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Medical Minute

The Painful Truth About Gout Attacks

October 30, 2000

It may sound like a disease that plagued kings in the Middle Ages, but gout still afflicts 2.1 million Americans today. Health spoke to Dr. Rodney Bluestone, a rheumatologist and clinical professor of medicine at UCLA who sits on the board of directors of the Southern California chapter of the Arthritis Foundation.

Question: When I think of gout, I picture King Henry VIII at a banquet table, propping up his red, swollen foot on a velvet stool while he eats overly rich foods. But that's a bit one-dimensional, isn't it?

Answer: Certain foods are associated with gout. Liver, sweetbreads, lots of red wine. But usually diet by itself isn't enough to bring it on. In fact, it's very hard on a contemporary American diet to get gout unless you want to do a King Henry VIII imitation--he would consume a side of venison and six bottles of red wine a night.

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Q: So then what causes it?

A: Gout, or gouty arthritis, is the acute inflammation of a joint caused by the crystallization of uric acid in that joint--and 90% of the time it's in the big toe, although it can spread to the rest of the foot. We don't know why. There's a theory that the big toe gets traumatized just by walking around, because it's such a high pressure-bearing area in your body.

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Q: Could you define uric acid?

A: It's a chemical produced by the liver that circulates in your bloodstream. It's useless and has no function whatsoever. With most people, uric acid is excreted from your system. But some of us, for reasons that aren't known, make too much. When uric acid exceeds the limits of solubility in the blood, it gets deposited in a crystallized form in a joint or a tendon sheath. The body's white blood cells see the crystals as foreign invaders and try to attack them, which releases cellular enzymes into the joint that cause a tremendously painful response. People feel their toe is glowing like a red-hot balloon. They can't stand the weight of bedsheets. While it's comical to talk about, it's agony to suffer.

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Q: How has treatment advanced since King Henry VIII's time?

A: Gout goes back further than that. It's mentioned in ancient Greek literature. The treatment back then was colchicine, from the crocus lily bulb. But that can cause diarrhea. Today we have various anti-inflammatory drugs that work well in high doses to stop acute attacks. Some people even take low doses to prevent recurrence, but you also need to bring down the uric acid level. There are two main drugs for that. Allopurinol slows the amount of uric acid your liver makes. Benemid helps your body excrete more uric acid. Those are the two main ones. You have to take one of these medicines daily for the rest of your life. They're incredibly safe drugs. But what's amazing is how many people don't have their gout under control because doctors and patients don't approach it firmly. Some people don't think it's worth their while. It's a commitment-for-life treatment, which some people don't like.

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Q: If you're on the drugs, can you eat liver and sweetbreads and drink Cabernet?

A: Yes, you can eat what you want. The reason those foods are associated with gout is that they contain a substance called purine, and when your body breaks it down, it can create more uric acid. But not enough to tip you into gout if you're taking your medicines.

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Q: Who's at risk?

A: We don't know why, but 75% of gout is seen in men, the balance in post-menopausal women. In men with a strong family history of gout, you can see it in the 30s and 40s age group. But usually it's middle-aged men. There's also a much higher incidence among Filipinos in the United States. When their diet changes, they don't have the metabolism to handle the purines, and they get high uric acid rates. There are also huge pockets of gout in the Southeastern United States, where they make their own alcohol. The lead in the moonshine poisons the kidneys and you get moonshine gout.

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Q: Can there be complications?

A: No one ever died of having an acute gout attack. But patients with gout often also suffer from hypertension, high cholesterol, heart attacks and obesity. And it's these more serious illnesses that govern the prognosis of the patient.

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For more information, call the Arthritis Foundation at (800) 954-CURE or go to http://www.arthritis.org. Dr. Rodney Bluestone is in private practice in Beverly Hills.

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