What Gout Treatment Options Are Available To Me Are Uric Acid Stones More Likely In People With Gout
Before you choose the right treatment for you, its important to understand what options are available.
A talk with your doctor may leave out some important options, so its important to be informed going into your visit. This article aims to explain every option you have, with some commentary on the pros and cons of each one for further discussion. Towards the end, we explore the newer, lifestyle based alternatives.
Uric acid production inhibitors
Scientifically known as xanthine oxidase inhibitors, these medications limit the amount of uric acid produced by the body. They help to reduce blood uric acid concentrations and reduce the overall risk of gout.
Like all drugs, unintended side effects are a part of use. This particular class of drugs can produce side effects including rash, low blood volume, nausea, and reduced liver function. Are Uric Acid Stones More Likely in People With Gout
Prevention Of Recurrent Attacks
Hyperuricemic therapy should be initiated in patients with frequent gout attacks, tophi or urate nephropathy. A low dosage of an NSAID or colchicine is effective in preventing acute gouty attacks. Hyperuricemic drug therapy should not be started until an acute attack of gouty arthritis has ended, because of the risk of increased mobilization of uric acid stores. A reasonable goal is to reduce the serum uric acid concentration to less than 6 mg per dL .
Uricosuric Drugs. These agents decrease the serum uric acid level by increasing renal excretion. Probenecid and sulfinpyrazone are used in patients who are considered underexcretors of uric acid. Uricosuric drugs should not be given to patients with a urine output of less than 1 mL per minute, a creatinine clearance of less than 50 mL per minute or a history of renal calculi. The physiologic decline in renal function that occurs with aging frequently limits the use of uricosuric agents.
Probenecid, in a dosage of 1 to 2 g per day, achieves satisfactory control in 60 to 85 percent of patients.23 It is important to note that the drug also blocks the tubular secretion of other organic acids. This may result in increased plasma concentrations of penicillins, cephalosporins, sulfonamides and indomethacin.
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Can Protein Supplements Cause Arthritis
Q) Is there any evidence to show that taking protein supplements can cause or worsen arthritis?
Antony 2017
A) If youre at risk of gout, excessive protein intake may be problematic. Gout is the most common inflammatory arthritis and is caused by having too much uric acid in your bloodstream. Uric acid is the waste product created when the body breaks down purines a type of protein found in many foods and all your cells.
Gout is a metabolic disease which is mainly influenced by our genes, age, gender and ethnicity. However, levels of uric acid are also affected by what we eat. If youre at risk of gout, eating a lot of protein in the form of red meat, soya or shellfish, all high in purines, makes attacks more likely. So, eating lots of protein is bad news for people with gout.
Protein supplements in the form of whey proteins contain gycomacropeptide, a component of milk that appears to reduce the risk of attacks of gout. However, people with gout should be careful about increasing their protein load with whey. The burden on the kidneys to excrete or clear the extra whey products might become excessive, so its always worth getting a blood test to check your kidney function if you have gout and are considering using whey protein supplements.
This answer was provided by Dr Tom Margham in 2017, and was correct at the time of publication.
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Wine And Plasma Antioxidant Capacity
Early studies by St Leger et al and Renaud et al demonstrated an inverse relation between incidence of coronary heart disease and wine consumption in different developed countries, which prompted the efforts to discover the mechanisms underlying the observed effects. Soon, it was recognized that polyphenolic compounds highly contained in wine, especially in red wine, were responsible for various biological effects, including potent antioxidative activity.
Antioxidative activity of polyphenols is based on two mechanisms: chelation of free metal atoms such as iron and copper, which prevents biochemical reactions generating reactive oxygen species and scavenging of free radicals as effective hydrogen donors . Indeed, Frankel et al showed in 1993 that red wine phenolics inhibited oxidation of human low-density lipoprotein in vitro .
An increase in serum antioxidant activity following ingestion of red wine was first described in 1994 by Maxwell et al . In a similar study, Whitehead et al showed that serum antioxidant capacity one hour after ingestion of 300 mL of red wine increased by 18%, which was comparable with 22% increase in serum antioxidant capacity after ingestion of 1 g of vitamin C.
What Else Should I Ask My Healthcare Provider About Gout
Consider asking your healthcare provider:
- What is causing the gout?
- Do I have any joint damage?
- What can I do to prevent future attacks?
- Can any gout medications help me?
- How long will I need to take gout medications?
A note from Cleveland Clinic
Gout is a painful form of arthritis. Extra uric acid in your body creates sharp crystals in the joints, leading to swelling and extreme tenderness. Gout usually starts in the big toe but can affect other joints. Gout is a treatable condition, and the uric acid level can be decreased by medication and lifestyle changes. Talk to your healthcare provider about medications that can reduce uric acid levels. They can also discuss changes you can make to your diet and lifestyle to prevent and reduce gout attacks.
Last reviewed by a Cleveland Clinic medical professional on 11/15/2020.
