Trent Sherrell's List: Gout

• Gout is a type of arthritis. It occurs when uric acid builds up in blood and causes inflammation in the joints. Acute gout is a painful condition that often affects only one joint; Chronic gout is repeated episodes of pain and inflammation. More than one joint may be affected.
• a disease in which defective metabolism of uric acid causes arthritis, esp. in the smaller bones of the feet, deposition of chalkstones, and episodes of acute pain.

• Gout is one of the most painful forms of arthritis. It occurs when too much uric acid builds up in the body. The buildup of uric acid can lead to:

    
   
  • Sharp uric acid crystal deposits in joints, often in the big toe
   
  • Deposits of uric acid (called tophi) that look like lumps under the skin
   
  • Kidney stones from uric acid crystals in the kidneys.

  • This information is from the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
• For many people, the first attack of gout occurs in the big toe.

• In addition to the big toe, gout can affect the:

    
   
  • Insteps
   
  • Ankles
   
  • Heels
   
  • Knees
   
  • Wrists
   
  • Fingers
   
  • Elbows.
• A gout attack can be brought on by stressful events, alcohol or drugs, or another illness. Early attacks usually get better within 3 to 10 days, even without treatment. The next attack may not occur for months or even years.
• Gout is caused by the buildup of too much uric acid in the body. Uric acid comes from the breakdown of substances called purines. Purines are found in all of your body’s tissues. They are also in many foods, such as liver, dried beans and peas, and anchovies.

• Normally, uric acid dissolves in the blood. It passes through the kidneys and out of the body in urine. But uric acid can build up in the blood when:

    
   
  • The body increases the amount of uric acid it makes.
   
  • The kidneys do not get rid of enough uric acid.
   
  • A person eats too many foods high in purines.
• When uric acid levels in the blood are high, it is called hyperuricemia. Most people with hyperuricemia do not develop gout. But if excess uric acid crystals form in the body, gout can develop.

• You are more likely to have gout if you:

    
   
  • Have family members with the disease
   
  • Are a man
   
  • Are overweight
   
  • Drink too much alcohol
   
  • Eat too many foods rich in purines
   
  • Have an enzyme defect that makes it hard for the body to break down purines
   
  • Are exposed to lead in the environment
   
  • Have had an organ transplant
   
  • Use some medicines such as diuretics, aspirin, cyclosporine, or levodopa
   
  • Take the vitamin niacin.

  • Purines are colorless crystalline compounds with basic properties, forming uric acid on oxidation.

• How Is Gout Diagnosed?

    

  Your doctor will ask about your symptoms, medical history, and family history of gout. Signs and symptoms of gout include:

    
   
  • Hyperuricemia (high level of uric acid in the blood)
   
  • Uric acid crystals in joint fluid
   
  • More than one attack of acute arthritis
   
  • Arthritis that develops in 1 day, producing a swollen, red, and warm joint
   
  • Attack of arthritis in only one joint, usually the toe, ankle, or knee.

• How Is Gout Treated?

   

  Doctors use medicines to treat an acute attack of gout, including:

    
   
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)
   
  • Corticosteroids, such as prednisone
   
  • Colchicine, which works best when taken within the first 12 hours of an acute attack.

• What Can People With Gout Do to Stay Healthy?

    

  Some things that you can do to stay healthy are:

    
   
  • Take the medicines your doctor prescribes as directed.
   
  • Tell your doctor about all the medicines and vitamins you take.
   
  • Plan followup visits with your doctor.
   
  • Maintain a healthy, balanced diet. Avoid foods that are high in purines, and drink plenty of water.
   
