Gout…

If you get gout, you are in good company.  Gout has had more mentions in literature than most other diseases, except perhaps for 'dropsy', 'palsy' and 'apoplexy'. 

Admittedly, diagnostic categories were limited  back then.

Hippocrates, King George IV, Samuel Pepys, Dickens, Thackeray and Joseph Conrad all wrote about the affliction, in the most colourful of terms.  What hasn't changed is the amount of sympathy you are likely to engender if you admit that you are a sufferer.  It is usually met with chuckles of derision and accusations about your lifestyle.

Traditionally seen as a disease of human folly and affluence, the caricature of gout is of an overweight  elderly man lying back in agony with his foot up on a pillow, having indulged in too much rich food and port.

         Some of this is true, but a lot of the myths about gout have been dispelled in recent years, and it is now being taken very seriously as a sentinel of more serious underlying disease.

Gout is a type of arthritis caused by deposits of a crystal, called uric acid, in joints.  Usually the foot (big toe) or ankle is affected, but it can occur in any joint.  The result is acute swelling, redness and  pain so severe that it has been  likened to childbirth for men.  Women do get gout, but it is much less common than in men, and usually occurs only  after the menopause.

Uric acid is produced by the kidneys.  It is the  end product of themetabolism of a compound called purine, and is eliminated in the urine (2/3) and intestines (1/3).  One's uric acid, or 'urate'  level,  is measured in routine blood tests as on e of the kidney function tests.  Gout occurs when there is too much urate in the body. Some rare people have inherited a gene that makes them produce too much urate, or have an inborn kidney problem that makes them retain too

much.  Both result in gout.  However, by far the most common causes of gout are 'acquired', and usually because  of a genetic predisposition (did your father get  gout?) coupled with lifestyle. 

         What needs to happen for an episode of gout to occur is for the blood level of urate to exceed a certain threshold.  Once this happens, urate leaves the blood and literally crystallizes out into a joint,  usually picking on a joint that has a bit of damage in it already.  So, big toes are  obvious targets, as most people have had some trauma to them over the years, as are ankles and to a lesser extent knees, elbows and fingers.  Fortunately, it only tends to attack one joint at a time, as the pain can be excruciating, and as I said, it may be compounded by a lack of sympathy.  Just hearing the word 'gout' seems to bring a smile to many people's faces, even though they have no idea what it is.  Cruel.

         But gout is not just a joking matter.  The pain can be treated with anti-inflammatory drugs (eg, Indocid, Naprosyn) and usually starts to subside within 4-8 hours, but if left untreated, or allowed to recur, the crystals can eventually erode the joints and bones of the affected area and damage them.  All those  pictures you see in old books of lumps on people's joints are lumps of crystallized urate.  They are called 'gouty tophi': another very unglamorous word for an unglamorous disease.  This leads to arthritis and subsequent debility. A high uric acid level can also contribute to kidney stones.

Gout is also more than a painful  inconvenience.  High circulating levels of uric acid are now recognised to be a marker for other things, especially high blood pressure,

insulin resistance (pre-diabetes) and high triglycerides.  Uric acid is considered to  be a member of a group of substances called 'inflammatory markers', just as cholesterol is a marker of atherosclerosis, itself now known to be a disease of inflammation.  (That's right, heart attacks are the end results of chronic inflammation of the insides of blood vessel walls.)

It appears that by the time you get your first attack of gout (usually after the age of forty), your circulating urate levels have been high for up to 20 years, so the disease is a symptom of a more serious underlying process. For up to 20 years your system  has been brewing inflammation which has only now declared itself.