References
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Should I Avoid All Rich Foods
No. Patients often ask me about desserts, as well as entrees with rich sauces, says Dr. Burg. Its a common myth that these foods cause gout. When eaten in moderation, desserts and other rich foods do not affect gout flare-ups. But moderation is the key word. Rich foods might not cause flare-ups directly, but they can cause weight gain. And obesity is a major risk factor for gout attacks.
At some point, the misconception spread that people with gout should avoid dairy. But in fact, certain dairy products especially milk can help you remove uric acid from your body, Dr. Burg adds.
Diagnosis And Management Of Gout
JOEL R. PITTMAN, PHARM. D., and MICHAEL H. BROSS, M.D., University of Mississippi Medical Center, Jackson, Mississippi
Am Fam Physician. 1999 Apr 1 59:1799-1806.
Gout is a disease resulting from the deposition of urate crystals caused by the overproduction or underexcretion of uric acid. The disease is often, but not always, associated with elevated serum uric acid levels. Clinical manifestations include acute and chronic arthritis, tophi, interstitial renal disease and uric acid nephrolithiasis. The diagnosis is based on the identification of uric acid crystals in joints, tissues or body fluids. Treatment goals include termination of the acute attack, prevention of recurrent attacks and prevention of complications associated with the deposition of urate crystals in tissues. Pharmacologic management remains the mainstay of treatment. Acute attacks may be terminated with the use of nonsteroidal anti-inflammatory agents, colchicine or intra-articular injections of corticosteroids. Probenecid, sulfinpyrazone and allopurinol can be used to prevent recurrent attacks. Obesity, alcohol intake and certain foods and medications can contribute to hyperuricemia. These potentially exacerbating factors should be identified and modified.
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Whats The Outlook For People With Gout
Untreated gout can lead to permanent joint damage. The buildup of uric acid in the joints and soft tissue is called tophus. Some people with gout can also develop other health problems, such as severe arthritis, kidney stones and heart disease. Its important to discuss your symptoms with a healthcare provider.
Resveratrol In Red Wine Can Regulate Immune Responses In Arthritis
Resveratrol has shown to modulate inflammatory arthritis in rodents by suppressing the immune responses, both cellular and humoral, thereby inhibiting the development of the disease.
Intake of red wine can reduce the intensity and severity of rheumatoid arthritis which is caused due to altered immune response in the patient.
Low levels of inflammatory cytokines and T helper cells were found in patients, showing arthritis protective effects.
What does this mean? Rheumatoid arthritis can be prevented by consumption of red wine as it modulates the immune response and alleviates the symptoms of the disease.
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When Is Surgery Considered For Gout
The question of surgery for gout most commonly comes up when a patient has a large clump of urate crystals , which is causing problems. This may be if the tophus is on the bottom of the foot, and the person has difficulty walking on it, or on the side of the foot making it hard to wear shoes. An especially difficult problem is when the urate crystals inside the tophus break out to the skin surface. This then can allow bacteria a point of entry, which can lead to infection, which could even track back to the bone. Whenever possible, however, we try to avoid surgery to remove tophi. The problem is that the crystals are often extensive, and track back to the bone, so there is not a good healing surface once the tophus is removed. In some rare cases, such as when a tophus is infected or when its location is causing major disability, surgical removal may be considered.
Since it is hard to heal the skin after a tophus is removed, a skin graft may be needed. For this reason, we often try hard to manage the tophus medically. If we give high doses of medication to lower the urate level, such as allopurinol, over time the tophus will gradually reabsorb. In severe cases, we may consider using the intravenous medication pegloticase , since it lowers the urate level the most dramatically, and can lead to the fastest shrinkage of the tophus.
How To Eat To Help Control Your Gout
There are several things you can do as part of an eating plan for gout.
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How Hyperuricemia Develops
It is normal to have a low level of uric acid in the bloodstream. Uric acid levels may get too high when one or more of the following occurs:
- The kidneys are not able to adequately filter and flush out uric acid from the bloodstream
- A person eats foods and beverages that are high in purines
- The body produces too much uric acid
When the body produces too much uric acid, there is typically a genetic cause.
Ruling Out Other Disorders
As part of the diagnosis, other disorders that cause gout-like symptoms or cause hyperuricemia should be ruled out. In general, it is easy to distinguish acute gout that occurs in one joint from other arthritic conditions. The two disorders that may confuse this diagnosis are pseudogout and septic arthritis. Pseudogout is a condition most likely to be confused with gout.
Chronic gout can often resemble rheumatoid arthritis. Other conditions may at some point in their course resemble gout.
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Red Meat And Organ Meat
Red meat and organ meats are high in purines. Eating these foods increases the uric acid levels in the blood and the risk of gout and gout attacks.
Keep your red meat and organ meats intake low. Chicken has moderate amounts of purines, and therefore should be eaten in moderation.
Protein is important for the body, and though you may need to limit protein from some animal sources, you can still get protein from other sources. Low-fat dairy seems to decrease the risk of gout and is a good source of protein in the diet. Other protein foods you can eat include eggs, nuts and nut butters, beans, and tofu.