  • Exercise regularly and maintain a healthy body weight. Ask your doctor about how to lose weight safely. Fast or extreme weight loss can increase uric acid levels in the blood.
• National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)

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• The word gout comes from Latin gutta and old French gote meaning "a drop". Several hundred years ago gout was thought to be caused by drops of viscous humors that seeped from blood into the joints. In fact, this supposition was not that far from the truth. When a patient experiences the symptoms of a gout attack uric acid has been accumulating in his blood, and uric acid deposits have been forming in the joints.
• Gout is a complex disorder, it is more prevalent among men, and afflicts women more commonly after the menopause. Men have higher uric acid levels in their blood than women.
• In 2011, the American College of Rheumatology announced that 8 million Americans have gout - nearly 6% of men and 2% of women.
• A disorder of purine metabolism, occurring especially in men, characterized by a raised but variable blood uric acid level and severe recurrent acute arthritis of sudden onset resulting from deposition of crystals of sodium urate in connective tissues and articular cartilage; most cases are inherited, resulting from a variety of abnormalities of purine metabolism.
• Signs and symptoms of gout are generally acute - they come on suddenly without warning. A significant proportion of patients experience them at night. 
   
  • Severe pain in the joints - The patient may experience pain in his ankles, hands, wrists, knees or feet. More commonly the big toe is affected (podagra). Many patients describe the affected areas as warm/hot. The fluid sacs that cushion tissue (bursae) may become inflamed (bursitis) - when this happens in the elbow it is called olcranon bursitis, while in the knee prepatellar bursitis.
  
   
  • Gradually goes away - A bout can last for over a week if left untreated - and then gradually goes away during the following week or two.
  
   
  • Itchy and peeling skin later - As the gout subsides the skin around the affected area may be itchy and peel. By the end of it the patient feels fine.
  
   
  • Redness and inflammation - The sufferer will most likely have tender, red and swollen joint(s) in the areas that experienced the most pain.
  
   
  • Red/purplish skin - The affected area may become red or purplish, making the patient think he has an infection.
  
   
  • Fever - Some patients have an elevated temperature.
  
   
  • Less flexibility - The affected joint may be harder to use, the patient has limited movement.
  
   
  • No symptoms - Some patients experience no symptoms. In these cases it may develop into chronic gout.
  
   
  • Nodules - The gout may first appear as tophi (nodules) in the elbows, hands, or ears.

• What causes gout?

   The levels of uric acid in your blood rise until the level becomes excessive (hyperuricemia), causing urate crystals to build up around the joints. This causes inflammation and severe pain when a gout attack happens.
  
   When the human body breaks down chemicals called purines it produces uric acid. Purines can be found naturally in your body, as well as in food, such as organ meats, anchovies, asparagus, mushrooms and herring.
  
   Most of the time uric acid dissolves and goes into the urine via the kidneys. However, if the body is producing too much uric acid, or if the kidneys are not excreting enough uric acid, it builds up. The accumulation results in sharp urate crystals which look like needles. They accumulate in the joints or surrounding tissue and cause pain, inflammation and swelling.
  
   Surprisingly, hyperuricemia is commonly found in many people who never develop gout. Scientists are not completely sure what causes hyperuricemia. There is definitely a genetic factor because a person who has close relatives with hyperuricemia is more likely to develop it himself.
• The following have been known to bring about a gout attack and may be contributory causes of gout:  
   
  • obesity
   
  • heavy alcohol consumption, especially beer
   
  • a diet high in purine foods, such as seafood and meat, and meat organs
   
  • extremely low calorie diets
   
  • regular aspirin use
   
  • regular niacin use
   
  • drinks high in fructose linked to gout risk - females who regularly consume beverages with a high fructose content are 74% more likely to develop gout, compared to women who consume such drinks no more than once a month, researchers from Boston University School of Medicine reported in JAMA (November 2010 issue).
   
  • regular use of diuretic medicines
   
  • medicines taken by transplant patients, such as cyclosporine
   
  • fast weight loss
   
  • chronic kidney disease
   
  • hypertension (high blood pressure)
   
  • psoriasis
   
  • tumors
   
  • myeloma
   
  • hemolytic anemia
   
  • lead poisoning
   
  • hypothyroidism
   
  • surgery
   
  • Kelley-Seegmiller syndrome
   
  • Lesch-Nyhan syndrome

  • Niacin is a B vitamin essential for the normal function of the nervous system and the gastrointestinal tract.

