The worst pain I’ve ever felt”, “I felt like there was a red hot poker in my toe”, and “I thought someone was sawing on my toes”. These are typical statements of people that have experienced the pain of gout. Anyone who has ever experienced a flare of gout never wants it to recur. Luckily, if treated correctly, flares can be easily prevented and destruction can be stopped.
Gout is a painful episodic inflammatory arthritis that usually affects the joint of the feet and ankles. In its classic form it causes redness, tenderness and swelling at the base of the big toe. Over time, if untreated, gout can cause tophi (hard chalky collections of uric acid crystals) that can get as big as a golf ball. Although any joint can be involved the joints of the feet and ankles are most commonly affected. Men develop gout much more frequently than women but women begin to catch up after menopause.
An overabundance of the protein breakdown product uric acid in the fluid of the joint causes gout. It happens in people with a diet high in purine or whose bodies don’t handle uric acid well either because genetics or kidney disease. Other factors that may make gout more severe are alcohol and certain medications (water pills, low dose Aspirin, and cyclosporine). Dairy products, coffee, Vitamin C and staying hydrated all protect against flares of gout.
Physicians diagnose gout when they see someone who has the classic presentation of intermittent flares of their joints in the setting of high blood uric acid. Although the blood uric acid is not always elevated during an acute flare it is almost always elevated between flares. A definitive diagnosis can be made when fluid is aspirated from the joint and it shows the colorful needle-shaped crystals of uric acid.
Treatment of gout involves two different approaches:
- Treating the inflammation
- Preventing flares by lowering the uric acid.
Treating flares of gout can be done with nonsteroidal anti-inflammatory agents, colchicine, and corticosteroids. Treatment of flares usually works best if started as soon as possible after an attack begins. Gout can be prevented with medications like allopurinol, febuxostat, and probenecid. These medications lower uric acid quickly but it will usually take months to completely prevent flares. Restricting foods high in purine is also important in controlling blood levels of uric acid. These include foods like seafood, organ meat and beer.
Although gout can be an extremely painful disease it also is one of the most treatable diseases. With careful attention to diet and strict compliance to medications most patients can lead normal active lives.
Cortisone (e.g. prednisone) and NSAIDs e.g. ibuprofen, naproxen can help symptoms but do not have the ability to modify the joint destruction and functional decline. They may cause stomach bleeding, poor kidney function, high blood pressure and cardiovascular side effects among other side effects.
Disease modifying anti-rheumatic drugs (DMARDs) have the capacity to drive the disease to a low activity state. The gold standard methotrexate at 15-25 mg per week, Arava, sulfasalazine, and the less potent Plaquenil are examples. But they often fail to induce remission. Newer biologic agents especially when used with methotrexate can affect good clinical outcomes. They include Enbrel, Remicade, Humira, Orencia, Rituxan, Cimzia, Simponi, and Actemra (listed in the order of approval by the FDA). However, even on these agents most RA patients do not achieve remission and they also may cause mild and serious side effect which limit their use. More research is needed to refine treatments with these agents and to identify new more effective, safe and less expensive drugs to help patients with RA. Only when RA patients volunteer for clinical research trials are better therapies discovered.
The physicians in practice at Arizona Arthritis & Rheumatology Associates and their research division Arizona Arthritis & Rheumatology Research are dedicated to the care of patients with RA. They helped develop the available RA therapies and are investigating new drugs on the horizon. We encourage patients with RA to contact us to participate in our growing research efforts and to become patients of our cutting edge rheumatology center.