GOUT
‘Disease of Kings’ Trickles Down to the Rest
By Jane E. Brody : NY Times : May 09, 2011
A 55-year-old neighbor of mine was awakened in the wee hours of the morning recently with an excruciating pain in his right big toe that rendered him unable to walk. As happens in a classic attack of gout, the onset was sudden and the affected joint red and swollen.
Long regarded as a “disease of kings” for its association with a diet rich in meats and alcohol, gout in modern times has become a decidedly more plebeian disorder. More than six million adults in the United States have had it, and the numbers are rising steadily as the population ages, becomes heavier and is exposed to foods and other substances that can precipitate the disorder in susceptible people.
And while historically gout has been a male disease (three-fourths of cases occur in men), the incidence has been rising in older women, with as many as one in 20 over age 70 now afflicted.
Fortunately for my neighbor, the fiery pain in his toe subsided in a few days, and while he has no idea what brought on the attack, he said he’s now “eating more healthfully.” Unfortunately, although some people never experience a second attack, others can suffer recurrences several times a year.
Gout Causes and Risks
Recurrent attacks are more likely if the underlying cause of gout is not treated. That cause is a high blood level of uric acid that forms irritating urate crystals that lodge in joints or soft tissues, causing intense pain.
Uric acid is produced when the body metabolizes purines, common components of many foods, especially organ meats, anchovies, herring, asparagus and mushrooms. Other dietary contributors include excessive consumption of alcohol and possibly soft drinks containing fructose.
A study published in November in The Journal of the American Medical Association linked an increased intake of sugar-sweetened soda to a raised risk of gout in women, who until menopause are relatively protected against the disease by estrogen, which helps the body excrete uric acid.
Elevated levels of uric acid can result either from the body’s overproduction of the substance or, more commonly, from an inability of the kidneys to excrete it adequately. Dr. Tuhina Neogi, a rheumatologist at the Boston University School of Medicine, explained that humans lack the enzyme uricase, present in most other animals, and thus are unable to convert urate into allantoin, the soluble end-product of purine metabolism.
Dr. Neogi noted recently in The New England Journal of Medicine that simply having a high level of uric acid is not, by itself, enough to cause gout. “Other factors play a contributing role,” she said in an interview.
As sometimes happens, the treatment of one disease can cause another. Among the medications linked to an increase risk of developing gout are thiazide diuretics, the first line of drug treatment for high blood pressure; cyclosporine, an immunosuppressant drug used to prevent organ rejection in transplant patients; and low-dose aspirin, commonly taken to reduce the risk of heart attack and stroke. (On the other hand, aspirin in high doses — three or more grams a day — protects against gout by increasing uric acid excretion, Dr. Neogi wrote.
Even drugs used to lower uric acid levels long-term can initially provoke an attack of gout, presumably by mobilizing body stores of urate, she said.
The risk of gout is also higher among people with disorders that are increasingly common in modern society, including hypertension, diabetes, high cholesterol, atherosclerosis and congestive heart failure. Obesity and the so-called metabolic syndrome, which includes insulin resistance, are other common factors that can make an attack of gout more likely.
People with a family history of gout also are at greater risk of developing it. Several genes have been linked to the disease.
Diagnosis and Treatment
Dr. Neogi noted that people vary in their response to uric acid. High blood levels are not always present during an attack of gout, she said, and some people with high levels never develop the disease.
Although symptoms are usually quite characteristic — rapid development of severe pain, redness and swelling, most often in the first joint of the big toe — a more certain diagnosis requires detection of urate crystals in an inflamed joint during an attack or between attacks. As this involves drawing fluid from the affected joint, it is not often done in routine medical practice, she said.
Sometimes in older people, especially women, multiple joints can be involved, leading to a mistaken diagnosis of rheumatoid arthritis.
If gout is untreated and the disease becomes advanced, deposits of urate crystals may form into nodules called tophi beneath the skin. While usually not painful, tophi can become swollen and tender during flare-ups of gout. Urate deposits may also cause kidney stones.
Treatment necessarily begins with lifestyle modifications, especially dietary changes to limit the intake of purines, which means avoiding organ meats and consuming other meats, poultry and seafood in limited amounts (a mere four to six ounces a day). Better to rely more on low-fat dairy, eggs and vegetarian sources of protein like tofu and nut butters.
In the beverage department, alcohol is best avoided (or limited to one drink a day, if that) and sugary soft drinks avoided altogether. They are nothing more than empty calories. Diet soda, however, is not a problem, at least not with regard to gout.
Caffeine appears to be protective; routine high intake of coffee (and perhaps also tea) can lower uric acid levels. Patients have also reported that cherry juice (or eating cherries or other dark-colored fruits, like purple grapes and blueberries) may be protective and prevent recurrences.