• When should you see a doctor?

   If you have a sudden and intense pain in a joint get in touch with your doctor. If you do not treat it, the gout can gradually get worse over time. If you also have a temperature, and the joint is hot and/or inflamed, get medical attention as soon as possible - it could mean you have an infection.

• What are the complications of gout?

   Gout does not commonly cause any further problems. However, some are possible: 
   
  • Recurrent gout - while some people just get one attack, and never experience another one again, others may have recurrent attacks. There are drugs which help reduce the number of recurrent attacks, or even eliminate them.
   
  • Advanced gout - If the gout is not treated urate crystals may form under the skin in nodules, they are known as tophi. They may become swollen and tender whenever the patient has a gout attack, but are not painful otherwise.
   
  • Kidney stones - Urate crystals can accumulate in the urinary tract of a patient who suffers from gout. This causes kidneys stones. There are drugs which can lower the chances of developing kidney stones.
   
  • Damage to joints - if the tophi (nodules) become inflamed the joints could become damaged.
   
  • Gout might spread - The gout could spread to other joints.
• 2) Self Help
  
   These measures may help ease the pain and swelling: 
   
  • Raise and rest your limb.
   
  • Some people use a splint to immobilize the joint.
   
  • Do not do vigorous exercise.
   
  • Keep the joint cool, apply an ice pack or bag of frozen vegetables wrapped in a towel. Do not apply directly to your skin without a towel as this could damage your skin. Allow the temperature of the affected area to return to normal before repeating this.
   
  • Do not cover the joint.
• 1) Medications
  
   There are some medicines which can reduce your risk of future gout attacks. These are usually taken after an attack is over: 
   
  • Reducing the production of uric acid - Allupurinol reduces the amount of uric acid your body produces, which in turn lowers your chances of having an attack recurrence. Some patients who take this medication may have a rash, and/or a low blood count.
   
  • Removing uric acid more effectively - Probenecid helps your kidneys eliminate uric acid more effectively, thus lowering your blood uric acid levels, which in turn reduces your chances of recurrence of an attack. Some patients may develop a rash when taking this medication, while others may have stomach pains, and a very small number may develop kidney stones.
• Although diets have not been proven to reduce a person's risk of gout, this is due to a lack of studies rather than the existence of studies that prove diet is ineffective.
• It would make sense not to consume too many foods that are high in purines, such as red meat, meat organs, and seafood. Reducing your consumption of alcoholic drinks may also be beneficial. Some people suggest you should consume more low-fat dairy products, while others mention a good intake of whole-grain breads is beneficial. If you drink plenty of water you might dilute the amount of uric acid in your blood, some say.

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• Eating cherries over a two-day period reduced the risk of gout attacks by 35%, according to a new study led by Boston University (BU) in the US that is  being published in the journal Arthritis & Rheumatism.
• They also found that the threat of gout flares fell by as much as 75% when cherry intake was combine with allopurinol, a drug that lowers uric acid  levels, compared to not taking the drug or having the cherries.

• he affected joint is hot, swollen and so tender that even the weight of the sheet on it may seem intolerable.
• Fortunately, gout is treatable, and there are ways to reduce the risk that gout will recur.

• Risk factors
• Lifestyle factors. Choices you make in your everyday life may increase your risk of gout. Excessive alcohol use — generally more than two drinks a day for men and more than one for women — increases the risk of gout.

• Lifestyle and home remedies
• Medications are the most proven, effective way to treat gout symptoms. However, making certain changes to your diet also may help.

• The American Dietetic Association recommends following these guidelines during a gout attack:  

   
   
  • Drink 8 to 16 cups (about 2 to 4 liters) of fluid each day, with at least half being water.
   
  • Avoid alcohol.
   
