AboutGout:What you need to know about gout and uric acid

2

Gout has been, and remains, a major cause of human suffering, and for that reason

it is worthy of attention.Ray Porter and G.S. RousseauGout: the Patrician Malady, 1998

IntroductionOnce called the “disease of kings” and “king of diseases,” gout has the distinction of being one of the most frequently recorded medical illnesses throughout history, as far back as 5 B.C. While it has been linked to status and wealth through the ages, its association with royalty provides little comfort to those who suffer the pain, swelling, immobility and inconvenience of gout. People may think gout died with Ben Franklin in the late 18th century, but more than two million people in the United States live with gout today.

A form of arthritis, gout is characterized by sudden and severe episodes of pain, tenderness, redness, stiffness and swelling of joints. Gout is most often felt in the large joint of the big toe, but it can affect other joints such as the instep, ankle, heel, knee, wrist, finger and elbow.

It is the most common type of inflammatory arthritis in men over 40. Sufficient levels of estrogen may protect women through much of their adult life and women typically do not suffer from gout until after menopause. Gout often runs in families and when it develops in men before the age of 30 it can be especially severe.

Because gout is associated with several other disorders, including high blood pressure and heart disease, it is important that the diagnosis of gout be prompt.

While it can be one of the most painful types of arthritis, the good news is that gout is manageable. The symptoms can be controlled with guidance from your physician and with a basic understanding of what causes and what successfully treats gout. Gout can be managed with adjustments to diet and lifestyle and with medication it often can be completely controlled. Through proper monitoring and treatment, painful episodes and long-term joint damage can be avoided.

This brochure and its accompanying Web site: gouteducation.org, are designed to help gout sufferers reshape their understanding of the disease and its treatments, embrace lifestyle modifications and, ideally, restore some control and spontaneity to their lives.

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What is Gout?Gout is caused by an accumulation of sodium urate crystals in the joints. These crystals form when there is an abnormally high level of uric acid in the body.

Uric acid is naturally present in small amounts in the body. It is a waste product that results from the body’s normal process of cells dying and releasing purines, as well as from the body absorbing purines contained in food.

Uric Acid and Hyperuricemia Normally, uric acid is dissolved in the blood and passes through the kidneys into the urine. When more uric acid is produced than the kidneys can eliminate, the serum uric acid level increases to greater than 6.8 mg/dL. This elevated level is known as hyperuricemia.

The Tipping PointYears of sustained hyperuricemia (often 20 years or more) can lead to storage of excess uric acid throughout the body that can be several times the normal level. When the uric acid level is above 6.8 mg/dL, crystallization of the uric acid as sodium urate can occur. These crystals accumulate in the joints and can set the stage for painful attacks of gout. For someone with hyperuricemia, trauma, surgery or excessive consumption of purine-rich foods or alcohol can tip the balance, setting a cascade in motion within the body that triggers a painful attack of gout.

Uric Acid Level < 6.0 mg/dLMost experts agree that lowering a person’s uric acid level to less than 6.0 mg/dL is helpful to prevent the consequences of hyperuricemia and gout. Your physician can measure your serum uric acid level through a simple blood test. Your uric acid level can be lowered by a combination of medication and lifestyle adjustments. (see pages 6, 13)

Gout is caused by an accumulation

of sodium urate crystals in the joints.

Men over the age of 40 are more likely than

women (of the same age) to suffer with gout.

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Diagnosis of GoutGout can occasionally be difficult for physicians to diagnose because the symptoms mimic several other conditions. Although most people with gout have hyperuricemia (too much uric acid in the body), it may not be present during an acute attack. In addition, hyperuricemia alone does not mean that a person has gout. In fact, most people with hyperuricemia do not develop the disease. Thus, having hyperuricemia is not the same as having gout.

To confirm a diagnosis of gout, physicians typically test the fluid from a person’s inflamed joint. The fluid, called synovial fluid, is viewed under a microscope. If a patient has gout, the physician will almost always see urate crystals. The absence of crystals, however, does not completely rule out a diagnosis of gout.

