What is one thing that Alexander the Great, Charlemagne, King Henry VIII and Benjamin Franklin all have in common? Apart from changing the course of history, all of these men shared the common affliction of gout.
But it’s not just famous figures from history who suffer from this painful inflammatory disease. Rates of gout are on the increase in Australia, affecting around two per cent of the population and one in five men aged over 70.
The good news is that today new treatments and a better understanding of the disease mean that gout can almost always be eliminated safely and effectively.
Below Professor Richard Day, Dr Matt Coleshill and Dr Eindra Aung from St Vincent’s Hospital Clinical School, University of NSW, discuss the causes of gout and some of the genetic and ethnic factors that influence its presentation.
They also outline why rates of gout are increasing and propose some strategies for improving awareness and management of this debilitating condition.
Richard Day and colleagues write:
Attacks of gout are no joke. They mostly strike the base of the big toes, but no joint is immune. The pain can be so bad that merely a sheet touching the affected area is agony.
Australia is second only to New Zealand for rates of gout– approaching one in fifty of us and 1 in 5 men over 70 years! And, unfortunately, the rates are increasing.
What is gout?
When our cells break down, a by-product of the DNA and RNA is uric acid. Humans, apes and Dalmatians are the only creatures who can’t rid themselves of uric acid (UA) efficiently – we have to excrete it in urine and to a lesser extent, into the gut, unlike other animals that transforms UA into very soluble, easily eliminated product. Some of us have relatively less efficient kidneys or guts than average for excreting UA. It then accumulates in blood as urate (salt of UA).
There is a strong genetic influence and the condition runs in families and ethnic groups. Pacific Islanders and Maori have the highest rates globally with at least 1 out of 10 men suffering from gout.
The higher the urate concentration in the blood, the greater the risk of developing gout attacks. Attacks occur when urate comes out of solution in joints forming beautiful, needle-shaped crystals. Intense inflammation in the joint is the result, with heat, redness, swelling, exquisite tenderness and gross interference with normal activities.
The impact of gout
If you have an attack in your feet you can barely put your shoes on, let alone walk. What’s more, these attacks aren’t brief and can last up to two weeks. We treat attacks with colchicine, anti-inflammatory drugs, such as Nurofen (ibuprofen) or Voltaren (diclofenac), or prednisone, the choice depending on the individual concerned, with factors such as age and other illnesses taken into consideration.
Men are affected much more commonly than women. In fact, gout is the most common form of inflammatory arthritis in men. Attacks typically start in a person’s thirties. Repeated attacks have much more of an impact than previously appreciated.
There is the pain and great inconvenience of attacks that lasts around one to two weeks, but the unpredictability of attacks, the disruption of a person’s life and impact on family, friends and work, the assault on self-esteem, the restrictions on diet and alcohol and the failure of therapies offered to stop attacks also add to the impact.
If attacks continue, damage to joints can occur, urate can deposit in unsightly collections typically around elbows and fingers, and organs such as the kidney can be damaged.
The good news is this condition can be controlled very successfully in almost everyone! That means no more attacks and also elimination of the risk of irreversible damage to joints.
In fact, this is the only arthritis type where essentially cure can be guaranteed. To achieve a gout free state, we need to keep the urate levels in the blood low, in fact below 0.36 mmol/L. Most commonly, allopurinol is prescribed – it very effectively blocks production of urate and the levels in the blood fall. We call this ‘urate lowering therapy’ or ULT.
So why is gout so prevalent and increasing?
Humans, especially males, have a problem with ‘adhering’ to treatments. To be fair, it’s understandable if the importance of adherence is not emphasised. And there are a couple of other tricky points – 1) counter intuitively, when ULT starts, and urate levels fall, there is an increased risk for attacks of gout for about the first six months and 2), when ULT is stopped, started or restarted, there is a greater risk of attacks.
It only takes forgetting to pack the ULT for the weekend away to precipitate an attack. This can be very demoralising and if people were unaware of this possibility, they can abandon the therapy as ‘ineffective’.
Reducing the risk
How do we deal with these challenges?
We reduce the risk of attacks occurring during the establishment of ULT by starting with a low dose and increasing slowly every 2 to 5 weeks. Increases are guided by serum urate levels, measured with a simple blood test. We prescribe one of the medicines that can be used to treat an attack if it occurs.
Commonly colchicine (Colgout) is used, optimally continued for 6 months along with the ULT. Stopping the ULT if an attack occurs is not recommended anymore; it should be continued ad infinitum! With these measures, titrating the dose upward and covering for possible attacks with colchicine, the odds of an attack are very much reduced as long as the sufferer continues to take the ULT without break.
GPs and pharmacists have recognised the need for more education about treating patients with gout successfully, especially avoiding gout attacks during the early use and establishment of ULT. Certainly, also patients need all the help they can get, to understand gout and how to treat it successfully. Technology might be helpful to people with gout in providing them with helpful information on their condition and treatment options at the very least.
Reminders to take ULT and personalised feedback to track the progress or control of their disease become possible with the use of electronic health and mobile health technologies. The GAPP trial is an opportunity for people who have had an attack of gout in the last 12 months to help evaluate mobile apps designed to help people with gout better manage their condition. The apps are available for both iPhone and Android devices. If interested, go to mygoutapp.com.
Gout is like the ‘canary in the mine’ – it often signals increased presence of risk factors for heart attack and stroke. Type II diabetes mellitus, hypertension, obesity and kidney function impairment are all more common in people with gout and vice versa.
As attacks become more frequent, exercise is less possible, exacerbating obesity and cardiovascular risk.
So, a diagnosis of gout is a very good opportunity to take stock of these risks and institute preventative measures – such as weight loss, blood pressure control, exercise and screening for diabetes.
Diet and gout
On the matter of diet, many patients with gout identify particular foods and beverages that they link to attacks. Thus, crustaceans such as prawns, red meat, whitebait and alcoholic drinks, particularly beer, will bring on an attack, related to the purine content of these products. Heavy intake of fructose in sugar sweetened soft drinks also increases urate levels and the risk of attacks.
However, diet alone is not always successful in eliminating attacks, particularly if urate levels are high. Some foods, such as cherries, are effective in lowering urate and for some patients can reduce the frequency of attacks. However, more often than not, if attacks are recurrent, ULT will be needed.
Finally, allopurinol, the predominantly used ULT, is generally very well tolerated but rarely can cause very severe adverse reaction involving the skin and internal organs. This is more often seen in Han Chinese and people from Thailand and the Philippines. We can now assess if risk is even greater in these ethnic groups by a simple blood test know as HLA B*5801, worth doing to avoid a serious outcome.
If you think you might have gout or know that you have but it is not controlled, seek medical help.
The condition is not a marker of alcohol excess in many gout sufferers and there should not be a stigma attached. Gout can be eliminated in just about everyone safely and very effectively.