Meats to avoid:
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What Do You Know About Hair Loss
- Keep in mind that even if you eat a good low purine diet everyday and just this once you want to eat a really high purine food the problem is not only higher uric acid, but also a sudden change in uric acid both of which can cause a gout flare up. All gout sufferers are not the same and do not respond to the same triggers. So pay attention to what caused your gout attack: Did you have shrimp three days in a row, or a wild birthday party in which you drank far too much or maybe some stressful situation.
- In any case if you have gout, a low purine diet will help keep it under control.
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The Role Of Diet In Gout Prevention
Dietary control may be sufficient in a patient with mildly elevated uric acid, for example, 7.0 mg/dL
For those with a higher level, for example, 10.0 mg/dL, diet alone will not usually prevent gout. For the latter, even a very strict diet only reduces the blood uric acid by about 1 mg/dL- not enough, in general, to keep uric acid from precipitating in the joints. The cutoff where patients with gout seem to dramatically reduce their number of attacks is when their uric acid level is taken below 6.0 mg/dL.4
Plenty Of Fruit And Vegetables
The recommendation is five portions per day, but try to include as many as possible. Bulking out meals, such as Bolognese, casseroles and stews with vegetables can help to reduce the meat content. Fruit and vegetables contain vitamin C. Although evidence is unclear, high intakes of vitamin C may help to reduce uric acid levels in the blood. Cherries may be particularly useful to include in the diet, as they have also been found to reduce levels of uric acid in the blood.
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The Four Stages Of Gout
Gout is best understood by seeing it as having four phases or stages :
Stage 1: High uric acid
Elevated uric acid without gout or kidney stone, this stage has no symptoms and is generally not treated.
Stage 2: Acute flares
This stage is marked by acute gout attacks causing pain and inflammation in one or more joints.
Stage 3: Intercritical periods
These are periods of time between acute attacks, during which a person feels normal but is at risk for recurrence of acute attacks.
Stage 4: Advanced gout
This is a stage of chronic gouty arthritis, in which there are lumps of uric acid, or tophi , frequent attacks of acute gout, and often a degree of pain even between attacks .
Figure 1: Stages of Gout
Figure 2: Illustration of Toe Joint with Gouty Tophus. normal toe joint Urate crystals, shown in white, at the “bunion joint,” represent a gouty tophus.)
Figure 3: Progression of Gout
What Drugs Raise Uric Acid
Diuretics are one of the most important causes of secondary hyperuricaemia. The use of loop diuretics, thiazide diuretics and thiazide-like diuretics was associated with an increased risk of incident gout .
It is best to avoid foods with added sugars if you suffer from gout. Fool your sweet tooth and eat strawberries and kiwi in place of cakes and cookies. Cherries are especially beneficial studies show that people who eat cherries or consume cherry juice experience fewer gout attacks. Be sure to eat lots of fruits that are rich in vitamin C as it helps the kidneys remove uric acid from your system. Gout is a form of arthritis that is caused by chronically elevated levels of uric acid in the diet.
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Typical Presentation Of Gout
Gouty attacks are usually associated with a precipitating event.6,20 These attacks consist of intense pain involving the lower extremity, with 80% of first attacks involving a monoarticular joint however, after long periods of time, gout attacks may become polyarticular.6,20,21 This pain and inflammation is a result of a dramatic inflammatory response. Some authors have estimated that between 50% to 90% of the initial attacks occur in the first metatarsophalangeal joint .6,21-23 In postmenopausal women, the distal interphalangeal joints may be involved.6 Attacks often occur at night and are associated with a precipitating event.6,20 Acute gouty arthritis may be accompanied by low-grade fever, chills, and malaise.6,21,23 The majority of patients experience a second acute gout attack within 1 year of the first episode.24 Untreated initial acute gout attacks resolve completely within 3 to 14 days.6,20,23
How Is Gout Diagnosed
In a clear-cut case, a primary care physician can make the diagnosis of gout with a high level of confidence. However, often there are two or more possible causes for an inflamed toe or other joint, which mimics some of the symptoms of gout, so tests to identify the presence of uric acid is performed.
Since the treatment for gout is lifelong, its very important to make a definitive diagnosis. Ideally, the diagnosis is made by identifying uric acid crystals in joint fluid or in a mass of uric acid . These can be seen by putting a drop of fluid on a slide and examining it using a polarizing microscope, which takes advantage of the way uric acid crystals bend light. A non-rheumatologist, when possible, can remove fluid from the joint by aspirating it with a small needle and send it to a lab for analysis. A rheumatologist is likely to have a polarizing attachment on their microscope at their office. Gout crystals have a needle-like shape, and are either yellow or blue, depending on how they are arranged on the slide .
Figure 11: Uric Acid Crystals Under Polarizing Light Microscopy
There are many circumstances where, however ideal it would be, no fluid or other specimen is available to examine, but a diagnosis of gout needs to be made. A set of criteria has been established to help make the diagnosis of gout in this setting .2
Table 1: Diagnosing gout when no crystal identification is possible
Ideally, 6 of 10 features will be present of the following:
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