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Harvard Commentaries
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Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School


Man to Man Man to Man
 

Gout -- A Common Cause of Joint Pain


January 24, 2013

By Harvey B. Simon M.D.

Harvard Medical School

The severe, almost unbearable joint pain often starts in the dead of night. You may have a fever, making you feel even worse. Lying still helps a bit, but even the touch of a sheet can be excruciating. Worst of all, your distress may be greeted with a sly smile instead of supportive sympathy. You are suffering from gout, a common disease that's often misunderstood.

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Myths and Realities

Gout is an old disease, and mistaken beliefs about it are just as old. Over the centuries, gout was considered a rich man's disease — a product of overeating, excessive drinking, and obesity.

Modern research, however, shows that gout has no relationship to wealth or social status, and only a slight link to diet and drink. But one traditional view has proved correct: Gout is primarily a man's disease. It occurs seven to nine times more often in men than women. It's also a common disease, striking an estimated 3.4 million American men annually.

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The Chemical Culprit

An attack of gout occurs when excess uric acid is deposited in a joint and forms crystals. The joint treats these crystals as foreign invaders. To fight the invaders, the joint sounds out signals that it needs help. The body makes more white blood cells, which are delivered to the joint through the blood stream. These white cells release chemicals that cause inflammation, swelling and pain.

Uric acid results when purines, a group of chemicals present in all body tissues and many foods, are broken down. It has no useful function in the human body.

Normally, uric acid is excreted in the urine. This keeps blood levels low. But some men have inherited a metabolic glitch that allows too much uric acid to build up in the blood. Ninety percent of the time the build-up occurs because the kidneys don't excrete enough uric acid. But sometimes the body just produces too much of the pesky chemical.

Certain medications, such as low-dose aspirin, thiazide diuretics and niacin, can also increase uric acid levels. Binge drinking, prolonged fasting, kidney disease, lead toxicity, extreme muscular exertion, leukemia and lymphomas are much less frequent causes of high uric acid levels.

These high levels eventually lead to gout, but not right away. In fact, uric acid levels are typically high for 20 to 30 years before they cause any trouble. That's why gout usually occurs in middle-aged and older men.

Uric acid levels in men are normally below 7 mg/dL. The higher the level, the more likely an attack of gout. However, up to 30% of men with gout have normal uric acid levels at the time of an attack.

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Ouch!

Gout is painful, very painful.

The most common manifestation of gout is acute arthritis, severe pain in a joint. In most cases, it strikes one joint at a time — usually the first joint in the big toe. Other frequent sites include the forefoot, instep, heel, ankle and knee.

Gout is less likely to affect the upper body, but it can strike fingers, wrists and elbows. At any site, the attack usually begins abruptly, often at night. Within hours, the joint becomes red, swollen, hot and painful. The pain and tenderness can be so severe that even gentle pressure from bedding is a problem. And even though only one small joint is affected, the inflammation can be intense enough to cause fever, muscle aches and other flu-like symptoms.

Without treatment, gout can also cause long-term arthritis, with chronic swelling and permanent joint damage. Uric acid crystals can build up to a remarkable degree, producing large, even grotesque, deposits called tophi in joints and other tissues. Crystals may also be deposited in the kidneys, where they can form kidney stones.

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How Is Gout Diagnosed?

Gout is easy to recognize when it hits the usual target — the big toe. Doctors can often make the diagnosis over the phone, and most men with gout can diagnose themselves — particularly when it's the second or third attack.

But the diagnosis can be tricky in other joints. It's simple to measure the level of uric acid in the blood. A high level supports a diagnosis of gout. But it's not definitive, because many healthy men have high levels and some men with gout have normal levels.

Other diseases can mimic gout, including rheumatoid arthritis, infections and "pseudogout," which is caused by crystals made of a different chemical. If the diagnosis is in doubt, doctors can remove a small amount of fluid from the inflamed joint and look for crystals using a special microscope.

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Treating Gout

Gout responds very well to nonsteroidal anti-inflammatory drugs (NSAIDs) if you start treatment as soon as possible.

Many prescription and over-the-counter NSAIDs are effective treatments for acute gout. Doctors most commonly prescribe naproxen, indomethacin or ibuprofen. One exception: Aspirin should not be used for gout because it can raise uric acid levels. After two to three days at full strength, you can cut the NSAID dose in half. In most cases, you can stop treatment after just five to seven days.

People who can't take NSAIDs because of gastritis, peptic ulcers or bleeding can take a similar drug, the selective COX-2 inhibitor, celecoxib (Celebrex). Another alternative is an old standby, colchicine. In addition, a brief course of prednisone or a similar steroid can also do the job. People who can't take oral medications can be given steroids intravenously. Or, they can be injected directly into the inflamed joint for rapid relief.

Inflamed joints need rest, but men with gout can resume their normal activities as soon as their attacks settle down.

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Preventing Gout

For centuries, diet was the main focus of prevention. But because only about 10% of the body's uric acid comes from the diet, it didn't work very well. Still, every little bit helps. Try to avoid these foods high in purine:

  • All meats, especially organ meats
  • Meat extracts and gravies
  • Seafood, especially sardines and anchovies
  • Yeast and yeast extracts
  • Beans, peas and lentils
  • Spinach and asparagus
  • Cauliflower
  • Mushrooms

(Modified from Emerson BT: New England Journal of Medicine, volume 334, page 445)

Watch what you drink. Beer is harmful; coffee is okay; and always drink enough water to avoid dehydration.

Although months or years can elapse between attacks, more than 75% of patients with gout have several episodes. Men whose attacks are infrequent don't need any preventive medication, but they should have an NSAID on hand to use at the first sign of another attack. If episodes occur often, prove hard to treat, or if very high uric acid levels predict frequent attacks, medications can help.

There are three ways to prevent a gout attack:

    • Medication to help the kidneys excrete uric acid. Probenecid (Benemid) is the traditional choice; the usual dose is 250 to 500 milligrams two or three times a day. The most common side effects are a rash and intestinal upsets. Because the drug increases uric acid in the urine, it can increase the risk of kidney stones. People with kidney disease should not take probenecid. When starting probenecid, you are likely to experience an acute attack of gout. However, this can be prevented by taking a low dose of colchicine or an NSAID daily. Aspirin doesn't work because it blocks the activity of probenecid.
    • Medication to reduce uric acid production. Allopurinol (Zyloprim) is the best treatment for men with chronic arthritis or kidney stones due to gout. Febuxostat (Uloric), a new drug that lowers uric acid production, was approved in 2009. It is an excellent choice for men who are allergic to allopurinol, but it is much more expensive. Like probenecid, both drugs can trigger gout. So daily low dose colchicine or an NSAID (but not aspirin) should be started at the same time.
    • Anti-inflammatory medication. A person with recurrent gout could
      take daily, low doses of NSAIDs (indomethacin, 25 milligrams twice a day, for example) or colchicine (0.6 milligrams once or twice a day) along with medication to lower blood levels of uric acid. This usually does not need to be continued indefinitely. Also NSAIDs and colchicine should be used with caution in people with impaired kidney function.

Gout is an old disease that has plagued men — and many women — for centuries. But the modern era has witnessed major changes in our understanding of gout and its treatment. While a healthful lifestyle is always wise, you can control gout by learning how to treat and prevent attacks themselves with just a little help from a doctor wise to the ways of gout.

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Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.

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