Battle Erupts Over How To Treat Gout No Longer The Disease Of Kings
It was once seen as the disease of kings, afflicting only the lazy and gluttonous. These days, however, gout is everywhere and a bitter battle has broken out among physicians about how best to treat it.
A form of arthritis, gout is characterized by unsightly bulges under the skin and incredible pain in the joints. Typically seen in older men, the disease now increasingly afflicts women and younger adults, often accompanied by obesity, diabetes, and high blood pressure.
It used to be the disease of kings, but now its really the disease of the people, said Dr. Robert Terkeltaub, a professor of medicine at the University of California, San Diego.
There are several medicines to combat gout, which is caused by a buildup of uric acid in the blood, and more are on the way.
But the American College of Physicians, the nations largest specialty medical association, this month put out new guidelines that call for less aggressive pharmaceutical treatment. Thats angered many gout specialists, who in recent years have created two new professional groups both backed by drug companies one to bolster gout research and the other to promote long-term use of medication to lower uric acid.
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What Type Of Doctor Specializes In Gout Treatment
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Medical Treatment Of Gout
- Pain management: Treatment of gout flares consists of nonsteroidal anti-inflammatory drugs such as ibuprofen and Indomethacin. Steroids are sometimes used acutely if NSAIDs cant be used, or in combination with them.
- Prevention: Changing or stopping medications associated with hyperuricemia may help prevent future flares. Some medications, such as Colchicine, may be prescribed to aid in prevention.
Your Gout Treatment Team
Proper gout treatment probably will involve more than visiting your primary care physician. Other specialists, like a rheumatologist, can help ease the pain and prevent further damage.
Gout is an incredibly painful and chronic form of arthritis that has been around since ancient times. People with gout can expect to experience problems directly and indirectly related to the disease. Because of this, it is important to have a gout treatment team available to make sure you are staying on top of your gout and limiting the harm it does to your body.
“It takes a team effort to get all of this down,” says Larry Edwards, MD, professor of rheumatology and clinical immunology in the department of medicine at the University of Florida in Gainesville.
Gout Treatment: Primary Care Physician
Gout treatment begins with a person’s primary care physician. These front-line doctors are:
- The first to see the warning signs of gout
- Usually the first to diagnose a patient’s pain as stemming from gout
- Often the primary deliverers of gout treatment
But primary care physicians and other internists often aren’t as aggressive as they could be in gout treatment, Edwards says. They focus on alleviating pain through anti-inflammatory drugs, but may not pay enough attention to the real cause of gout, the build-up of uric acid in the bloodstream and joints. “There’s been so little education that the primary care physicians have been poorly treating this disease,” Edwards says.
Gout Treatment: Dietitian
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Diagnosing Gout: What To Expect At The Doctors Office
If youre unsure about whats causing your pain and other symptoms, youll likely visit various health care providers, which could include your internist/general practitioner, orthopedist, or podiatrist.
While your GP or internist may be able to diagnose and manage gout, if the diagnosis of gout is not clear, or if you arent getting better with initial treatment, you may be referred to a rheumatologist. A rheumatologist is a specialist who treats musculoskeletal disease and systemic autoimmune conditions, including gout.
There is no single, simple test to diagnose gout.
First, your doctor will perform a physical examination to assess your overall health and ask about your history of joint pain and other symptoms that suggest gout, as well as your family history and any pre-existing medical conditions you have or medications you take.
The doctor may check for pain in multiple joints. Over half of cases of acute gout occur in the big toe for the first time. Then over time, it can spread to other areas, like the middle of the foot, the ankle, knees, hands, the wrists, the elbows, and other joints as well, says Jonathan Greer, MD, a rheumatologist with Arthritis & Rheumatology Associates of Palm Beach in Florida.
Risk factors of gout that your doctor may consider:
- Family history of gout
Risk Factors And Complications
Gout is a direct result of elevated levels of uric acid in the body. There are certain factors that can increase your risk of developing gout, including:
- Family history: Gout is often inherited and associated with other hereditary conditions such as high blood pressure, diabetes, and obesity.
