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Clinician’s Corner: Gout

Gout is the most common inflammatory arthritis, affecting approximately 8.3 million Americans (6.1 million men and 2.2 million women). Gout has been increasing over the last half century, due to the aging of the population, increased use of medications that can trigger gout, and the obesity epidemic. It is no longer a disease of the rich and well fed.

Gout occurs when uric acid forms crystals that precipitate in the joints, most commonly the big toe.  Gout attacks usually occur suddenly at night, may cause a patient to wake up. Gout attacks are often triggered by stressful events, alcohol, drugs, or another illness. These nasty uric acid crystals can cause kidney stones, and lumps under the skin.

Common Drugs that Raise Uric Acid levels:

  • Alcohol
  • Chemotherapeutic drugs
  • Aspirin greater than 2g/day. BUT greater than 5gm/day decrease uric acid.
  • Low dose (81mg) aspirin does not affect uric acid levels.
  • Nicotinic acid (niacin)
  • Diuretics: all diuretics except spironolactone cause hyperuricemia.

Conditions that can increase uric acid levels.

  • Hypothyroidism– low thyroid may cause elevated uric acid levels
  • Psoriasis– quick turnover of cells and systemic inflammation may elevate uric acid levels
  • Obesity– can be a contributory factor

HIGH URIC ACID LEVELS: Can be caused by increased production uric acid OR decreased excretion by the kidneys.

Uric Acid Stones

  • Up to 20% of patients with gout develop uric acid stones.
  • Uric acid stones are found in 5-10% of urinary stones. Additionally, 15-20% of patients with calcium stones have excess uric acid in the kidneys.
  • The 3 mechanisms responsible for uric acid related stone formation include:
    • an acidic urinary environment (pH < 5.5) is the most important factor observed in patients with uric acid stones)
    • dehydration
    • Urine uric acid levels in these patients may be elevated

High purine foods to avoid if following “gout diet”

Most of us are aware that gout was called the “King’s disease” since excessive consumption of purine-rich foods and alcoholic drinks are independent risk factors for gout.  Since most of us do not consume organ meats such as liver, kidneys and “sweatbreads” research has recently shown that fructose (think high fructose corn syrup) and sugar-sweetened soft-drinks increase the risk of developing gout. Here is a quick list of foods to be avoided:

  • Organ meats and seafood
  • Meat extracts and gravies
  • Yeast and yeast extracts, which includes beer and other alcoholic beverages
  • Beans, peas and lentils
  • Oatmeal
  • Spinach, asparagus, cauliflower, mushrooms

SAFE FOODS:  Low-fat dairy products, coffee, and vitamin C appear to have a protective effect.

As you can see from the list above, following this low purine diet can be challenging, since so many nutritional foods need to be avoided.

Definitive diagnosis:

Definitive: birefringent monosodium urate crystals in affected joint appear as needle like shape

Suggestive:

  • More than 1 attack of arthritis
  • Development of maximum inflammation within 1 day
  • Redness over joint
  • Painful or swollen great toe (usually on one side)

NON-PHARMACOLOGICAL TREATMENT MEASURES

  • Modification of diet
  • Rest of the joint
  • Application of ice
  • Physiotherapy
  • Losing weight decreases stress on affected joint. Big toe gets most “shock” and most likely to be affected by uric acid crystals. The great toe is the coldest joint, due to distance from core of the body, and the insoluble uric acid crystals are more likely to settle there.

Your Thompson Pharmacist is a great resource to help you when you have problems with the gout, especially if you have frequent attacks.  Have your Thompson Pharmacist check your med list.

Go Ahead and ASK… at Thompson Pharmacy it’s all for YOU!