Diagnosing gout in a patient this week — much to his disgust — I was tempted to remind him that in the 18th century doctors used to say that people affected by this problem were ‘more rich than poor and more wise than fools’! Victims were said to include ‘kings and potentates, generals and admirals, philosophers and the like’, so if you had gout, you were in good company.
The usual myth about gout is that only port-swilling members of the landed gentry are prone to it, but around one in 200 adults in the UK are affected. It affects men of any age, and women usually after the menopause; in about one in five cases there is a strong family history of it occurring. Men are affected more than women, with middle age being the typical time that attacks develop. Fortunately, it remains one of the most easily treatable of all rheumatic conditions and is basically due to an underlying problem with the body’s chemical processes. A naturally occurring chemical called uric acid can build up and form crystals in our joints (classically the big toe). These crystals then irritate the tissues in the joint to cause inflammation, swelling and often excruciating pain. It’s not only joints that are affected — earlobes are vulnerable too.
Eating and drinking too much has long been seen as the key to gout occurring but this is false, although it is true to say that too much beer, wine and rich food will do you few favours here. A diet rich in certain foods, such as offal, sardines and herring, mussels and yeast extract, can increase your chance of an attack of gout. Other potential triggers I often see in my surgery are not having enough vitamin C in the diet and drinking lots of sugar-sweetened soft drinks high in fructose.
High blood pressure, high levels of fat in the blood, kidney problems and diabetes are common medical triggers, and some medications may make the problem worse. The usual suspects here are diuretics (‘water tablets’), full-strength aspirin and some chemotherapy treatments.
An acute attack typically comes on at night in the big toe that becomes red, swollen and so tender that even the touch of the bedclothes can be agony. Although most attacks appear out of the blue, worry, tiredness and other illnesses can all play a part in triggering them. In theory, any joint of the body can be affected — and sometimes two or three joints at the same time — and if left untreated, an attack can last for up to ten days. Some people never suffer from another attack, others have attacks every few months and require long- term treatment to prevent them.
Fortunately, a simple attack of gout causes no long-term damage to a joint — it is only when there are repeated and untreated attacks that chronic damage leading to arthritis may occur. On occasion, the uric acid crystals can form bumps known as tophi under the skin, and as a medical student I remember seeing a case where a patient with chronic gouty tophi on the end of his fingers could write his name on a blackboard without using any chalk!
The diagnosis is usually made simply from the history and the obvious appearance of the affected joint alone, but blood tests can confirm an excess of uric acid in the blood, although this alone is not diagnostic. The gold standard here is to remove some of the fluid from around the joint and examine it under a microscope, where the urate crystals show up as brightly coloured and very beautiful patterns.
Treatment is with drugs, preferably at the very beginning of an attack, and the drug of choice here is a non-steroidal anti-inflammatory drug (such as indomethacin) that reduces the inflammation around the joint very quickly. Aspirin is not a good choice, and you may need to put a ‘cage’ over the feet when in bed to stop the bedclothes resting on them for a few days until the attack has settled.
If attacks become more frequent, then there are regular preventive treatments available that aim to keep the levels of uric acid low and so prevent it being deposited in the joints. However, this treatment is usually for life: if it is stopped, the uric acid levels often slowly build up once more. The most commonly prescribed of these is called allopurinol and is a remarkably safe drug even when used over many years, with the only side effect being a rash that disappears when the tablets are stopped.
Diet should be sensible but not restrictive, although protein should be eaten in moderation and offal is best avoided. Life can therefore still be enjoyed with gout — despite what you might have seen in 19th-century cartoons.
Seven myths about gout
1. ‘Gout is an upper-class condition.’ Wrong. All social classes get gout, and if your parents had it, you’re more likely to as well. Karl Marx, Laurence Olivier and Beethoven all suffered.
2. ‘Only men get gout.’ No. Men are ten times more likely to get gout than women before women reach the menopause, but thereafter both sexes get it equally.
3. ‘You only get gout in the big toe.’ Nope. It can develop in the feet, hands, ankles and knees and if left untreated, can cause permanent joint damage.
4. ‘Teetotallers can’t get gout.’ I wish. Alcoholic drinks are high in purine that helps trigger attacks, but non-drinkers are still at risk.
5. ‘Gout is a real pain but basically pretty harmless.’ Hmm. Some studies suggest it can increase your risk of stroke and heart attacks.
6. ‘There are no proper treatments for gout.’ So no. There are great treatments available, so always get treated sooner rather than later.
7. ‘Once you’ve got gout, you may as well not change your lifestyle.’ Wrong. Lifestyle matters. Losing weight and altering your diet can dramatically improve things.