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Posted on: Sunday, January 21, 2001

New treatments hold out hope of relief for gout

By Dr. Landis Lum
Special to The Advertiser

The great English physician Thomas Sydenham was afflicted with gout, and his famous treatise on the condition, "Tractus de Podagra," written in 1683, remains a classic. See if you recognize the symptoms.

"The victim goes to bed and sleeps in good health. About 2 in the morning he is awakened by a severe pain in the great toe; more rarely in the heel, ankle, or instep. Then follow chills and shivers, and a little fever.

"The pain becomes more intense; after a time this comes to its height, accommodating itself to the bones and ligaments of the tarsus and metatarsus. Now it is a violent stretching and tearing of the ligaments - now it is a gnawing pain and now a pressure and tightening. So exquisite and lively meanwhile is the feeling of the part affected, that it cannot bear the weight of bedclothes nor the jar of a person walking in the room. The night is passed in torture, sleeplessness, turning of the part affected, and perpetual change of posture; the tossing about of the body being as incessant as the pain of the tortured joint."

Gout is an arthritis six times more common in men than women. Besides the feet, it can also affect the knees and, less frequently, the wrist, fingers and elbow. Untreated, it can last hours to days. The peak age of onset is 45.

What causes gout? The body makes uric acid from foods with a high purine content, such as organ meats (such as liver), sardines and shellfish. Gout occurs when so much uric acid accumulates in the body (usually from an inherited inability of the kidneys to get rid of it) that crystals form in the joint fluid.

White blood cells called neutrophils try to attack and dispose of these crystals, but in their unsuccessful attempt to destroy them, they release natural chemicals of inflammation into the joint space, causing pain, swelling and redness.

In my experience, certain racial groups such as Filipinos have a particularly high risk of gout. Filipinos living in the United States have higher uric acid levels than those living in the Philippines. Their kidneys have a limited ability to get rid of uric acid, thereby increasing uric acid blood levels when eating the usual American diet (which has a relatively high purine content).

What’s more, Filipinos have a high frequency of high blood pressure, and diuretics (water pills) commonly used to treat this also tend to raise uric acid levels. In general, one out of five patients with gout have relatives with gout.

Should high uric acid levels be treated even if a person has never had gout? No. In less than a fifth of such patients will gout ever develop. And you risk taking a potentially dangerous medication for the rest of your life for nothing. Allo-purinol (Zyloprim), the most commonly used drug to lower uric acid levels, in rare cases can cause a hypersensitivity syndrome with kidney failure, hepatitis and a life-threatening skin condition called Stevens-Johnson syndrome. This serious complication has been reported most commonly in patients with elevated uric acid levels alone and not in patients with gout. It is more likely to occur in patients on diuretics or with kidney dysfunction.

Acute gout attacks can be treated with anti-inflammatories like Indocin or Motrin (if no conditions like ulcers exist; in this situation, steroid injections into the joint may be necessary).

Sometimes drugs like colchicine may be necessary. Drugs like Allopurinol or Probenecid to lower uric acid levels should not be started until after a gout attack has subsided (otherwise it can actually worsen the attack).

Proper treatment is needed to help prevent permanent joint and even kidney damage. Excessive alcohol intake and obesity are both associated with high uric acid levels and should be avoided and/or treated.

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