Risk Factors for Goutl Obesity – a Body Mass Index (BMI) of 30 or higher (see page 11)

l Joint injury – urate crystals are more likely to form in a joint that was previously damaged and/or a recent injury can bring on an attack

l Diuretic medicines (taken for high blood pressure, leg swelling or heart failure) – can decrease the kidney’s ability to remove uric acid, resulting in hyperuricemia

l Untreated high blood pressure, diabetes or high cholesterol

l High levels of serum triglycerides (a fatty substance) in the blood – associated with an increased risk of heart disease

l Chemotherapy – the breakdown and turnover of cells leads to an increased production of uric acid

l Kidney disease

l Genetics – one out of four people with gout have a family history of the condition

l Hyperuricemia – elevated uric acid levels

Triggers for Goutl Regular, excessive alcohol intake, especially beer; or a drinking “binge”

l Surgery or sudden severe illness

l Consumption of large quantities of purine-rich foods, especially meat products (see pages 8 – 9)

l Radiation therapy

l Crash diets, particularly high-protein fad diets

l Starting a uric acid-lowering treatment medicine (even though it may be the correct long-term therapy)

l Taking the drug cyclosporine (an anti-rejection transplant medication)

To best prepare for a visit to your physician, be ready to answer the following questions:l What joints of the

body are affected?

l When did you fi rst notice the pain?

l Did the pain come on suddenly or gradually?

l What was the pain like?

l Was the pain worse during the day or at night?

l Was the area hot, red or swollen?

l Have you had similar episodes in the past? If so, how long did they last?

l Did you experience other symptoms, such as fever, general achiness, a loss of appetite, at the time the area became painful?

l Have you noticed any lumps under your skin, especially on the ridge of the outer ear, the fi ngers, elbows, toes or around the Achilles tendon (connects the heel bone to the lower leg)?

l Have you ever had kidney stones?

l Does anyone in your family have gout?

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Is gout serious?Gout is one of the most painful forms of arthritis and is the source of incapacity for millions. Gout causes sudden intense pain and swelling in the joints, which also are typically warm and red. Following their first attack of gout, approximately 60 percent of patients will experience another attack within the first year and 78 percent within the next two years.

If gout is left untreated it can lead to permanent joint damage and destruction of tissue. Other disorders associated with untreated gout include the following:

l Deformity and crippling arthritisWhile tophi (deposits of urate crystals that settle under the skin in the joint space and tendons) are relatively painless, acute inflammation can occur around them. Eventually, extensive destruction of joints and large tophi beneath the skin may lead to deformities, particularly of the hands and feet, and to progressive crippling.

l Kidney stonesKidney stones are extremely painful. They often are composed of uric acid. They may block the urinary tract and, if left untreated, can result in infection and damage to the kidneys. Approximately one out of five gout sufferers will develop kidney stones.

l Impaired kidney functionHyperuricemia and gout can be associated with decreased kidney function. Moderate impairment is defined as less than one half the normal function rate of an adult’s kidneys. If the kidneys’ function drops below 25 percent it is considered severe impairment; below 10-15 percent is referred to as end-stage renal disease (ESRD).

Why the big toe?Fifty percent of first-time acute attacks are experienced in the big toe and 90 percent of patients will suffer podagra, gout of the big toe, at some time during the course of their disease. The pain of gout is such that the big toe may feel as if it is caught in a mechanical device. Some believe that the big toe becomes vulnerable and more prone to an attack because of the pressure it receives from walking. Another explanation is the fact that urate crystals form more readily at cooler temperatures, and the big toes are cooler than the central part of the body. While gout strikes most often in the big toe, the instep, the knee and the Achilles tendon also are common sites.

The Pain of GoutA gout attack is extremely painful. It is said that the pain rivals that of childbirth or the fracture of long bones. On a pain scale of one to ten, most gout patients rank their pain as nine or ten. Medical professionals generally agree that pain that ranks as a “fi ve” requires intervention.

