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Sunday, January 11, 2015

Gout: General Treatment Thoughts

Gout: Treat the symptoms Immediately

By Richard L. Blake, DPM

  Gout can affect many patients in a podiatry practice. The number one location for a gout attack is the big toe joint, but the other foot joints, the ankle, and the knee can have the excitement of an acute gout attack. In the photo below, the man's left big toe joint is slightly enlarged with some run of the mill wear and tear, and a prime suspect for developing gout in the future. Gout attacks have a propensity for affecting already damaged joint surfaces.


    I look at the source of a gout attack from 3 angles (or a combination of all 3): the kidneys for some reason are not flushing out the uric acid from the blood stream well enough, there is a systemic reason for increased metabolism which is producing more uric acid into the blood stream (uric acid being a normal breakdown product of nucleic acids called purines), and a recent diet of food rich in purines (which breakdown to uric acid).

    Common food concerns include:
  1. Limit organ meats, herring, mackerel, and anchovies
  2. Limit red meat such as beef, pork, and lamb (only 4-6 oz daily)
  3. Limit fatty fish and other seafoods such as tuna, shrimp, scallops, and lobster
  4. Limit beer
  5. Limit white bread, cakes, and candies
  6. Limit high fructose soft drinks and sodas
  7. Increase use of plant based proteins
  8. Increase use of low fat and fat free dairy
  9. Increase 100% juices
  10. Use of 5-10 ounces wine daily okay
  11. Use complex carbs such as whole grains, fruits and veggies
  12. Use of 4-6 cups of coffee for men seems to be helpful

When you get an acute gout attack, your involved joint is normally red, hot, and swollen. The health care provider asks about your kidneys, your overall health, medications you are taking that may affect uric acid metabolism, any recent crash dieting, any recent changes in your diet like a vacation of eating rich foods, beer, etc, and possible infections anywhere that could have seeded the sore area, like a sore throat. A Gout Attack Looks Like An Infection. To help in the diagnosis of possible infection, the lab is asked to get Uric Acid, CBC with differential, and Sed Rate. The last 2 help with infection evaluation. Patients with an infection also may have systemic signs of fever, chills, malaise, etc, not seen with gout attacks.

It is extremely important to know that once you get a gout attack, uric acid levels in your bloodstream drop as the crystals go into the joint, and your blood test is read as normal. But, you are still high normal, and you still did have a gout attack. At my hospital, Saint Francis Memorial Hospital in San Francisco, 8.7 mg/dl is still normal. When a patient comes into the office after a gout attack, the lab may read between 6.5 and 8.0. This patient has gout in my mind. I ask them to get a repeat uric acid test in 1 month and then 2 months to see what the uric acid levels are doing. In a patient whom has suffered a gout attack, even if they are mindful of their diet, their uric acid levels begin to go back up over the next 2 months. It takes these 3 blood tests to get a feel of how unstable the uric acid levels are for this patient.

When a patient has a gout attack, any anti-inflammatory medication helps, like Advil, but I prefer to use indomethacin, but not advised in the elderly or children or those with a history of GI problems. In a normal size adult, you can use 75 mg 3 times over the first 24 hours as a loading dose, then drop to twice daily for the next 9 days. After these first 10 days, it is obvious how easy or hard it is going to be to get the symptoms under control. Most of my gout attack patients are placed into a removable cast to minimize the bending of the big toe joint, with EvenUp on the other side. The patient is advised to take food with indomethacin since it can be hard on the stomach. Gout attacks can occur from 2 days to 3 + months, so you need to treat quickly. Icing is important to both reduce blood flow to the inflamed joint and for pain relief. I prefer the ice slush, but how cruel can I be!! Patients are told to drink, and drink, and drink water to hydrate, deluting the concentration of uric acid quickly in the blood stream. They must also become familiar with foods rich in purines, and try to minimize the ingestion (not eliminate) on a daily basis. Injections into the involved joint to analyze the crystals seem too academic to torture the patients initially, but if the pain is not subsiding in 4 or 5 days, then aspiration and injection of steriod may be appropriate to reduce the inflammation quickly. Since cortisone takes 3 to 7 days to work, and the acute aspect of the gout attack may naturally be over by then, it takes some sixth sense to know who should have the joint aspirated. Ask anyone with an acute gout attack and they will say that the injection was somewhat draconian!!

The blood level goal has always been 6mg/dl, but to accomplish that your primary care doctor is normally reluctant to place you on kidney eliminating drugs for the rest of your life like Allopurinol. So, most doctors prefer to counsel their patients on hydration (the more dehydrated you are, the higher the concentration of everything goes in the blood stream including uric acid), exercise for weight reduction, sensible dieting,  and medications to possibly change.

    To summarize: the top 10 initial treatments for gout are:

  1. Begin a series of 3 uric acid levels.
  2. Rule out infection with history, evaluation of area, and blood work up.
  3. Immobilize the joint involved.
  4. Ice the involved area 3-5 times daily with various forms of cooling.
  5. Begin using an oral anti-inflammatory medication like indomethacin or ibuprofen.
  6. In very severe cases, or if symptoms are not calming down quickly, consider an oral Prednisone Burst, or cortisone injection into the joint. To use cortisone you must be sure that you are not dealing with an infection.
  7. Hydrate well (4-8 glasses of 8 oz water daily).
  8. Understand what foods to avoid.
  9. Discuss the possible role of any new medications started before.
  10. Discuss overall health and weight loss/gain situation.

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.