Gout is
a disease characterised by recurring pain and swelling of joints typically occurring
in young or middle-aged men. Usually it starts in one joint at a time and usually
it is the joint at the base of the big toe. In gout there is a high level of
uric acid in the blood. This is the result of defective body chemistry dealing
with purines, nitrogen containing compounds that are important for energy. The
purines can be eudogenous (synthesised within the nuclei of cells in the human
body) or exogenous (detained from foods). The end-point of purine metabolism
is uric acid which is produced in the liver. Most uric acid is excreted by the
kidneys through urine and some is disposed through the intestines. These processes
keep the uric acid levels within the normal range. However, under certain circumstances,
the body produces too much or excretes too little uric acid, resulting in higher
levels of uric acid in the blood. In the disease, crystals of sodium urate are
deposited in and around the joints and the soft tissue, causing pain and inflammation.
Crystals can also accumulate in the kidney causing urate stones and even kidney
damage.
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This may be caused by : v
Certain hereditary factors causing the production of more purines. v
Some diseases of the blood where there is an increased breakdown of cells,
some severe forms of skin diseases etc.
Decreased excretion of uric acid.
This may be caused by : v
Long standing renal disease. v
Certain drugs that are taken e.g. diuretics. v
Reduction in elimination of water from the body in certain diseases e.g. high
blood pressure, starvation. Signs and Symptoms - Acute Gout
An acute attack starts when there
is a sudden increase in the blood uric acid level. When the blood is examined,
the blood uric acid is found to be more than 420 millimol per liter (7mg per
100ml). An acute onset can be precipitated by a variety of factors such as taking
a diet high in purines, over-consumption of alcohol, stress, infection, joint
injury, and certain kinds of drug treatment by a person predisposed to gout.
v
Onset is sudden with severe pain, redness and swelling, usually in the base
of the big toe. Other frequently affected sites are the joints of the foot,
ankle, knee, wrist and fingers. If not treated, the attack can last days or
weeks and stop spontaneously. Attacks can recur at monthly or yearly intervals. v
There might be nausea, flatulence and vague abdominal pain. v
Passing more urine and frequently. v
Slight fever might be present.
Signs and Symptoms - Chronic Gout
In chronic cases crystals of monosodium
urate get precipitated in and around the joints, cartilage of the ear and in
the kidneys causing permanent damage.
v
Deposits in the cartilage of the ear can cause hard swellings called ‘tophi’ v
In the joints, destruction of cartilage and bony erosion leading to pain, stiffness
and disability of joints. v
Progressive kidney damage can lead to formation of kidney stones and kidney
failure.
Treatment
Drugs For Acute Attacks
v
Non-steroid anti-flammatory drugs (NSAIDS)
These drugs are commonly used to treat the acute attack
e.g. diclofenac, indomethacin and ketoprofen. These drugs are given to relieve
the swelling and the pain. (Note. Aspirin should be avoided as it reduces
the excretion of uric acid from the kidneys)
v Colchicine
This drug is effectively used in the treatment
of acute gout. For patients with chronic gout, who have frequent attacks, joint
changes or consistently high uric acid levels, long term treatment is necessary.
v Corticosteroids
They are used only when the patient cannot tolerate NSAIDS. They are used
only for short periods.
Drugs For Long-Term Treatment
These drugs are recommended when the patient has had several acute attacks of gout
or when the hyperuricemia is caused by some in-born metabolic deficiency.
v
Uricosuric drugs e.g. probenecid and sulphinpyrazone
These drugs increase
the excretion of uric acid in the urine by preventing the re-absorbtion of
uric acid in the kidneys.
v
Xanthine-oxidase inhibitors e.g. allopurinol - an enzyme inhibitor
Allopurinol is the
drug of choice for older patients and for patients with a history of kidney
renal impairment and tophaceous gout. It prevents the formation of uric acid.
The above two drugs should
not be started during an acute attack, but several weeks after an acute attack.
Once started it should be continued indefinitely to prevent further attacks.
Good Habits
v
Reduce intake of protein in the diet e.g. legumes, beans and red meat. v
Eat less high purine food e.g. organ meats, (liver, kidney, brain, heart , pancreas)
meat
extracts,
goose, duck, turkey, fish roe, sardines and herring. v
Reduce intake of beer, tea and coffee. v
Restrict the intake of fat especially by those who are obese. v
Drink plenty of water (up to 8 glasses a day) to flush out the kidneys. v
Do not go on sudden weight reduction diet. Maintain a healthy weight.
Risk Factors For Gout
v
Males – males account for more than 90% of the patients with gout. v
Family history – 10-20% of patients have a family history of gout. v
Obesity v
Hypertension v
Alcohol use v
More prevalent in urban than in rural communities
