Gout is one of the more common forms of arthritis, and it can be easily managed with medications and diet modifications.
EVEN without national statistics, I do not find it difficult to believe consultant rheumatologist Dr Chow Sook Khuan when she says gout is one of the most common arthritis seen in general practice.
Because almost everyone I know, know of someone who is living with gout. And the mention of gout often elicits more nods than blank stares.
“I don’t know exactly why, but it has something to do with uric acid,” says a mother’s friend, as she continues to name a surprisingly accurate list of foods to restrict if you have gout.
“You can’t eat too much beans, meat, seafood, animal organs … and oh, stay away from alcohol,” she says. “But I’m not sure whether there is treatment for it.”
While she might not know that the foods she mentioned are rich in purine, a chemical compound that breaks down into uric acid in the body, she had gleaned the knowledge from observing the little trial-and-error experiments her friends who have gout perform every day.
However, the knowledge often stops there, and those who live with gout often suffer for years before they are willing to seek treatment because they are not sure whether anything could be done.
Sometimes, even doctors are confused. “Many doctors still erroneously tell their patients there are no treatment for gout besides avoiding trigger foods, or do exactly the opposite – prescribe gout medications even though all their patients had were just elevated uric acid levels,” says Dr Chow.
“But gout is the easiest to treat among all treatable arthritis,” she says. It is as simple as keeping blood uric acid levels low and keeping an eye on the complications of gout (such as kidney stones) and related conditions (obesity, hypertension, high cholestrol and diabetes).
“Usually doctors diagnose it accurately, but some of the patients are not properly managed,” she adds.
A joint misunderstanding
Most of us know that gout is in some way related to blood uric acid levels in the blood. The question is, how?
It’s like dissolving sugar in water. If you continuously add sugar into a fixed amount of water, you will find after a certain amount is added, the extra sugar you add no longer dissolves.
In gout, uric acid is like sugar added to your blood. After its amount reaches a certain level in the blood, it no longer dissolves and starts to form crystals that deposit in your tissues, especially in the joints. When that happens, it may trigger a gout attack – an inflammatory response in the joint which causes the joint to become red, swollen, warm to the touch, and painful.
So, it is true that the higher your blood uric acid level, the higher your chances of getting gout. But contrary to popular belief, high uric acid levels is not synonymous with gout.
Dr Chow explains: “If a person has high blood uric acid levels but does not have the symptoms of gout, he or she does not have it. What he or she has instead, is asymptomatic hyperuricemia – which means raised uric acid levels without clinical manifestation.”
How, then, do you know you have gout?
A clinical practise guideline (CPG) on the management of gout launched by the Health Ministry’s Health Technology Assessment section provides the following guide.
You can be diagnosed with gout if you develop two of the following:
- A tophus (a nodule-like deposit of uric acid in one of the joints, cartilage or bone)
- A podagra (a painful swelling in the big toe caused by gout)
- At least two gout attacks in two weeks.
An acute gout attack is totally different from rheumatism, or fong sap in Cantonese, says Dr Chow, who is also chairperson of the CPG working group.
“It is so characteristic you can’t miss it when you see it,” she adds. “When excessive uric acid crystallises and starts to accumulate in tissues or joints, they set off an inflammation process that leaves the affected site – usually the big toe – hot, red, and swollen.
“This can be triggered by the intake of alcohol or high-purine foods, dehydration, or mild trauma (such as an injured toe), especially in people whose gout is poorly controlled.”
The pain, as most gout patients will tell you, is “like having a thousand needles under your skin” for a few days or two to three weeks. Most of them could barely walk during an attack.
As raised uric acid levels and gout are said to be caused by the overproduction of uric acid in the body or its poor excretion by the kidneys (both are largely genetically determined), Dr Chow says there may be little one can do to prevent gout.
Recommended lifestyle modification and dietary advice could perhaps, delay the onset of gout, but “even with a zero-purine diet, you could only reduce your blood uric acid levels only up to 20%,” she says.
So, whether you are an overproducer or a poor excretor, you can still develop gout , particularly when it runs in your family.