REQUIRES INTERVENTION

PATIENTS TYPICALLY

RATE GOUT HERE

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Lifestyle Adjustments/Self-Care Strategiesl Maintain a healthy, balanced diet. Avoid purine-rich foods, as well as large amounts of

foods containing a moderate concentration of purines, as they increase the amount of uric acid in the body and may trigger a gout attack. Refer to the diet section on pages 8 – 9 for additional information regarding gout-friendly diet strategies.

Some dietitians recommend creating a gout and lifestyle diary so that you can keep track of foods that for you may trigger an attack of gout. See sample diary on page 7. It is best to work with your physician and/or a registered dietitian to determine the diet that is appropriate for you.

l Exercise regularly. According to the Centers for Disease Control and Prevention (CDC), adults should engage in moderate-intensity physical activities for at least 30 minutes most days of the week. Moderate-intensity physical activity refers to a level of effort in which a person experiences:

l Some increase in breathing or heart rate;

l A “perceived exertion” – the effort a healthy individual might feel while walking briskly, mowing the lawn, dancing, swimming or bicycling on level terrain; or

l Any activity that burns 3.5 to 7 calories per minute. Examples include: Walking for 30 minutes at a brisk pace or swimming laps for 30 minutes.

Increasing the intensity or the amount of time you are physically active can have even greater health benefits and may be needed to prevent weight gain. It is important for you to work with your physician to develop an appropriate exercise program that is tailored to your body, lifestyle and needs. Always check with your physician before starting any exercise program.

l Maintain a healthy body weight. An obese person is four times as likely to develop gout than someone with a normal body weight. Obesity is defined as a body mass index (BMI) of 30 and above. See ‘Health Issues Associated with Gout’ section on page 11 for more information on obesity. While it is important to maintain a healthy body weight, avoid crash diets as quick or extreme weight loss can increase the amount of uric acid in the body.

l Stay hydrated. Many dietitians recommend you get at least 64 ounces of water per day, and if you are exercising you might need a bit more. Water makes up 50 to 80 percent of our body weight. The body needs water for transporting nutrients and wastes, regulating its temperature and cushioning joints and tissues. Research also suggests that drinking adequate water might guard against kidney stones and constipation. Some experts also believe that drinking water can help remove uric acid from a person’s bloodstream.

l Drink less alcohol, especially beer. Consumption of alcohol, especially beer which is high in purines, can increase the amount of uric acid in your body. It is suggested that men who are at risk for gout should consume no more than two drinks a day and women over the age of 65 should limit alcohol consumption to one drink a day.

l Take your medication as directed. It is important to work with your physician to find the right medication for you to effectively manage your gout. Always take your medication as directed. Speak with your physician or pharmacist if you have any questions regarding possible interactions. See page 13 for more information on medication for gout.

l Know what your uric acid level is. Ask your physician to test your uric acid level at least twice a year.

Additional helpful hints: • Take your medication with a full glass of water

• Discard old medications

• Do not take other people’s medications

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7

Diet and GoutThe idea is not to go on a diet,

but to improve your eating style

by emphasizing and de-emphasizing,

gradually creating a modifi ed pattern

that is an enjoyable part of your life.

Jeremiah Stamler, M.D.Professor emeritus and founding chairman of the Department of Preventative Medicine at Northwestern University, Chicago

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Diet plays an important role in the management of gout. Foods rich in purines, as well as large amounts of foods containing a moderate concentration of purines, should be avoided as they increase the amount of uric acid in the blood and may trigger a gout attack. Purines are the very basic molecular building blocks of DNA and RNA. As the body breaks down purines in foods uric acid is formed.

A 2004 study by Dr. Hyon Choi, et al. published in the New England Journal of Medicine found that each additional serving of purine-rich red meat was associated with a 21 percent increase in the risk of gout in men over age 40, and each additional weekly serving of seafood was associated with a seven percent increase in risk. The study also found that protein, purine-rich vegetables and moderate wine drinking are not as harmful to gout sufferers as once believed. In addition, the study found that low-fat dairy products, specifically skim milk and low-fat yogurt, may actually decrease the risk or provide some protection against gout.

