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December 7, 2009

Gout’s Resurgence
By Lindsey Getz
For The Record
Vol. 21 No. 23 P. 24

The recent increase in the number of gout cases has providers and medical researchers taking a closer look at the disease’s underlying causes and new treatments.

While many people have heard of gout, the idea that it’s a “disease of the past” has made it one of those ailments about which most know very little. But older adults who suffer from this excruciating form of inflammatory arthritis know it’s a condition that warrants attention. In fact, gout has made a massive resurgence, and some studies even suggest the number of cases in this country has doubled in only the last three decades.

Once called the disease of kings because of its association with living the high life, gout can strike anyone, although it’s three to four times as common in men as in women. And there are certainly factors that put some at higher risk than others. While we know that it’s not just a rich man’s disease, it’s easy to understand the origin of this former belief.

Modern research has demonstrated that the overconsumption of luxury foods such as red meat, shellfish, hard liquor, and beer may increase the risk of a gout attack. The reason, explains Christopher Magee, MD, an orthopedic surgeon and the chief medical officer at Washington Adventist Hospital in Takoma Park, Md., is that these foods are rich in purines, or chemical components that eventually become uric acid and, in cases of excess, can metabolize into crystals that settle into the joints and cause great pain.

In addition to being linked with eating purine-rich foods, gout is also associated with obesity in general, as well as with conditions such as diabetes, hypertension, and heart disease—all of which seem to be on the rise in America. “And there’s even been studies that show high incidence of gout in people who drink sugary beverages,” adds Magee. His reference is to a recent BMJ study that found men who consume at least two soft drinks per day had an 85% greater likelihood of developing gout than those who drank less than one per month. In fact, even at lower levels, soda consumption increased the risk for gout in the study’s participants.

Another potential cause of gout is a kidney malfunction, which can result in a buildup of uric acid. Also, like most diseases, there can also be a genetic component. In fact, one in four gout sufferers has a family history of dealing with the condition. “It may be entirely hereditary,” explains Magee. “It’s important that those with a family history of gout go out of their way to avoid foods that are high in purines and live a healthy lifestyle.”

While genetics have left some people predisposed to developing the disease, the resurgence of gout is likely linked to the way Americans live today. There is a lot of speculation that the rising number of cases may correlate with America’s obesity epidemic. It also happens to be a disease that affects older adults. “Because it occurs in the aging population, as more Americans get older, it makes sense we’re seeing more cases surface,” says Magee.

When Gout Strikes
Gout is most commonly known for causing sudden pain and swelling in the big toe. While that’s not the only place it can strike, about 90% of gout sufferers will at some point experience such pain and swelling in that area. Gout can actually affect any number of joints, including the knees, elbows, wrists, and those of the hands and feet. Symptoms include swelling and redness around the affected joint, sudden and severe pain, limited movement in the affected joint and, in some cases, a fever. In addition, as the crystals accumulate within joints, they can form tophi, or chalklike lumps and bumps that can actually become deforming over time. Once the gout attack subsides, it’s also possible for the skin around the joint to peel. An initial gout attack may last anywhere from three to 10 days.

While it may not always be possible to prevent gout, especially when it’s hereditary, there are ways to decrease the likelihood of an attack. According to Naomi Schlesinger, MD, chief of the division of rheumatology at the University of Medicine & Dentistry of New Jersey’s Robert Wood Johnson Medical School, losing weight or maintaining a healthy weight, eating a diet low in purine-rich foods and fructose, and treating underlying conditions such as hypertension and diabetes are effective preventive measures.

The emergence of a gout attack has also been associated with cold temperatures. “This may be one reason why it occurs in the joints of the big toe, which are the farthest away from the center of the body,” Magee hypothesizes. “Classically, an attack of gout comes on at night. Gout sufferers often describe episodes of waking up in the middle of the night with cold feet and a tremendous amount of pain in their big toe. It’s not proven as an effective preventive measure, but it can’t hurt to try and keep your feet warm during the night, perhaps sleeping with a pair of socks on.”