Gout, in all its stages
Tee Kin Chye, a chirpy 50-year-old with a smile perpetually etched on his face, is one of Dr Chow’s many patients.
Of the 30 years he lived with the disease, he spent over 25 years of it visiting doctors in clinics, chiropractors, and other specialists to seek relief from the painful gout attacks and tophi he eventually developed.
“In the beginning, I thought the recurrent swelling in my big toe was just sprains. So I went to chiropractors to have it massaged. But most of the time, it became more painful.
“It did not occur to me that it was gout until a doctor diagnosed me when I was 20,” he says. “However, I was told there is no cure and given only a list of foods to avoid.”
But even after Tee diligently avoided foods that trigger his gout attacks, they still came intermittently. “During an attack, I was literally jumping around with my left leg. My right was too painful to set on the ground.”
After many attacks, which his doctors often resolved with anti-inflammatory jabs or oral painkillers, white, chalky nodules (tophi) started to appear on his left elbow and right toe.
“I’ve tried everything – supplements, alternative therapies – you name it. I had little confidence then because the tophus protruding from my elbow looked awful and the one in my leg was so big I couldn’t wear my shoes properly.
“Several times I had them surgically removed, but they just grew back months later,” he says.
What Tee had was a usual progression of typical gout through its three clinical phases: acute gout, intercritical gout (remission in between attacks), and chronic gout.
At the beginning of the disease, patients usually experience intermittent gout attacks and remissions, followed by a chronic phase, where painless but firm tophi start to form in one or more joints of the body.
Treatment is available, but not for everyone
Gout usually starts when one reaches 40 and affects more men than women. However, after 65 years old, it affects both sexes equally. Older patients also tend to develop tophi early in the course of their illness while younger ones develop tophi only after years of intermittent attacks.
But if there is one message Dr Chow emphasises over and over again throughout our interview, it is that “treatment is available, but not everyone with high blood uric acid levels or gout need to be treated”.
Treatment for gout first aims to reduce the patient’s blood uric acid levels (with uric acid lowering drugs such as allopurinol and probenecid), and second to relieve the pain and inflammation during a gout attack (with anti-inflammatory jabs or drugs).
Here it becomes a little complicated.
If you only have raised uric acid levels and nothing else, you might benefit from lifestyle and dietary modifications (lose weight, drink more water, avoid alcohol, take less purine-rich food, and control other related medical conditions like high cholesterol and hypertension). You do not need to be treated with any medications.
And even if you have already had an acute attack, you may not need medications to lower your uric acid yet, says Dr Chow.
It depends on how frequent your gout attacks, whether you have tophi, and whether you have other medical problems like heart disease.
For example, Dr Chow offers, “If you come to me for your first gout attack, I’d probably give you non-steroidal anti-inflammatory drugs to treat your acute gout, but I will not put you on allopurinol because your next attack might come only in the next 10 years!
“But if you’ve had more than three episodes per year, I might consider putting you on the drug,” she says.
Tee was considering having his big toe amputated when he consulted Dr Chow and was advised against it. This is because his gout, if not well controlled, would still recur and attack other joints even if he removed his toe. Also, as the surrounding tissue is packed with uric acid crystals, they might make it more difficult for his wound to heal.
The only indication for surgical removal is when a patient’s tophus is infected, or when it puts a lot of on pressure on surrounding structures, for instance, on a nerve, says Dr Chow. “It should be considered as a last resort,” she adds.
What doctors can do instead is to help the patient reduce his or her blood uric acid level below 0.36mmol/L or 6mg/dL. “At those levels, the uric acid that is deposited will dissolve by itself with time,” says Dr Chow.
After half a year on uric acid lowering drugs, the tophi in Tee’s elbow and right toe gradually subsided. “They practically saved my toe,” he chuckles. “Now, whenever I notice gout symptoms in my friends, I encourage them to have it checked by a doctor.”
By LIM WEY WEN
This article was first published in www.thestar.com.my on Sunday January 10, 2010.