  • Eat a moderate amount of protein, preferably from healthy sources, such as low-fat or fat-free dairy, tofu, eggs, and nut butters.
   
  • Limit your daily intake of meat, fish and poultry to 4 to 6 ounces (113 to 170 grams).

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• Coffee. Studies have found an association between coffee drinking — both regular and decaffeinated coffee — and lower uric acid levels, though no study has demonstrated how or why coffee may have such an effect. The available evidence isn't enough to encourage noncoffee drinkers to start, but it may give researchers clues to new ways of treating gout in the future.
• Vitamin C. Supplements containing vitamin C may reduce the levels of uric acid in your blood. However, vitamin C hasn't been studied as a treatment for gout. Don't assume that if a little vitamin C is good for you, then lots is better. Megadoses of vitamin C may increase your body's uric acid levels. Talk to your doctor about what a reasonable dose of vitamin C may be. And don't forget that you can increase your vitamin C intake by eating more fruits and vegetables, especially oranges.
• Cherries. Cherries have been associated with lower levels of uric acid in studies, but it isn't clear if they have any effect on gout signs and symptoms. Eating more cherries and other dark-colored fruits, such as blackberries, blueberries, purple grapes and raspberries, may be a safe way to supplement your gout treatment, but discuss it with your doctor first.

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• How Gout Changed History
• painting by Eduardo Rosales, a Spanish painter of the 19th century, who painted a portrait of King Charles I of Spain, also known as Holy Roman Emperor Charles V, receiving Juan de Austria at the Monasterio de Yuste. This interested me because Charles was seated in the chair with his right leg raised and resting on a pillow.
• It turns out that King Charles suffered from the king of diseases and the disease of kings, gouty arthritis.
• Shortly thereafter in 1528, because of his excesses, Charles enjoyed drinking alcohol -- and naturally had a 4-handled mug -- so he developed gouty arthritis. He also enjoyed eating meats and rich foods.
• In addition to suffering from gout, Charles was plagued with epilepsy, but his gout became progressively more active. By 1552, his gout caused him to postpone an attempt to recapture the Flemish city of Metz. He couldn't lead his forces into battle and ultimately told his son, Philip II, to take over. By 1556, his gout had become so severe that he actually abdicated the Spanish throne and retired to a solitary existence at the Monastery of Yuste, where he lived for 2 more years, surrounded by clocks to remind him of the passage of time and the passage of his reign. In 1558 Charles died of malaria in solitary retirement at the monastery.
• Charles had a chair constructed with a footrest for himself. It is still on exhibit at this monastery. It points out how a disease such as gout could actually change the course of history. Had Charles been aware of the dietary recommendations which are now part of the American College of Rheumatology guidelines for the prevention of gout, perhaps Metz would have been recaptured and history would have been changed. This and other paintings of Charles are interesting and prompt an interest both in Spanish history and gout.

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• 8 Famous People With Gout
• Gout may seem like a quaint historical ailment that no one gets anymore, but nothing could be further from the truth.
• This type of arthritis is on the rise—particularly among men. More than 8 million people have it, and the rates have doubled in the last 50 years.
• Once considered a disease of the upper class, gout can strike anyone, even professional athletes and young adults.

