Gout

Do you suffer from the Disease of Kings?

In this section, Cypress Foot and Ankle specialist Dr. Christopher Correa discusses Gout, which causes sudden redness, swelling, and pain, typically of the big toe joint. Gout was nicknamed the “Arthritis of the rich” by Hippocrates in the 5th century when he noted that only “people of means” seemed to come down with it. While the exact reason for its predilection for the wealthy class was perplexing then, it is now clear that only people who ate large quantities of luxury foods such as meat and wine were at risk. Fast forward to the present day, and now that protein-rich food is much more widely available, many more people are finding themselves with sore red toes.

The burning of a gout attack

What is Gout?

Gout is a buildup of uric acid in the blood that can settle out in one or more parts of the body. Uric acid is a byproduct of protein metabolism, which is normally created and then removed by the kidneys. As we age, sometimes our kidneys no longer process uric acid as efficiently as they once could, causing uric acid levels to creep up. Once a certain threshold is reached, the uric acid supersaturates the blood, causing the molecules to settle in a joint in the form of urate crystals. The most common areas affected by gout are the joints of the foot, with a predilection for the big toe. The crystals continue to propagate, becoming larger and larger, triggering the immune system and causing a severe local inflammatory response. This is known as a gout attack.

Symptoms of Gout

Gout symptoms can present in two ways. 1. Sudden onset of an extremely tender joint with redness and swelling. The most common presentation is one where people report feeling fine at bedtime, only to wake up with a red-hot, swollen toe and terrible pain. Oftentimes, the joint is so tender that any stimuli, such as air blowing on the toe from a fan or light pressure from a bed sheet, will elicit an extremely painful response. Many people describe it as one of the worst pains they have ever felt. 2. Slow build-up and prolonged peak. Alternatively, gout can sometimes start with a heralding, tender red spot on or around a joint that gets worse over the course of a few days and then lingers. Oftentimes, it is reported that these symptoms are worse at night and can go on for weeks if not treated. Regardless of which presentation occurs, a possible trigger for gout attacks is trauma. While trauma is typically not a prerequisite for a gout attack, it is worth mentioning that minor to moderate trauma can precipitate an attack. This can range from stubbing a toe to foot or ankle surgery. If you have a history of gout, be sure to let your foot and ankle surgeon know so that proper measures can be taken to avoid a flare-up postoperatively.

Causes of Gout

The main risk factor for gout is a diet rich in proteins that, when broken down, produce purines. Purines are a natural byproduct of protein metabolism that, when further processed, produce uric acid. Some foods that have a high purine content are red meats, beer, wine, organ meat, asparagus, sugary drinks (fructose), beef, anchovies, sardines, scallops, lentils, legumes, black-eyed peas, and more. Other risk factors for gout include obesity, certain medications such as hydrochlorothiazide HCTZ, and other metabolic conditions like diabetes and dehydration. Especially during the summer and in hot climates such as Houston, we tend to see an increase in gout cases during July and August from increased rates of dehydration. Dehydration leads to concentration of all of the elements found in blood, including uric acid. increasing the relative concentration, triggering a gout attack. The most common age ranges affected are typically men aged 30 and over and post-menopausal women. While not common, men with a strong family history of gout can see symptoms at ages younger than 30. Generally speaking, sufferers of gout should shift their diet towards a more plant based whole food diet and reduce alcohol intake. Some sources have indicated that Cherries/ Cherry juice, Vitamin C supplementation, and a moderate amount of caffeine may also reduce the risk for gout attacks. If this is not effective, there are daily medications available help modulate uric acid levels. It is important to note that while high uric acid levels are necessary to cause a gout attack, the time during a gouty flare-up, when the joint is red, swollen, and painful, the excess uric acid is located almost wholly within the inflamed joint. Take-home point: Uric acid blood draws taken during an acute gout attack may read as normal. It is not a bad idea to draw a uric acid level, but a better measure of what your actual uric acid level can be obtained between flare-ups.

One or two gout attacks over the course of a lifetime usually produce no lasting damage. When uric acid crystals are deposited into the tissues during an acute attack, there is typically enough time for the crystals to dissipate back into the blood before the next attack. Untreated gout, causing multiple attacks a year, can lead to a buildup of uric acid in the tissue that does not have time to dissipate. These buildups are known as tophi (pl.). The acidic nature of these tophi damages the surrounding structures in such a way that it can erode the bone adjacent to the joint. If this bony degradation goes on long enough, it can ultimately lead to arthritis. When viewed on X-ray, the bony destruction is said to look like a rat has nibbled on the bone, a radiological finding known as Martel’s sign. In the most severe cases, gouty tophi can become so large that they swell, making them visible to the naked eye.

Treatment of Gout

Gout attacks are easily treatable with a variety of medications, including steroid pills or injections, non-steroidal anti-inflammatory medications, and other gout-specific medications such as Colchicine. All of these medications serve to stop the inflammatory process. It is also imperative that you stay hydrated, especially during the summer months. Try to identify triggers that may kick-start your gout attack. Two often overlooked triggers are dehydration and consumption of Fructose or other sugars. For people who have trouble controlling uric acid levels, drugs like Allopurinol and Probenecid exist to prevent gout attacks before they start. Only your doctor will know if any of these medications are right for you. If you think you or someone you know is suffering from gout, give the experts at Select Foot and Ankle Specialists a call and take your first step toward recovery.