It is most helpful to drink lots of water throughout the day — one to two liters, plus another one to two liters of other liquids — to limit the buildup of urate and keep kidneys flushed.
In terms of medication, my neighbor did the right thing when his gout attack occurred. He took a hefty dose (800 milligrams) of ibuprofen, an over-the-counter nonsteroidal anti-inflammatory drug (Advil and Motrin are common brand names), to reduce the pain and inflammation in his affected joint.
Had he seen a doctor, he might have been prescribed colchicine, which is most effective if taken soon after gout symptoms develop. Unfortunately, this medication can cause side effects, like nausea, vomiting and diarrhea, that limit its usefulness.
If neither of these medications can be used, a corticosteroid like prednisone may be taken orally or injected into the affected joint to reduce pain and inflammation.
Patients who experience frequent attacks may require continuing treatment with urate-lowering drugs called xanthine oxidase inhibitors, like allopurinol and febuxostat, which reduce the amount of uric acid the body produces. Another drug, probenecid, helps the kidneys excrete uric acid.
By Jane E. Brody : NY Times : May 09, 2011
A 55-year-old neighbor of mine was awakened in the wee hours of the morning recently with an excruciating pain in his right big toe that rendered him unable to walk. As happens in a classic attack of gout, the onset was sudden and the affected joint red and swollen.
Long regarded as a “disease of kings” for its association with a diet rich in meats and alcohol, gout in modern times has become a decidedly more plebeian disorder. More than six million adults in the United States have had it, and the numbers are rising steadily as the population ages, becomes heavier and is exposed to foods and other substances that can precipitate the disorder in susceptible people.
And while historically gout has been a male disease (three-fourths of cases occur in men), the incidence has been rising in older women, with as many as one in 20 over age 70 now afflicted.
Fortunately for my neighbor, the fiery pain in his toe subsided in a few days, and while he has no idea what brought on the attack, he said he’s now “eating more healthfully.” Unfortunately, although some people never experience a second attack, others can suffer recurrences several times a year.
Gout Causes and Risks
Recurrent attacks are more likely if the underlying cause of gout is not treated. That cause is a high blood level of uric acid that forms irritating urate crystals that lodge in joints or soft tissues, causing intense pain.
Uric acid is produced when the body metabolizes purines, common components of many foods, especially organ meats, anchovies, herring, asparagus and mushrooms. Other dietary contributors include excessive consumption of alcohol and possibly soft drinks containing fructose.
A study published in November in The Journal of the American Medical Association linked an increased intake of sugar-sweetened soda to a raised risk of gout in women, who until menopause are relatively protected against the disease by estrogen, which helps the body excrete uric acid.
Elevated levels of uric acid can result either from the body’s overproduction of the substance or, more commonly, from an inability of the kidneys to excrete it adequately. Dr. Tuhina Neogi, a rheumatologist at the Boston University School of Medicine, explained that humans lack the enzyme uricase, present in most other animals, and thus are unable to convert urate into allantoin, the soluble end-product of purine metabolism.
Dr. Neogi noted recently in The New England Journal of Medicine that simply having a high level of uric acid is not, by itself, enough to cause gout. “Other factors play a contributing role,” she said in an interview.
As sometimes happens, the treatment of one disease can cause another. Among the medications linked to an increase risk of developing gout are thiazide diuretics, the first line of drug treatment for high blood pressure; cyclosporine, an immunosuppressant drug used to prevent organ rejection in transplant patients; and low-dose aspirin, commonly taken to reduce the risk of heart attack and stroke. (On the other hand, aspirin in high doses — three or more grams a day — protects against gout by increasing uric acid excretion, Dr. Neogi wrote.
Even drugs used to lower uric acid levels long-term can initially provoke an attack of gout, presumably by mobilizing body stores of urate, she said.
The risk of gout is also higher among people with disorders that are increasingly common in modern society, including hypertension, diabetes, high cholesterol, atherosclerosis and congestive heart failure. Obesity and the so-called metabolic syndrome, which includes insulin resistance, are other common factors that can make an attack of gout more likely.
People with a family history of gout also are at greater risk of developing it. Several genes have been linked to the disease.
Diagnosis and Treatment
Dr. Neogi noted that people vary in their response to uric acid. High blood levels are not always present during an attack of gout, she said, and some people with high levels never develop the disease.
Although symptoms are usually quite characteristic — rapid development of severe pain, redness and swelling, most often in the first joint of the big toe — a more certain diagnosis requires detection of urate crystals in an inflamed joint during an attack or between attacks. As this involves drawing fluid from the affected joint, it is not often done in routine medical practice, she said.
Sometimes in older people, especially women, multiple joints can be involved, leading to a mistaken diagnosis of rheumatoid arthritis.