Keeping Gout at Bay
Besides making lifestyle changes to control gout, there are medications that can ease the pain and help prevent future attacks. Nonsteroidal anti-inflammatory drugs, colchicine, and steroids have all long been used for treatment. However, the rapid reappearance of this disease has prompted many drug companies to scramble to improve on old treatments with stronger and more effective drugs. The medical field expects a variety of options to arise in the near future. “There are many more treatments on the horizon,” says Schlesinger.

One drug that is now available after being approved in February by the FDA is febuxostat, marketed under the trade name Uloric. Schlesinger calls it an important drug that is helpful for patients with renal disease, which comprises a majority of gout patients.

Krystexxa, another new drug, will also likely be available soon, possibly late next year. It has gone through the FDA process and was even recommended for approval by the committee but ultimately turned down because of some concerns about the manufacturing process. While there has been discussion raised that Krystexxa may increase the risk of heart problems, it is said to be a drug that will bring relief to patients with chronic gout who have shown no previous improvement with other treatments or are unable to take alternative treatments for whatever reason.

As researchers continue to make advances toward better treatment for gout, healthcare professionals have been advised to educate patients about the disease. Since gout is not at all a disease of the past and is actually a modern-day concern, patients need to be empowered with the latest information. But first, it’s imperative for those on the front lines to be self-educated. Individuals in positions to recognize the symptoms of gout need to become more familiar with the disease. “Education is definitely important in making the right diagnosis and knowing the different treatment options available today,” says Schlesinger.

Becoming educated can help caregivers recognize symptoms early and help prevent future attacks. Magee adds that the prevention of gout dovetails nicely with the prevention of many other chronic medical problems that are known to affect the aging population—obesity, cardiovascular disease, and diabetes, in particular.

“It really comes down to weight control, balanced diet, and activity level,” he says. “These are three areas that should already be focused on to prevent other medical conditions in older adults. It’s interesting that the rise of gout has paralleled the rise of these other chronic diseases within our society, and it’s easy to link them all to being inactive, overweight, and making bad food choices. I think it’s important for people to recognize that a lot of these chronic medical conditions really have the same common genesis and require making the same lifestyle changes for better health.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.


Got Gout? Get Milk
Drinking skim milk may help people manage their gout, according to research presented recently at the American College of Rheumatology Annual Scientific Meeting.

Gout is a painful and potentially disabling form of arthritis that has been recognized since ancient times. Initial symptoms usually consist of intense episodes of painful swelling in single joints, most often in the feet (especially the big toe). Treatments are already available to prevent or control the arthritis associated with gout, but managing this disorder can be difficult, and treatment plans often have to be tailored for each person.

Previous studies have indicated that individuals who drink a lot of milk have a lower risk of developing gout. Researchers recently studied the effects of skim milk on serum uric acid concentrations, which, when at an elevated level, increase the risk of gout.

With the help of 16 healthy male volunteers, researchers studied the effects of drinking soy milk and three different types of skim milk produced at different times of the milking season from grass-fed cows.

Each participant received a single dose of each product (each containing 80 g of protein) in random order. Researchers collected samples of serum and urine immediately before each participant drank one of the beverages and then hourly over a three-hour period. They completed this with each participant for each of the four beverages with one week in between each session.

Researchers found that after drinking the soy milk, the serum uric acid increased by about 10%. In contrast, all skim milks led to a decrease in serum uric acid by approximately 10%. All beverages, including the soy milk, rapidly increased the kidneys’ ability to remove uric acid from the body.

Additionally, researchers found that late-season skim milk led to a greater increase in the removal of uric acid by the kidneys compared with the other skim milks. Late-season skim milk is primarily available from countries where milking is seasonal and cows are grass fed, such as New Zealand and Australia, and is known to contain higher levels of orotic acid, a substance that promotes uric acid removal by the kidneys.

Ultimately, the study shows that skim milk has a specific uric acid-lowering effect, and it may be a good dietary way to assist in the prevention and treatment of gout.

“This study has shown that skim milk can significantly reduce the serum uric acid concentration in the short term,” explains Nicola Dalbeth, MD, FRACP, senior lecturer of clinical medicine at the University of Auckland in New Zealand and the lead study investigator. “The results suggest that increasing the amount of skim milk in the diet may help with preventing the development of gout and also assist with treatment for those with the disease. We are now continuing this work by studying the longer term effects of milk in people with gout.”

— Source: American College of Rheumatology