What should you eat? Listed on page 9 are examples of high and moderately high-purine content foods and drinks. Gout may be easier to manage if you minimize your intake of high-purine foods and limit your intake of moderately high-purine foods. For most people with gout, it is best to base your diet on low-purine foods such as low-fat dairy products, fresh fruit and vegetables, nuts and grains. It is important to avoid crash diets as quick or extreme weight loss increases the amount of uric acid in the body.

Some dietitians recommend creating a gout and lifestyle diary so that you can keep track of foods that for you may trigger an attack of gout. It is best to work with your physician and/or a certified dietitian to determine the diet that is appropriate for you.

Please see page 6 for additional ideas regarding Lifestyle Adjustments/Self-Care Strategies

High-Purine ContentGout patients should consume foods in this group sparingly

• Anchovies

• Beer

• Bouillon (meat based)

• Brains

• Broth (meat based)

• Clams

• Consommé

• Goose

• Grain alcohol

• Gravy

• Heart

• Herring

• Kidney

• Lobster

• Mackerel

• Meat extracts

• Mincemeat

• Mussels

• Oysters

• Partridge

• Roe (fish eggs)

• Sardines

• Scallops

• Shrimp

• Sweetbreads

• Yeast (baker’s and brewer’s) taken as a supplement

These food lists may vary from the lists supplied by your physician or dietitian.This information is not intended as a substitute for the advice given by your physician. Please be sure to follow your physician’s instructions.

Source: Krause’s Food, Nutrition and Diet Therapy, 2004

Moderate-Purine ContentGout patients should limit their consumption of foods in this group

• Asparagus

• Beans, dried

• Fish (except those in the high-purine content list)

• Lentils

• Meat (except those in the high-purine content list)

• Mushrooms

• Peas, dried

• Spinach

9

10

Stages of Gout

Asymptomatic Hyperuricemia Elevated levels of uric acid are present in the body, but no symptoms of gout are experienced in this stage. This may represent a precursor to actual gout. Most patients will have elevated levels of uric acid for many years before their first attack, and the risk of an attack increases as the uric acid level increases. Treatment is usually not necessary during this stage.

Acute Gout AttackYears of sustained hyperuricemia may lead to small deposits of sodium urate crystals in and around the joint space. Following certain triggering events (see page 4), these deposits release crystals into the joint space, triggering an acute attack. The first attack often occurs at night when intense pain and swelling in the joint awakens the patient. The pain of the first attack usually goes away (even without treatment) after three to 10 days. The patient may not experience another attack for months or even years. It is important to consult a physician during an acute gout attack to obtain appropriate therapy and to be certain the pain is not due to another form of arthritis.

Intercritical GoutDuring this time a patient who has experienced a prior gout attack has no gout symptoms and their joints are functioning normally. It may be human nature to push disease management out of mind when you are not troubled by symptoms, but this symptom-free period is precisely the time to consult with your physician to prevent future attacks and pain. During this time, you and your physician can:

l Determine if medications may aggravate the conditionl Review dietary guidelines about purine-rich foodsl Assess alcohol intake and determine if there is a need to cut backl Assess body mass and determine if there is a need to lose weightl Discuss the therapeutic options to prevent or treat future attacks

Unfortunately, if ignored, this phase is frequently followed by continued attacks of gout.

Chronic Tophaceous GoutAfter many years of gout attacks, some patients enter into the most disabling stage of gout. Uric acid crystals have been depositing within and around the joint space resulting in an ongoing destructive inflammatory process, or chronic arthritis. As urate pools expand, deposits of crystals or tophi, collect in cartilage, tendons, soft tissues and elsewhere. In this stage, the disease has caused deformity and destruction of the bone and cartilage. There may be damage to the kidneys during this stage as well.

With proper medical attention and treatment, most patients will not progress to this advanced stage.

STAGE 1

STAGE 2

STAGE 3

STAGE 4

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Health Issues Associated with Goutl Obesity

Obesity is a condition that exists when a person is carrying excess body fat that is severely out of proportion to their height. The Body Mass Index (BMI), a calculation used by the Department of Health and Human Services Centers for Disease Control and Prevention, divides a person’s weight in pounds by their height in inches. A BMI of 30 is about 30 pounds overweight.