If gout is untreated and the disease becomes advanced, deposits of urate crystals may form into nodules called tophi beneath the skin. While usually not painful, tophi can become swollen and tender during flare-ups of gout. Urate deposits may also cause kidney stones.
Treatment necessarily begins with lifestyle modifications, especially dietary changes to limit the intake of purines, which means avoiding organ meats and consuming other meats, poultry and seafood in limited amounts (a mere four to six ounces a day). Better to rely more on low-fat dairy, eggs and vegetarian sources of protein like tofu and nut butters.
In the beverage department, alcohol is best avoided (or limited to one drink a day, if that) and sugary soft drinks avoided altogether. They are nothing more than empty calories. Diet soda, however, is not a problem, at least not with regard to gout.
Caffeine appears to be protective; routine high intake of coffee (and perhaps also tea) can lower uric acid levels. Patients have also reported that cherry juice (or eating cherries or other dark-colored fruits, like purple grapes and blueberries) may be protective and prevent recurrences.
It is most helpful to drink lots of water throughout the day — one to two liters, plus another one to two liters of other liquids — to limit the buildup of urate and keep kidneys flushed.
In terms of medication, my neighbor did the right thing when his gout attack occurred. He took a hefty dose (800 milligrams) of ibuprofen, an over-the-counter nonsteroidal anti-inflammatory drug (Advil and Motrin are common brand names), to reduce the pain and inflammation in his affected joint.
Had he seen a doctor, he might have been prescribed colchicine, which is most effective if taken soon after gout symptoms develop. Unfortunately, this medication can cause side effects, like nausea, vomiting and diarrhea, that limit its usefulness.
If neither of these medications can be used, a corticosteroid like prednisone may be taken orally or injected into the affected joint to reduce pain and inflammation.
Patients who experience frequent attacks may require continuing treatment with urate-lowering drugs called xanthine oxidase inhibitors, like allopurinol and febuxostat, which reduce the amount of uric acid the body produces. Another drug, probenecid, helps the kidneys excrete uric acid.
Gout Overview
Gout is a kind of arthritis that occurs when uric acid builds up in the joints.
Gouty arthritis - acute; Gout - acute; Hyperuricemia; Tophaceous gout; Tophi; Podagra; Gout - chronic; Chronic gout; Acute gout; Acute gouty arthritis
Causes:
Gout is caused by having higher-than-normal levels of uric acid in your body. Your body may make too much uric acid, or have a hard time getting rid of uric acid. If too much uric acid builds up in the fluid around the joints (synovial fluid), uric acid crystals form. These crystals cause the joint to swell up and become inflamed.
Not everyone with high uric acid levels in the blood has gout.
The exact cause is unknown. Gout may run in families. It is more common in males, postmenopausal women, and people who drink alcohol. People who take certain medicines, such as hydrochlorothiazide and other water pills, may have higher levels of uric acid in the blood.
The condition may also develop in people with:
Symptoms »
Symptoms of acute gouty attacks:
Some people may develop chronic gouty arthritis, but others may have no further attacks. Those with chronic arthritis develop joint deformities and loss of motion in the joints. They will have joint pain and other symptoms most of the time.
Tophi are lumps below the skin around joints or in other places. They may drain chalky material. Tophi usually develop only after a patient has had the disease for many years.
After one gouty attack, more than half of people will have another attack.
Exams and Tests »
Tests that may be done include:
Treatments for a sudden attack or flare-up of gout:
Your doctor may prescribe these medicines if:
Some diet and lifestyle changes may help prevent gouty attacks:
Outlook (Prognosis):
Proper treatment of acute attacks allows people to live a normal life. However, the acute form of the disease may progress to chronic gout.
Possible Complications
When to Contact a Medical Professional:
Call for an appointment with your health care provider if you have symptoms of acute gouty arthritis.
Prevention:
The disorder itself may not be preventable, but you may be able to avoid things that trigger your symptoms. Limit alcohol consumption and follow a low-purine diet.
Gout is a kind of arthritis that occurs when uric acid builds up in the joints.
- Acute gout is a painful condition that typically affects one joint.
- Chronic gout is repeated episodes of pain and inflammation, which may involve more than one joint.
Gouty arthritis - acute; Gout - acute; Hyperuricemia; Tophaceous gout; Tophi; Podagra; Gout - chronic; Chronic gout; Acute gout; Acute gouty arthritis
Causes:
Gout is caused by having higher-than-normal levels of uric acid in your body. Your body may make too much uric acid, or have a hard time getting rid of uric acid. If too much uric acid builds up in the fluid around the joints (synovial fluid), uric acid crystals form. These crystals cause the joint to swell up and become inflamed.
Not everyone with high uric acid levels in the blood has gout.
The exact cause is unknown. Gout may run in families. It is more common in males, postmenopausal women, and people who drink alcohol. People who take certain medicines, such as hydrochlorothiazide and other water pills, may have higher levels of uric acid in the blood.
