†Expert Patients (Gout)
May I govern my passions with absolute sway,
And grow wiser and better as strength wears away,
Without gout or stone, by a gentle decay.
†††††††††††††††††††††††††††††††††† The old manís wish, 1685, †by Walter Pope
This quotation illustrates how little mitigation of the miseries of gout was available before modern medicine.† Gout is unique among the chronic forms of arthritis in that it can now be completely controlled by medication.† Gouty arthritis is caused by inflammation induced by uric acid (really monosodium urate) deposits in or near joints.† Several inherited and acquired metabolic defects, which are very nearly universally present in affected patients, result in increased blood levels of uric acid,.† In a particular patient the defect can result from either increased production or decreased renal excretion of uric acid.† Those of us with increased production of uric acid are susceptible to kidney stones in addition to the susceptibility to gouty arthritis.
Over 50% of initial attacks are in the big toe joint.† The attacks come on like gang busters usually in the middle of the night and without any apparent provocation.† The pain is severe.† Even the weight of bed covers can be offensive.† Walking is extremely difficult.† Untreated, an attack will subside in a few days to a little over a week.† Treatment with any of the modern anti-inflammatory agents is effective within hours.† Aspirin is best avoided because it has variable effects on uric acid excretion.† For those patients who do not tolerate non-steroidal anti-inflammatory agents (NSAIDs), cortisone congeners are also effective, and not harmful because prolonged dosing is not needed.† Examples of NSAIDS include Advil (ibuprofen), Aleve (naproxen), Indocin (indomethacin). (Never† take these medications on an empty stomach).
After the acute attack has been controlled, the agenda becomes long term planning.† This requires solid knowledge for the patient to avoid counterproductive instincts.† After the initial attack 78% of sufferers will have a recurrence within two years.† Long before a rapid sequence of attacks occurs, permanent preventive measures need to be instituted, if only to prevent progressive joint damage and permanent disability.† The tricky part of the education effort is that the agents for prevention do nothing for acute attacks already under way. And when first initiated they may even precipitate an attack or two.† This sequence of events is best avoided by the use of colchicine in small doses.† A generation or two ago, colchicine was the only anti-inflammatory medication effective for gout.† The large doses needed for prompt relief of an acute attack are now seldom used because of inconvenient, if not dangerous, side effects.† Small doses of colchicine are well tolerated and effective in preventing recurrences, and are needed for only a few months after acute attacks or after initiating preventive therapy.
The educational effort about the details of gout is somewhat daunting for student and teacher alike, hence this article.† Please hang in there a moment longer.
†Uric acid is the final waste product of the breakdown of nuclear material (the nucleic acids of DNA) from either cells in items of diet or from the patientís own cells.† For several decades we have had a medication (allopurinol), which stops the breakdown of nucleic acids just before uric acid is formed.†† The result is hypoxanthine accumulation instead of uric acid.† Normally it is immediately converted to uric acid.† (Dalmatian hounds excrete hypoxanthine instead of uric acid, and they are as healthy as other dogs).† Hypoxanthine is also more soluble than uric acid and readily excreted in urine without risk of kidney stones.† The result of an effective dose of allopurinol is that enough uric acid production is diverted to hypoxanthine that the blood level of uric acid drops to normal, the uric acid deposits dissolve, and no gout will recur as long as such a dose continues.† Remember it is deposits of uric acid that initiate attacks of gout.
We also have medications, which increase the excretion of uric acid, but they do not prevent uric acid kidney stones.† About 20% of gout patients end up with kidney stones; some even get kidney stones before they get the arthritis.† Old timers remember that gout patients are not supposed to eat red meat (because of the high content of nucleic acids). Allopurinol is so effective that we donít have to emphasize diet in the treatment of gout.† If a patient acts neglected without dietary restrictions, we tell him to avoid liver and sweetbreads (a collective term for pancreas or thymus glands used as food).† Alcohol also aggravates gout.† Again modern drugs remove the need to make an issue of this, unless the patientís alcohol intake is enough to be harmful in other ways.
Another pitfall requiring education: after a year or two of preventive therapy (usually with allopurinol as mentioned above) the patientís situation becomes similar to what it was long before his first attack (believe me, most gout sufferers are male).† So if he stops taking allopurinol, history will repeat itself and he will get the gout back in a few years. I tell them, ďTake allopurinol at least until you check into a nursing home.Ē† Note added January 5, 2006: febuxostat is about to be available for those who cannot tolerate allopurinolóvery few in my experience.
John A. Frantz, M.D.
March 13, 2003
††††††††††††††††††† Aristotle taught that heavy objects fall faster than light ones, and everybody agreed until Galileo came along. It simply seemed like common sense.
††††††††††† ††††††† Galileo reasoned that if you attach two objects together with a rope perhaps, they should fall faster because their combined weight is greater than either one, but the lighter one, trying to fall slower as if by itself, should slow the fall of the larger of the original two.† Now we have a contradiction.† The new body is expected to fall both faster and slower than the larger of the original two.† This contradiction, on a moments reflection, leads to the conclusion that all objects fall at the same speed (neglecting wind resistance).† Galileo, the great experimentalist, had solved an age old problem without lifting a finger†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††