- Diet: Consuming a diet high in purines, such as red meat and seafood, as well as sweetened beverages, increases your risk of gout. Consuming alcohol, especially beer, also increases your risk.
- Medical conditions: Certain diseases and conditions such as high blood pressure, diabetes, heart disease, and kidney disease are often associated with gout.
- Sex: Gout more commonly affects men, due to naturally higher uric acid levels in the body.
- Age: Men typically start to develop gout between the ages of 30-50. It is more common for women to develop gout after menopause, when uric acid levels increase.
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Family Medicine Vs Internal Medicine Physicians
Although family medicine and internal medicine physicians can both treat adults, the American College of Physicians say that there are some key differences.
For example, internal medicine doctors have training in both general medicine and subspecialties. They also tend to be more focused on medical issues that affect adults.
Family physicians, meanwhile, have broader training in medicine that allows them to care for both children and adults. They can treat a wide range of medical issues and emphasize disease prevention and health maintenance.
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.
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A Civil War Over Painkillers Rips Apart The Medical Community And Leaves Patients In Fear
In an era when many long-standing medical guidelines such as how often to get a mammogram or how aggressively to target blood pressure are being vigorously scrutinized, the terse disagreement highlights recurring tensions over just what constitutes scientific evidence.
Its true, as the ACP says, that theres a lack of gold-standard evidence in the form of randomized, controlled clinical trials to prove that patients with gout should be put on a long-term drug regimen to lower their uric acid to any specific level.
Strong data just doesnt exist, said Dr. Robert McLean, a rheumatologist with Northeast Medical Group in New Haven, Conn., and associate clinical professor at the Yale School of Medicine. It may be the right thing to do in many clinical situations, but we dont have data to say that with certainty, so we cant endorse it.
But rheumatologists argue that the expensive clinical trials that the ACP wants to see are unlikely to be conducted on already approved drugs and that it makes no sense to wait until a patient suffers from a painful flare-up before treating him or her.
They say their own experience in the clinic and numerous observational studies which dont control for the placebo effect show that lowering uric acid prevents the recurring, painful flares that bedevil 70 percent of gout patients and may also prevent permanent bone and joint damage. They recommend reducing uric acid to levels of 6 mg/dL or lower as a matter of course.
What To Expect During Your Visit
Whether you see a general doctor or a specialist for your gout, be prepared to answer a number of questions to help them during your diagnosis. Your doctor may ask:
- What are your symptoms?
- When did you first experience them?
- Is this the first time you have experienced this?
- Do your symptoms come and go? Are they constant?
- Could you identify anything in particular or different that you might have done to trigger these symptoms, such as eating certain foods or your current physical or emotional state?
- Are you currently being treated for any other medical conditions?
- What medications are you currently taking, including prescriptions, over-the-counter drugs as well as vitamins and supplements?
- Do you or are you aware of a history of gout in your family?
- What does your diet typically comprise of?
- Do you drink alcohol? If so, how much and how often?
Depending on your answers and the doctor’s observation, you may have to undergo further exams or testing to confirm the diagnosis of gout. These exams and test may include:
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Do Dermatologists And Rheumatologists Ever Work Together
- Combined rheumatology-dermatology clinics are a newer frontier in the treatment of psoriatic arthritis, with just over 20 clinics in the United States
- Depending on the clinic, some rheumatologists and dermatologists may see a patient at the same time in the same room. Sometimes, separate back-to-back visits are required
- Studies show this combined care approach could achieve better outcomes for both skin and musculoskeletal symptoms
- A survey from the Psoriasis and Psoriatic Arthritis Clinic Multicenter Advancement Network found over 80% of doctors thought a combined clinic accelerated an accurate diagnosis
- Challenges are largely related to scheduling and billing
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A Rheumatologist Has Extensive Experience In Treating Gout
Rheumatologists see a higher volume and concentration of patients with gout, and thus are more experienced in treating the condition successfully. Because they see lots of patients with gout, they can add real-world knowledge of the disease to their academic and clinical training. Theyre able to assess how well patients respond to certain treatments, have a deeper understanding of how gout progresses over time, share insight about effectively implementing lifestyle changes, and recognize symptoms that a general practitioner may miss, among other skills.