An obese person is four times as likely to develop gout than someone with a normal body weight.

BMI can be calculated using pounds and inches with this equation

Weight in Pounds x 703

(Height in inches) x (Height in inches)

BMI WEIGHT STATUS

Below 18.5 Underweight

18.5 – 24.9 Normal

25.0 – 29.9 Overweight

30.0 and Above Obese

From the Department of Health and Human Services Centers for Disease Control and Prevention

l DiabetesDiabetes is a disease in which blood glucose (sugar) levels are above normal, due to a lack of insulin in the blood or resistance to the action of insulin. Preliminary research suggests that insulin resistance may play a role in the development of gout, and hyperuricemia may worsen insulin resistance.

Is gout linked to hypertension and heart disease?

Gout often is associated with cardiac problems, including high blood pressure, coronary artery disease and congestive heart failure. Hyperuricemia has been associated with a higher risk of death from these conditions.

Gout may contribute to unhealthy cholesterol and lipid levels. Although necessary for normal functioning of cells, when certain lipids are increased or deposited in blood vessel walls, blockages may result in a heart attack or stroke.

Because an elevated uric acid level is strongly associated with cardiovascular disease, hypertension, kidney disease and obesity, studies are underway to determine if uric acid has a direct role in causing these disorders.

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Management of GoutWith the right treatment, most people who suffer with gout are able to control their symptoms and maintain their normal lifestyle.

To help prevent and minimize future attacks:

l Take your medication as prescribed

l Treat gout when the symptoms first occur

l Follow-up with your physician until you find a treatment that is right for you

l Tell your physician about all the medications and over-the-counter products you take including herbs and vitamins

l Maintain a healthy, balanced diet

l Exercise regularly and maintain a healthy body weight

Questions for your physician:l Are there any

lifestyle changes I can make that might reduce my risk of developing gout or having a gout attack?

l Will any of the current medications that I am taking increase my riskfor hyperuricemia?

l How does medication work to help my gout?

l How and when should I take gout medication?

l How long should I take gout medication?

l What are the most frequent side effects with gout medication?

l Could gout medication interact with other medications I am taking?

l What should I do if I miss a dose?

l What should I do if my symptoms are not relieved while taking gout medication?

Management of PainTo decrease the pain of an acute attack, you can try the following:

l Rest the affected joint for 24 hours after the initial attack or until the pain eases

l Elevate painful joints

l Apply cold packs wrapped in towels to the affected joints for 20–30 minutes several times a day

l Relieve inflammation by taking nonsteroidal anti-inflammatory drugs (NSAIDs), such as Advil® or Aleve®*

l Aspirin may abruptly change uric acid levels and make symptoms worse. Patients taking low-dose aspirin (75–325 mg/day) for prevention and/or treatment of cardiovascular disease or stroke should continue to take aspirin as prescribed, even in the setting of an acute gout attack. However, patients should not take higher doses of aspirin (6–12 tablets or 2000–4000 mg per day) to treat a gout attack.

* If you have high blood pressure, heart disease, kidney disease, ulcers, heartburn or easy bruising check with your physician before taking NSAIDs.

TreatmentsThe goals of treatment are to:

l Ease the pain associated with acute attacks

l Prevent future attacks

l Avoid the formation of tophi and kidney stones

Successful treatment can reduce both the discomfort caused by the symptoms of gout and reduce the risk of longterm damage to the affected joints. Treatment will help prevent disability due to gout.