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• • Gout is relatively unique among rheumatological diseases in that its effects were common and, at least in
    history, disproportionately represented in prominent authority figures. Effective treatments have only been
    available for just over a century and therefore for the most part, the disease has run relatively unchecked.
    Consequently, it may have had global ramifications. The history of gout, from apocryphal orthodoxy to medical clarity, is reviewed, using a few of the more colourful characters in its considerable pantheon.
• • However, in rheumatology few conditions have captured the imagination of people from
    all walks of life as gout.
• • Evidence of uric acid deposition in joints has been
    found in mummified Egyptian remains in Philae
    dating from approximately 4000 years ago. However,
    Hippocrates was thought to be the first person to accurately describe it c. 400 BCE.
• • At the time, and for many centuries thence, gout was
    thought to be the result of an intemperate, bacchanalian
    lifestyle.
• • Galen, the celebrated Roman physician of Greek origin,
    wrote prolifically on all matters medical. He is said
    to have opined: ‘Gout is the daughter of Bacchus and
    Venus.’
• • Roman literature is littered
    with descriptions of gouty epidemics among the
    aristocracy. However, it seems that such attacks may
    have carried with them a darker subtext, and contributed
    to the demise of the Roman empire.
• • Conservative estimates therefore place
    the Roman intake of lead at many times those required to
    cause lead poisoning, and the pleasure-loving aristocracy
    would certainly have been disproportionately exposed.
• • Among the many effects of lead poisoning, neuropsychiatric effects including impaired mentation and, by
    extension, decision-making, are prominent. Moreover,
    plumbism is strongly associated with hyper-uricaemia
    and gout by virtue of chronic kidney disease and effects
    on the renin-angiotensin-aldosterone axis. Claudius, Nero,
    Caligula and Tiberius were but a few of the prominent
    Romans thought not only with gouty symptoms, but also
    with many oddities of speech and behaviour. Important
    decisions taken by them, and quite possibly many of
    their contemporaries, may therefore have been made
    through lead-lined glasses – with unpredictable consequences for the empire.
• • Charles V,
    whose 40-year reign occurred during the transition
    from the Middle Ages to modern times, presided over
    a global empire spanning Europe, Africa, Asia and parts
    of South America. However, he was crippled by intense
    arthritic pain and swelling, which his physicians diagnosed clinically as gout.8
     Charles V had a renowned
    proclivity for meat, beer and wine – he reportedly
    ordered a specially designed 4-handled drinking mug
    built to satisfy his thirst. Running thus unchecked, his
    attacks became so severe and frequent that he found
    himself ‘. . . not able to write long because of the gout . . .’
    in his later life. The nation-altering ramifications of his
    disease are amply illustrated by the battle of Metz. In
    the mid-1500s, a severe attack of gout forced Charles V
    to postpone his attempt to recapture the city of Metz
    from the French. As with the Russians in World War II
    Stalingrad, the arrival of winter allowed the French to
    resist and inflict defeat on the emperor’s army. Charles
    V was said to be so guilt-ridden at the defeat, which he
    ascribed to his disease, that he promptly abdicated.
• • The British aristocracy of the 1600s were staunchly
    conservative when compared to their Roman counterparts; however, they too were not spared the tender
    ministrations of gout. Once again, lead may have been
    a contributing factor. In the late 1600s, the English
    Parliament sought to limit commercial competition by
    the Dutch fleet by banning the importation of French
    wines, a cargo not carried by the British, in favour of
    Spanish and Portuguese wines. Port was particularly
    popular, but also happened to be rich in lead.9,10 This
    may explain the large number of people suffering from
    gout seen in caricatures of the time.
• • Thomas
    Sydenham, himself a sufferer, chronicled his attacks in
    the late 1600s as being 
    ‘. . . so exquisitely painful as not to endure the weight of the
    clothes nor the shaking of the room from a person’s walking briskly therein . . .'
• • The Reverend Sydney Smith, considered to be one of
    Britain’s greatest wits of the 19th century, had a more
    economical but no less colourful description, likening
    attacks of gout to ‘. . . walking on eyeballs . . .’6
     Nonetheless,
    the notion of gout as an affliction of the privileged, and
    therefore highly desired, had a strong foothold.
• • 20 of the 34 kings of France were
    said to have been afflicted. Ambrose Bierce applied his
    mordant wit to the issue, defining gout in his Devil’s
    Dictionary as ‘. . . a physician’s name for the rheumatism
    of a rich patient . . .’
• • Walpole considered podagra to be
    a natural result of the body’s attempt to expel ‘depraved
    humours’ to the extremities...
• • The product is thought to have been introduced
    to America in the late 1700s by Benjamin Franklin,
    himself a sufferer of gout.

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