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Understanding Gout

by Robert F. Hynd, MD

Gout is a serious metaboilic disease caused by an excess of uric acid in the body. The buid-up of uric acid can occur in all organs of the body resulting in severe arthritis, bone destruction, kidney stones and kidney failure. The process aggravates high blood pressure and worsens cardiovascular disease.

What causes uric acid to increase? Recall, that new cells in our tissues constantly replace the old ones that die. The old cells release nitrogen wastes. One of these is uric acid. While our kidneys remove uric acid and other nitrogen wastes some people can't rapidly excrete uric acid and levels rise above 6 mg/dl; then crystals of urate deposit in tissues, especially around joints. When urate crystals inject into a joint like the big toe or ankle the result is a painful arthritic attack. These attacks are often the first sign of gout.

Medications control and prevent gout attacks and keep uric acid levels below 6 mg/dl or less. Colchicine, taken within six hours of an attack, treats most acute arthritic attacks. Anti-inflammatories like Ibuprofen or corticosteroids like prednisone may also work. One to two doses of colchicine per day also prevents the attack even without lowering the uric acid.

Once on colchicine for a week or two, then allopurinol (Xyloprim) or febuxostat (Uloric) can be increased slowly while carefully titrating uric acid to levels below 6 mg/dl. Lowering uric acid quickly without first giving colchicine could precipitate an acute attack of gout. Probenicid also lowers uric acid but it's an older drug and depends on good kidney function to work. Pegloticase (Krystexxa) treats very persistent gout flares and actually dissolves piles of urate crystals (called tophi) all over the body. Infusions of the drug two weeks apart are often helpful for resistant cases.

Gout greatly concerns us because it is reaching near epidemic levels in the western world. Gout affects 8.3 million adults in the United States. Over the last 20 years, its prevalence has markedly increased. A number of co-morbidities like hypertension, hyperlipidemia, Type II diabetes and obesity drive up uric acid levels and make gout more likely. Use of diuretics in cardiovascular disease increases uric acid levels while worsening dietary trends and use of alcohol, especially beer, increases the possibility of gout. Also an aging population of post-menopausal women increases the chance of gout.

So what is the take home message? Get our risk factors for gout under control; they are the same ones for cardiovascular disease (i.e. - hypertension, hyperlipidemia, Type II diabetes, and obesity) then get your uric acid checked and work with your doctor to keep it under 6 mg/dl!