By Henrylito D. Tacio
The great 18th-century arbiter of social caste, the Earl of Chesterfield, announced that rheumatism was for hackney coachmen but “gout is the distemper of a gentleman.” English physician Thomas Sydenham, himself a gout victim, liked to think he shared the disease with “kings, princes, generals, admirals, philosophers.”
American statesman Benjamin Franklin debated whether gout was his friend or his enemy. The best advice was thought to be to hold on to your gout, and make sure it stayed in the foot. This did not help Edward Gibbon, whose gout didn’t protect him from a swollen testicle, which went septic after surgery and killed him. The worst fate was imagined by Jonathan Swift. “As if the gout should seize the head,” he wrote, “doctors pronounce the patient dead.”
Gout is one of the oldest diseases known to mankind, first identified by the Egyptians in 2640 BC and later recognized by Hippocrates, the father of medicine, in the fifth century BC. In the past, it was known as a disease that disabled and hurt, but did not kill. But today, physicians believe otherwise.
In 1952, gout was unknown in Asia, but is now common in Japan and other parts of the region. In the Philippines, a study conducted in 2003 showed that more than six percent of those surveyed were afflicted with arthritis, with gout topping the list. In Singapore, the majority of gout patients seen in hospital setting are middle-aged men. “I don’t think there is low prevalence of gout,” says Dr Koh Wei Howe, a consultant rheumatologist at the Mount Elizabeth Medical Centre. “It is the most common form of arthritis and many family doctors treat gout as well.”
Unfortunately, most of those who are suffering from gout don’t even recognize they have the disease. “For one, these people are not aware of gout,” laments Dr Koh. “For another, there are many causes of joint pains and swelling.” As a result, many of them are not aware of the available treatments.
Gout, which comes from the Latin word gutta (which means “drop”), is caused by the chemical uric acid, a waste product normally present in blood, produced by the breakdown of dietary substances called purines. In health, uric acid dissolves in blood and is taken to the kidneys, from where it is discarded through urine.
For some reasons, too much uric acid is produced or too little is expelled from the kidneys and its blood levels increase, which result in the formation of urate crystals called tophi. When uric acid crystallizes, it lodges in the joints causing excruciating pain. “Picture what happens when you put too much sugar in a glass of water with ice,” explains Dr Eric Jason Amante, clinical associate professor at the Philippine General Hospital of the University of the Philippines. “The sugar will dissolve up to a point, and the remaining crystals pile up at the bottom.”
When this happens, the joints can get hot, swollen, and tender. “Sharp, throbbing, and piercing pain” is how Edwin Bibera, a 45-year-old Filipino computer analyst now working in California, describes it. “It feels like a sprain. Skin is very sensitive to touch.”
Gout delivers a royal pain to the big toe, ankle, foot, wrist, fingers, cartilage, tendons or ear lobes. The agony can start very quickly. One minute, you’re skipping along with a smile on your face and a song in your heart. The next, you’re in excruciating pain.
Because of genetic factors, gout tends to run in families and is usually inherited. A 2001 study in Taiwan found out those patients with possible inherited conditions are more likely to have an earlier onset (about 41 years) compared to those whose gout is due to other factors (48 years).
Insulin resistance, a condition in which excess amounts of insulin are required to use blood glucose, is also associated with gout. This condition progresses to frank diabetes if not attended to in time. Dr. S. Takahashi, from the Third Department of Internal Medicine at Hyogo College of Medicine in Japan published a study in Metabolism in April 2001, which suggests that gout patients have some factors that cause insulin resistance.
Certain drugs – such as thiazide diuretics, cyclosporine, pyrazinamide, ethambutol, nicotinic acid, and low doses of salicylates – are considered risk factors for the development of gout. Certain cancers and blood disorders, hypothyroidism, lead poisoning, obesity, radiation treatment, renal failure, and starvation may also lead to gout.
There are two treatments for gout: medications to control the attacks of joint pain such as non-steroidal anti-inflammatory drugs – such as indomethacin (Indocin) and naproxen (Naprosyn) – colchicines, and corticosteroids, and urate-lowering drugs like allopurinol (Lopurin, Zyloprim) so that attacks occur less frequently or not at all.
Among the new drugs available for gout are rilonacept (IL- Trap) and etorixocib (Arcoxia), both anti-inflammatory drugs which are used to treat acute gout. Undergoing clinical trials is febuxostat, which can reduce plasma levels of uric acid more effectively than the current allopurinol.
“Early treatment is important for acute attacks with medications,” points out Dr Amante. He adds that some patients stop taking the medication once the pain has subsided. This would cause the gout to flare-up again very quickly.
Dr. Wan Syamimee Ghazali, a rheumatologist at University Science of Malaysia in Kelantan, warns that what works well for one person may not work as well for another. As such, the Malaysian physician urges gout patients to see a rheumatologist not just a family doctor. “A rheumatologist will look closely at how acute your gout is before he will make a final decision on the course of treatment for you,” she explains.
“Once gouty always gouty” is an old medical maxim, yet doctors believe that gout attacks can be reduced by following healthy habits. Research from the University of British Columbia suggests long-term coffee consumption is associated with a lower risk of gout. According to the findings the risk of gout was 40 percent lower for men who drank 4 to 5 cups a day and 59 percent lower for men who drank 6 or more cups a day than for men who never drank coffee.
But watch out what you drink, especially alcoholic beverages. A study of nearly 50,000 men has found those who over-indulge in beer, in particular, are at heightened risk, said a study by a team at Massachusetts General Hospital. Men who drank two or more beers per day were 2.5 times more likely to develop gout than those who did not drink, said the study which was published in The Lancet. The same level of spirit consumption raised the risk – but only by 1.6 times.
But drinking water is another story. In fact, water may help ease the pain. “You can help your kidneys flush excess uric acid from your system by going heavy on water,” says Dr Koh. Uric acid can also deposit in the urinary tract causing kidney stones and drinking water regularly reduces the chance of forming the stone. Although he admits that there’s no fixed recommendation for water intake, he recommends no fewer than two liters of water each day.
On the other hand, eating less red meat and seafood while consuming more low-fat dairy products cuts the risk of developing the painful joint condition gout by about half, said Dr. Hyon K. Choi, a rheumatologist at Massachusetts General Hospital. Eating lots of vegetables and fruit, shunning alcohol use and maintaining a normal body weight also significantly reduced the chances of getting gout.
Due to advances in medical research, gout can be well controlled these days. If correct treatment program is closely followed, gout becomes an easily manageable illness. “The problem is that patients often do not accept that they need long term treatment and diet control,” says Dr Koh. “The level of serum uric acid takes time to normalize even with medication and patients may not be compliant with recommended treatment.” — ###