deposited in the joints. There is a tendency for preference for the near joint a big toe and this is characteristically the one in which symptoms occur. But any joint may be affected. Cases of early gout are often missed when the big toe not the object involved.
Uric acid is the end point of urine metabolism, and the kidneys are geared to just cope with its excretion in the urine. If any circumstances exist in which this fine balance is upset, then blood plasma excesses are likely. Certain illnesses seem notorious for aggravating such a situation.
“Secondary gout” is the result known cause that upsets the excretion of uric acid. Certain preparations may modify this, such as the oral diuretics (well-known in many who regularly use these common “fluid” medicines). Alcoholic excesses may play a similar role. Starvation may precipitate an attack. Small doses of the salicylates can produce similar result. This is the most important bit of treatment, for if the patient takes these drugs (as aspirin or in APC compound, for the pain) instead of helping relieve the cause, he is actually aggravating it. It’s best to avoid aspirin in any form unless you have certain disorders, such as psoriasis skin disease and more serious such as leukemia, which may also aggravate gout due to the effect on the kid’s filtering system.
“Disease of the wealthy” is the term used to describe gout occurring when nothing obvious is present. It seems to follow a history, genetically. It seems more common in those of higher social status. It was stated that “it affects more rich than poor, more wise than fools.”
At one stage this was attributed to alcoholic excesses of the wealthy, but this is not now believed, for chronic alcoholics do not necessarily suffer more often than do those who are abstainers from alcohol. People who suffer from rheumatoid arthritis are seldom gout subjects, and vice versa. Eunuchs never have the complaint, which indicates a hormonal relationship in some.
Diagnosis may be confirmed by withdrawing fluid from the affected joint and finding urate crystals there on microscopic examination. But it is seldom necessary to go to this extent to confirm diagnosis. Urate deposits (tophi) occur in a certain number, and affect the joints. It is estimated that about 20 per cent suffer from similar stones in the kidneys. There is also a fairly close relationship with elevated blood pressure.
An attack of gout follows a typical pattern and can frequently be accurately diagnosed by a layperson.
Typically the joint of the big toe (between the foot and first part of the toe, called the metatarso-phalangeal joint) is affected, although any joint of the body may be involved. (The hip and shoulder joints arc rare.)
Onset is usually abrupt. There may be a few vague symptoms immediately beforehand, such as feeling off-color, irritable, and some vague joint pains. The experienced sufferer may be able to quickly recognize these “prodromal symptoms” as a harbinger of a full-blown attack in the very near future.
Within a few hours the joint becomes red, swollen, tender and shiny. The overlying skin is stretched, extremely tender and dry. Usually only one joint is affected, but later on there may be more than one. The attack may occur at any time, but spring is claimed to he the most common season.
Frequency of attacks is variable. It may be months or years. (Up to 20 years has been recorded.) After a few days the swelling subsides and the attack is over.
With the passage of time and the laying, down of urate crystals in the joint, tophi may develop, and the joints may become deformed. Renal colic and the passage stones (often small ones called grave: can take place.
Some patients are aware of the adverse effect of certain foods or beverages, and will make an effort to restrict these (such as alcohol in some, or some foods Anxiety, stress, physical fatigue and emotional upsets may affect others.
The diagnosis of gout is very important, for with therapy on a long-term basis, future attacks may be totally preventable. A misdiagnosis may result in incorrect treatment being given, as well as the gross discomfort of further bouts. The doctor will most likely order some tests to be sure of diagnosis, even though the appearance may indicate it readily. The uric-acid blood test is usually diagnostic. The very acute tenderness of the join plus dry skin are diagnostic clues.
Treatment consists of two parts. It must be given under medical supervision. First, the acute stage must be managed. Second, efforts are made to prevent recurrences. Various drugs are used. Fairly high doses of the NSAIDs (non-steroidal anti-inflammatory drugs) are given, and these are the same as those administered for arthritis.
High doses are given for the first few days, and as the pain and inflammation reduce, the dose is also reduced. Once snore, they may cause gastric irritation, so are best given after food. Some of the medications come in suppository form and are inserted rectally. Some patients prefer this form of medication, although generally, in Australia and New Zealand, suppository medication is not popular. In many European countries, it is often the “first choice” method, but not here. This medication will bring dramatic relief in a few says, and indeed, often within a few hours of administration.
Colchicine 0.5 mg two-hourly is also still used. But as it often produces gastric side effects, its popularity has waned in of the other drugs named. In severe cases the corticosteroicl drugs will bring dramatic relief also, but these are rarely needed.
As this form of medication brings rapid relief, there is usually no need for other analgesics. Indeed, aspirin and its compounds are definitely unwise, for they may aggravate rather than assist. Also, drugs given for long-term use are not be given in the acute stage. Local measures include the application warmth, or icepacks, whichever seems work more efficiently. Often keeping clothes off the affected part helps.
Entirely preventable long-term therapy is very important, and as every doctor knows, gouty arthritis should be entirely preventable. This consists of the continuous use of the so-called “uricosuric” preparations, producing an increased rate of elimination of uric acid by the kidneys.
Doctors usually prescribe allopurinol, a so-called inhibitor of xanthinc oxidase. By interfering with the final stages of purine breakdown, it prevents the excessive production of uric acid. This also must be taken continuously, on an indefinite basis. If it is left off, the uric acid build-up may recur with the evidence of the original symptoms of gout. As with the other drugs, it must not be given during an acute attack of gout. Short courses are useless, and the patient must understand the underlying reasons for the need for continual treatment.
Several older drugs are available, such as probenecid, and sulphinpyrazone is equally effective. These must not be given during an acute attack, for they may worsen the situation. But afterwards, they may be taken long-term, continuously. Plenty of fluids are advised, particularly in hot climates. The idea is to continually flush out the excess amounts of uric acid from the blood. With modern forms of therapy, previous advice often offered about dietetic restrictions now no longer applies. Adhering rigidly to medication is the answer to the problem.
The doctor will also check for any underlying cause of the disease, and make efforts to correct these.