Studies in the last few years have shown that men with gout are 50% more likely to die of a heart attack than men without gout. That was after controlling for other variables : high blood pressure, cholesterol, smoking, obesity, alcohol intake, family history, kidney disease, and medications . One researcher described gout as the 'smoke around the fire', adding that patents should be aggressively screened for high uric acid levels and their risk factors tightly managed.  If you have gout or high uric acid, it is - like high cholesterol, family history, high blood pressure and smoking - a risk factor for heart disease.  This fact is  not widely publicised yet.  High uric acid usually goes hand in hand with these characteristics, but occasionally there is a person who is fighting fit but has high uric acid.  Scarily, they have also found that  having high uric acid is an independent risk factor for death, not just from cardiovascular disease, but from 'all causes'.  This is not saying that uric acid causes death, but a high level correlates with dying earlier, from an otherwise preventable cause.

The usual gout sufferer does fit a stereotype, to a certain extent, as high uric acid tends to go with high blood pressure, lack of exercise, a fat midriff and high blood fats, especially triglycerides.  Occasionally I encounter  a person who is otherwise in the bloom of health and has high urate, but  this is not common.  Generally I can anticipate a lot about a patient I have never seen before just from looking at their blood test results, and I am no genius.  I know  whether they are likely to be overweight, sedentary, hypertensive and partial to a drink before I even set eyes on them.  I can also tell whether they drink inadequate water , or are at risk of diabetes, heart attack or diabetes.  Bear in mind that  my practice is preventative health, so these  are people who are not yet 'patients' , and who are otherwise without complaint, and whose  blood results from the laboratory often come back marked as 'within normal limits'.

So, what is a 'normal' uric acid level?  All the studies mentioned above have found a urate in excess of 0.41 mmol/L to  place one at  increased risk, not just of gout but of cardiovascular disease. (0.36 for women). Often people don't get gout until their level is over 0.54.  Labs generally label a urate under about 0.48 as 'normal'.

There are a lot of old wives tales around about how diet affects urate levels, but no-one had systematically investigated  what is true and what is fallacious until a few years ago,  when Dr Hyon Choi at Harvard medical School published a study.

His group discovered that the consumption of meat, particularly red meat, significantly increases the risk of gout, and seafood also carries a  high risk  They found that more than one dish of canned tuna per week increased the risk of gout by 28%, but eating meat more than twice  per week increased the risk by 50%.

Beer also increases the risk of an attack, much more so than wine.  No increased risk was seen with purine rich veggies, such as peas, beans, mushrooms, cauliflower and spinach.  Instead, they found a protective effect from vegetable and dairy products .   In fact, the consumption of  low-fat dairy products , eg., the ingestion with more than two cups of skim milk per day , decreases your risk by 48%.  A low protein diet had no effect, as what is important is the purine, not the protein, content of foods, and given that purines are in DNA and RNA, it is contained in growing and multiplying cells.  Thus, purines are in abundance in animal muscle, beer (from the yeast) and sprouting things, like alfalfa sprouts. Harder to eat too many sprouts than drink a lot of beer, admittedly.  Once again, the old advice of 'everything in moderation' seems to prevail.

I advice people who have already have had an attack of gout to never leave home (especially travel overseas) without a supply of Indocid,  to avoid dehydration and don't binge on beer and seafood/meat.  A classic scenario is the man who goes to a wedding or a day's sailing, drinks little water but a lot of beer and eats a lot of the above.  He wakes up in the night with a very hot and painful joint.  Long dehydrating plane journeys can also be problematic.   If you do get an attack of gout, start taking anti-inflammatories  immediately  (Indocid is the old favourite, but they all work) and drink plenty to try to dilute out the urate.  Rest the joint to try to avoid damaging it and call in sick (you don't have to own up to gout).  If you have recurrent gout you should be on a tablet called allopuriniol, which prevents the synthesis of urate , with the aim of keeping your level less than 0.36.  Much better to prevent attacks rather than to put up with them and risk joint damage.

If you are overweight, losing some weight will reduce your level of urate, as well as helping your blood pressure and blood fats.  Walking most days for 30 minutes will also make a big difference to just about everything.

So, next time you go for a checkup, make sure you find out what your uric acid level is, as well as your cholesterol, liver function, glucose etc. If your GP is puzzled by your curiosity, just say you've been reading Hogarth.

(All references available on request)