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GOUT

August 11, 2013

GoutGout is derisively referred to as “the disease of kings”, but this “aristocratic ache” has less to do with blue blood flowing through your veins than … an excess of uric acid. Uric acid is produced when the body breaks down certain foods. At high serum concentrations, uric acid crystallizes, and the crystals deposit in joints to produce symptoms of gout.

At first, it tends to affect only one joint — most frequently the big toe — and is characterized by a red, tender, hot and swollen joint. When left untreated, patients experience more frequent attacks, longer attacks, and symptoms can spread to multiple joints. Repeated attacks of gout over many years can lead to the development of  tophi, while high levels of uric acid in the urinary system can result in kidney stones. Men are four times more likely than women to develop gout, where it is seen commonly at older ages and in association with obesity, diabetes, hypertension, high cholesterol, and heart disease.

Diet 

As a gout sufferer, one needs to avoid foods containing high amounts of purines ( e.g. meat, seafood, fructose, and alcohol ). Follow this link for dietary recommendations.

Acute Attacks

During an attack, a patient should rest, ice and elevate the affected joint. Medical treatment consists of anti-inflammatory drugs. I typically prescribe colchicine, celecoxib , naproxen, or prednisone until the gout attack resolves.

Uric Acid Lowering and Prophylaxis

In order to prevent attacks of gout, doctors prescribe uric-acid lowering drugs and prophylactic therapy. Uric acid lowering drugs are suggested for patients under the following conditions:

–  the presence of a tophus or tophi

– frequent attacks of acute gouty arthritis (e.g.  two per year)

– chronic kidney disease, or

– a history of kidney stones with high uric acid.

When using uric acid lowering drugs, the goal is to achieve a target uric acid level below 360 micromol/L. This means that a patient will require blood work every 2-4 weeks until he reaches his target serum urate level of ≤360 µmol/L.

Medications used to enforce this target are allopurinol and febuxostat. Less commonly, probenecid, fenofibrate or losartan are used. Prescribers usually wait 6 weeks after the last attack of gout before prescribing uric acid-lowering drugs because — during the initial phase of treatment — there is an early increase in acute gout attacks. In order to mitigate this risk, prophylactic drugs are prescribed. Prophylactic drugs are colchicine, naproxen, or prednisone. The duration of prophylaxis is usually 6 months.

Benjamin Franklin, Meat, and Drink

Dialogue Between Franklin and the Gout

Benjamin Franklin (1706–1790)

Midnight, 22 October, 1780.

BenFranklinDuplessisFRANKLIN. Eh! Oh! eh! What have I done to merit these cruel sufferings?

GOUT. Many things; you have ate and drank too freely, and too much indulged those legs of yours in their indolence.

FRANKLIN. Who is it that accuses me?

GOUT. It is I, even I, the Gout.

FRANKLIN. What! my enemy in person?

GOUT. No, not your enemy.

FRANKLIN. I repeat it, my enemy; for you would not only torment my body to death, but ruin my good name; you reproach me as a glutton and a tippler; now all the world, that knows me, will allow that I am neither the one nor the other.

GOUT. The world may think as it pleases; it is always very complaisant to itself, and sometimes to its friends; but I very well know that the quantity of meat and drink proper for a man, who takes a reasonable degree of exercise, would be too much for another, who never takes any.

 

Matthews, Brander, ed. (1852–1929).  The Oxford Book of American Essays.  1914

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