It often starts in the dead of night. The pain is severe and fever may make you feel even worse. Lying still helps a bit, but even the touch of a sheet can be excruciating. You are suffering from gout, a common disease that's often misunderstood.
Myths and realities
Over the centuries, gout was considered a rich man's disease, a product of overeating, excessive drinking, and corpulence. Modern research, however, shows that gout has no relationship to wealth or social status and little to diet and drink. But one traditional view has proved correct: Gout is a man's disease, occurring seven to nine times more often in men than women. It's also a common disease, striking an estimated 3.4 million American men annually. That makes gout the most prevalent form of inflammatory arthritis in men older than 40.
The chemical culprit
Gout is caused by an accumulation of uric acid. Uric acid has no useful function in the human body; it is simply a breakdown product of purines, a group of chemicals present in all body tissues and many foods. In normal circumstances, the body rids itself of uric acid by excreting it in the urine, keeping blood levels low. But some men have inherited a metabolic glitch that allows blood uric acids to rise. Certain medications, such as low-dose aspirin, thiazide diuretics, and niacin, can also increase uric acid levels.
These high levels lead to gout — but not right away. In fact, uric acid levels are typically elevated for 20 to 30 years before they cause any trouble, which is why gout usually occurs in middle-aged and older men. But gout can also be triggered by a rapid drop in uric acid levels, which is why up to 30% of men with gout have normal uric acid levels at the time of an attack.
An attack of gout occurs when excess uric acid is deposited in a joint and forms urate crystals that irritate the joint lining. White blood cells try to gobble up the crystals, but they are not equal to the task. The white blood cells are themselves damaged, releasing chemicals that cause inflammation, swelling, and pain.
Gout is painful, very painful.
The most common manifestation of gout is acute arthritis, severe pain in a joint. In most cases, it strikes one joint at a time; in half, it's the first joint in the large toe. Other frequent sites include the forefoot, instep, heel, ankle, and knee. At any site, the attack usually begins abruptly, often at night. Within hours, the joint becomes red, swollen, hot, and painful. And even though only one small joint is affected, the inflammation can be intense enough to cause fever, muscle aches, and other flu-like symptoms.
Without treatment, gout can also cause long-term arthritis, with chronic swelling and permanent joint damage.
Gout is easy to recognize in the big toe, where it causes the characteristic inflammation called podagra. Doctors can often make the diagnosis over the phone, and most men with gout can diagnose themselves — particularly in their second or third attack of this recurring disease. But in other joints the diagnosis can be tricky. If the diagnosis is in doubt, doctors can remove a small amount of fluid from the inflamed joint.
Gout responds very well to nonsteroidal anti-inflammatory drugs (NSAIDs) if two rules are observed. First, the NSAID should be started as promptly as possible, and second, it should be used at the maximum recommended dose. Many physicians prescribe indomethacin (Indocin), but the other prescription and over-the-counter NSAIDs are also effective. One exception: Aspirin should not be used for gout because it can raise uric acid levels.
Men who can't take NSAIDs because of gastritis, peptic ulcers, or bleeding can get relief from a closely related drug, the selective COX-2 inhibitor, celecoxib (Celebrex). Joints that are inflamed should be rested, but men can resume their normal activities as soon as their gouty attacks settle down.
For centuries, diet was the mainstay of prevention, but since only about 10% of the body's uric acid is derived from dietary sources, it didn't work very well. Still, every little bit helps.
High-purine foods that may increase the risk of gout
Modified from Emmerson BT, New England Journal of Medicine, Vol. 334, No. 7, pp. 445–51.
Although months or years can elapse between attacks, more than 75% of patients with gout have several episodes. Men whose attacks are infrequent don't need any preventive medication, but they should have an NSAID on hand to use at the first sign of another attack.
There are three ways to prevent gout:
- Anti-inflammatory medication. Taken daily, low doses of NSAIDs or colchicine can prevent acute attacks.
- Medication to promote uric acid excretion. Probenecid (Benemid) is the traditional choice. Since the drug increases uric acid in the urine, it can predispose a person to kidney stones, and it should be avoided in patients with kidney disease.
- Medication to reduce uric acid production. Allopurinol (Zyloprim) is the only currently available drug in this category.