Doctors Who Accepted Meals From Drug Makers Prescribed More Of Their Pills
Terkeltaub, a staunch advocate for medication, has received about $35,000 in consulting fees from drug companies that make gout medications in recent years, according to the Open Payments database that tracks such payments. Many of the rheumatologists who have called for treating gout with drugs have also received money from pharmaceutical companies. Edwards, for instance, received about $27,000 in 2015.
Terkeltaub dismissed concerns about a conflict of interest, saying it was unlikely that commercial bias could have tainted three different rheumatology groups that in recent years all came up with similar guidelines for pharmaceutical intervention to treat gout. Others argue that banishing all physicians with ties to drug companies from the debate would mean losing the input of people like Terkeltaub and Edwards, who are considered leaders in the field.
But studies have shown that doctors who receive compensation from pharma companies are more likely to prescribe brand-name drugs than their peers. The Institute of Medicine urges professional physicians groups to limit such conflicts of interest on any panel that writes up treatment guidelines. Most groups do not do that.
The debate frustrates Dr. Tuhina Neogi, a rheumatologist, epidemiologist, and professor of medicine at Boston University. She understands the virtues of high-quality evidence, yet said its myopic to ignore decades of wisdom that specialists have gained from treating actual patients.
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When To See A Doctor
If you are experiencing symptoms of gout, it is important to see a doctor while the symptoms are present. Your doctor will review your symptoms and medical history, perform a physical exam, and perform any necessary tests in order to make a diagnosis. These tests include x-rays of your joint and a fluid sample to check for uric acid buildup.
You can speak with a primary care doctor for your initial treatment and diagnosis, but depending on the severity of your gout, you may be referred to a rheumatologista doctor who specializes in jointsfor further treatment.
When Should You Call Your Doctor
if you have:
- Severe pain in a single joint that comes on very quickly.
- Swollen, tender joints with warm, red skin over them.
It’s important to see your doctor even if the pain from gout has stopped. The uric acid buildup that caused your gout attack may still be irritating your joints and could eventually cause serious damage. Your doctor can prescribe medicines that can prevent and even reverse the uric acid buildup.
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Heres What To Expect At The Doctors Office When You Suspect You Might Have Gout
If you have been experiencing warmth, redness, and excruciating and sudden pain in your big toe overnight or first thing in the morning, gout could be to blame. Gout, a form of arthritis that impacts 8.3 million American adults, causes a sudden onset of joint pain and inflammation that can impact your range of motion and ability to perform daily activities.
Some people in the middle of a gout flare report the pain being so severe that they cant bear to have a bedsheet touch their toes and find it hard to walk around.
Arthritis Of The Foot
Arthritis refers to the swelling and inflammation within a joint. This Swelling of the feet and foot pain caused by arthritis makes walking and exercise very uncomfortable. Many treatments are available from the best podiatrist in New York, including orthotics, oral medications, joint injections, and sometimes surgery. Several different types of arthritis can affect your feet, such as:
- Osteoarthritis
- Surgery when indicated.
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A Rheumatologist Never Stops Learning About Gout
To maintain their board certifications, rheumatologists must keep up with new developments in their field. They must complete continuing education and renew their licenses every few years, depending on the state in which they practice and other factors. By following these requirements, board-certified rheumatologists stay on top of new treatments and discoveries about the mechanisms involved in gout, so they can then provide their patients with insightful, informed, and up-to-date treatment plans.
Who Is Affected By Gout
Gout can affect anyone. It usually occurs earlier in men than women. It generally occurs after menopause in women. Men can be three times more likely than women to get it because they have higher levels of uric acid most of their lives. Women reach these uric acid levels after menopause.
People are more likely to get gout if they have:
- Obesity, or a lot of extra weight.
You are also more likely to develop gout if you:
- Consume a diet high in animal proteins
- Consume a significant amount of alcohol
- Are on water pills .
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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.