Treatments to relieve pain and reduce swelling include:l Adrenocorticotropic Hormone (ACTH) INTRAMUSCULAR INJECTION

OR SUBCUTANEOUS INJECTION. ACTH suppresses the inflammation of an acute gout attack. [Example: Acthar Gel]

l Colchicine TAKEN ORALLY. This drug may be most effective when taken within the first 12 hours of an acute attack. Physicians may ask patients to take oral colchicine three to four times a day, or as often as every hour until joint symptoms begin to improve or side effects such as nausea, vomiting, abdominal cramps or diarrhea make it uncomfortable to continue the drug.

l Glucocorticosteroids TAKEN ORALLY OR INJECTED INTO THE AFFECTED

JOINT OR INTRAMUSCULAR INJECTION. Glucocorticosteroids suppress the inflammation of an acute attack. [Example: Prednisone]

l Nonsteroidal anti-inflammatory drugs (NSAIDs)TAKEN ORALLY. NSAIDs reduce the inflammation caused by deposits of uric acid in the body. [Example: Aleve or Advil]

Treatments to lower uric acid levels and prevent future attacks include:l Allopurinol TAKEN ORALLY. Allopurinol decreases the body’s

production of uric acid. Recommended to use if you have a history of kidney stones or tophi. [Example: Lopurin]

l Probenecid TAKEN ORALLY. Probenecid increases the kidney’s ability to remove uric acid from the body. Not recommended if there is a history of kidney stones. [Example: Benemid]

Drugs don’t work in patients who don’t take them.

C. Everett Koop, M.D.Former United States

Surgeon General

13

Importance of Taking Your MedicationFor most patients, medications are the most effective way to fi ght gout. Even strict adherence to a healthy diet will only reduce uric acid levels by 1 mg/dL. For most, this is not enough to reach less than 6 mg/dL, which many experts agree is a reasonable goal for gout sufferers. Work with your physician to fi nd the right medication for you so that you can effectively manage your gout.

Brand names are registered trademarks of their respective owners.

14

When to Use*

Medication Type Medication ExamplesSome brand names listed

Relieve Pain and Reduce Swelling

Adrenocorticotropic Hormone (ACTH)

Acthar Gel

Colchicine Colchicine

InjectableGlucocorticosteroids

Oral Glucocorticosteroids

Methylprednisolone (Medrol); Prednisone (Deltasone); Triamcinolone (Kenalog)

Nonsteroidal anti-infl ammatory drug (NSAIDs)

Celecoxib (Celebrex); Ibuprofen(Advil); Indomethacin (Indocin)Naproxen (Aleve, Naprosyn)Many additional and equally effective NSAIDs are available. Log on to gouteducation.org for more information

Lower Uric Acid Levelsand Prevent Future Attacks

Allopurinol Lopurin; Zyloprim

Probenecid Benemid; Probalan

Medications for goutRelieve pain. Reduce swelling. Lower uric acid levels. Prevent future attacks.

14

Brand names are registered trademarks of their respective owners.

15

How It Works Most Common Side Effects**

Suppresses the infl ammation and painof acute gout (may have the most rapid onset)

Retention of sodium (salt) and fl uids, weight gain, high blood pressure, loss of potassium and headache

Suppresses the infl ammation and pain of acute gout

Nausea, vomiting, abdominal pain and diarrhea

Suppresses the infl ammation and pain of acute gout

Retention of sodium (salt) and fl uids, weight gain, high blood pressure, loss of potassium and headache

Suppresses the infl ammation and pain of acute gout

Nausea, stomach discomfort, heartburn, kidney problems, retention of sodium (salt) and fl uids

May interact with blood pressure and heart medications

Decreases the body’s production of uric acid

Rash, diarrhea, nausea and drowsiness

If initiated without the use of the anti-infl ammation medications listed above, the patient may experience frequent episodes of gout during the fi rst year of treatment

Increases the kidney’s ability to remove uric acid from the bloodstream

Diarrhea, headache, nausea and liver function abnormalities

If initiated without the use of the anti-infl ammation medications listed above, the patient may experience frequent episodes of gout during the fi rst year of treatment

Should not be used by patients with kidney stones or patients taking methotrexate and some other medications

* Take as directed by physician or pharmacist according to prescription label and ask your health care professional to explain anything you do not understand. Do not take more or less medication than prescribed.

** Ask your physician or pharmacist about other possible side effects. See product package insert or log on to gouteducation.org for a complete list of side effects.

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