If you’ve seen the old movie Little Lord Fauntleroy, or read the beloved children’s book by Frances Hodgson Burnett, you may remember the grumpy old grandfather, who often bellowed with pain because of his gouty big toe, and how his housekeeper scolded him about eating too many rich foods. She was right.
Eating foods such as liver, anchovies, and kidneys can contribute to or cause gout. These rich foods are high in purines, substances your body can change to uric acid. But we also produce uric acid in our bodies, and some people just produce too much.
When there’s too much uric acid, some of it forms crystals in the joint and the joint lining (synovial membrane). Deposited calcium crystals in a joint cause a similar problem, pseudogout, which means false gout. Pseudogout usually involves the large joints, such as the wrists and knees and not the foot.
There are two types of gout: inherited, or primary, and secondary gout. In primary gout, the body simply produces too much uric acid, or you don’t excrete as much in your urine as is normal. With secondary gout, there is too much uric acid in your blood either because you take diuretics (drugs that encourage urination) or because your kidneys are failing. Secondary gout can also result from chemotherapy treatment for cancer or from a disease such as leukemia that results in the breakdown of red blood cells. Most victims of gout are men over 40.
Unfortunately, gout attacks don’t give you much warning. They often occur at night, and they hit fast. Three times out of four, they will strike the big toe with excruciating pain. The pain will gradually diminish over a one-to two-week period. You may not have another attack for months or years, but usually they begin to occur more frequently. Gout can affect the feet, knees, and elbows.
Your doctor will suspect gout from the swelling, tenderness, and redness of your joints and from your other symptoms. Blood tests will usually show high uric acid. You may also have small lumps under the skin often in the cartilage of your ear, caused by uric acid accumulation. If your doctor just isn’t sure it’s gout, he may aspirate, or draw fluid from, the joint to look for uric acid crystals. Occasionally, the doctor may give you a test dose of colchicine, a drug that can ease gout pain if given within 48 hours of an attack but won’t work well on other types of arthritis. Later in the disease, X-rays can show bone damage caused by gout. (Pseudogout can also be diagnosed by calcium buildup in cartilage visible on X -rays and by the presence of calcium crystals in the joint fluid.)
First, gout-proof your diet. High-purine foods, which include sardines, anchovies, sweetbreads, brains, kidney, and liver, are engraved invitations to a gout attack. But overweight itself is also a cause of gout. So if you’re too heavy, adopt a commonsense, gradual weight loss plan. (But do it slowly and sensibly and never by fasting. Ironically, if you drop pounds too quickly, that can trigger gout attacks, too.) Be sure to drink plenty of water, and especially avoid alcohol, which not only is high in purines, but also prevents you from eliminating them through your urine.
You’ll want to review your medications with your doctor if you are prone to gout. If you are taking the blood pressure medication hydrochlorothiazide (Esidrix, HydroDIURIL) or the diuretic, or “fluid pill,” furosemide (Lasix), your doctor will want to switch you to different medicines. Niacin, sometimes prescribed to lower cholesterol, and daily aspirin can also cause problems. All of these drugs decrease the amount of uric acid that your kidneys can eliminate. Your doctor can steer you toward alternative drugs that won’t encourage gout.
Finally, be aware that gout may flare up whenever you are admitted to the hospital, whether for surgery or a medical reason. It’s not quite fair to discuss this under “Prevention,” because if you could avoid injury or hospitalization, of course you would. But either event can raise your risk of gout. Make sure all your doctors know you’re prone to gout problems if you’re in the hospital or need surgery.
Generally, it’s best to stay in bed for 24 hours after a gout attack, because moving around can cause swelling and trigger another. A variety of medicines will help. Pseudogout is treated with aspirin or other NSAIDs. Primary and secondary gout are essentially treated in two stages. First, for an acute attack, your doctor may prescribe NSAIDs for the inflammation and pain or corticosteroids if NSAIDs are troublesome for you. In some cases your doctor may inject a drug called ketorolac (Toradol) into a muscle for pain. Or she may use indomethacin if you’re having an acute attack. Sometimes corticosteroids are injected or fluid is drained from the joint to ease pain. Although a drug called colchicine was once widely prescribed for gout attacks, it’s used less often today, because it is effective only at doses high enough to also cause diarrhea. Warning: If you take diuretics or low-dose aspirin for gout, you’ll actually make things worse, as these drugs prevent your kidneys from excreting uric acid.
Then, after the attack subsides, your doctor will determine whether your uric acid levels need to be lowered by medication. Medications that lower uric acid levels do so in two ways. Drugs called uricosuric agents, such as probenecid and sulfinpyrazone, increase the amount of uric acid your kidneys eliminate. Others, such as allopurinol, work by lowering the amount of uric acid your body produces. You can’t take uricosuric agents, however, if you have kidney problems. And, because gout medicines can interact with other drugs, be sure your doctor is aware of all the drugs you are taking.
One particularly dangerous interaction happens when allopurinol is mixed with azathioprine (or Imuran), an immunosuppressive drug sometimes prescribed for rheumatoid arthritis. The problem? Allopurinol can make the effect of Imuran from 3 to 10 times stronger.