The condition may also develop in people with:
- Diabetes
- Kidney disease
- Obesity
- Sickle cell anemia and other hemolytic anemias
- Leukemia and similar types of disorders
Symptoms »
Symptoms of acute gouty attacks:
- Symptoms develop suddenly and usually involve only one or a few joints. The big toe, knee, or ankle joints are most often affected.
- The pain frequently starts during the night and is often described as throbbing, crushing, or excruciating.
- The joint appears warm and red. It is usually very tender (it hurts to lay a sheet or blanket over it).
- There may be a fever.
- The attack may go away in several days, but may return from time to time. Additional attacks usually last longer.
Some people may develop chronic gouty arthritis, but others may have no further attacks. Those with chronic arthritis develop joint deformities and loss of motion in the joints. They will have joint pain and other symptoms most of the time.
Tophi are lumps below the skin around joints or in other places. They may drain chalky material. Tophi usually develop only after a patient has had the disease for many years.
After one gouty attack, more than half of people will have another attack.
Exams and Tests »
Tests that may be done include:
- Synovial fluid analysis (shows uric acid crystals)
- Uric acid - blood
- Joint x-rays (may be normal)
- Synovial biopsy
- Uric acid - urine
Treatments for a sudden attack or flare-up of gout:
- Your doctor will recommend that you take nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, or indomethacin as soon as your symptoms begin. You will need to take prescription-strength medicines for 4 - 10 days.
- Your health care provider may occasionally prescribe strong painkillers such as codeine, hydrocodone, and oxycodone.
- A prescription medicine called colchicine helps reduce pain, swelling, and inflammation.
- Corticosteroids can also be very effective. Your doctor may inject the inflamed joint with steroids to relieve the pain.
- The pain often goes away within 12 hours of starting treatment, and is completely relieved in 48 hours.
Your doctor may prescribe these medicines if:
- You have several attacks during the same year
- You have signs of gouty arthritis
- You have uric acid kidney stones
Some diet and lifestyle changes may help prevent gouty attacks:
- Avoid: alcohol, anchovies, sardines, oils, herring, organ meat (liver, kidney, and sweetbreads), legumes (dried beans and peas), gravies, mushrooms, spinach, asparagus, cauliflower, consommé, and baking or brewer's yeast.
- Limit how much meat you eat at each meal.
- Avoid fatty foods such as salad dressings, ice cream, and fried foods.
- Eat enough carbohydrates.
- If you are losing weight, lose it slowly. Quick weight loss may cause uric acid kidney stones to form.
Outlook (Prognosis):
Proper treatment of acute attacks allows people to live a normal life. However, the acute form of the disease may progress to chronic gout.
Possible Complications
- Chronic gouty arthritis
- Kidney stones
- Deposits in the kidneys, leading to chronic kidney failure
When to Contact a Medical Professional:
Call for an appointment with your health care provider if you have symptoms of acute gouty arthritis.
Prevention:
The disorder itself may not be preventable, but you may be able to avoid things that trigger your symptoms. Limit alcohol consumption and follow a low-purine diet.
Gout
Once called ‘the disease of kings,’ it can hit anyone — and it’s on the rise
Kay Lazar : Boston Globe : August 29, 2011
The sudden pain in Greg Hannoosh’s left big toe was so intense one night he thought his entire foot was going to “blow up.’’
The West Newbury public relations executive hung on until morning, then hobbled in to see his doctor, who took one look at Hannoosh’s swollen, angry foot and concluded that the 41-year-old had gout.
“I didn’t even know what that was,’’ recalled Hannoosh, now 51. “I thought it was an old man’s disease.’’
Gout, long known as “the disease of kings’’ or “rich man’s disease,’’ is a form of arthritis, first identified centuries ago, that is becoming more common as Americans age and pile on the pounds, say researchers and health care providers.
Over the past two decades, the prevalence has risen from an estimated 2.7 percent of the population to 3.9 percent in 2008, and is estimated to affect more than 8 million Americans, according to a study published last month in the journal Arthritis & Rheumatism.
Along with the increase has appeared a crop of new gout medications; federal regulators have approved three new drugs since 2009. They are the first new gout medications after a 40-year drought, and come with a flurry of recent advertisements from pharmaceutical companies touting them.
The promotions have raised questions among health care providers about whether the new therapies, which can be significantly more expensive, are any better than the conventional ones at treating the age-old disease.
“If you convince a lot of people that there is this terrible disease lurking, then it is hard for Americans not to say, ‘Gee, that new medicine sounds good to me,’ ’’ said Dr. Nortin M. Hadler, an arthritis specialist and professor at the University of North Carolina School of Medicine.
Hadler said that in his experience, the new drugs don’t seem to be more effective than those that have been on the market for decades. A self-described skeptic, Hadler has written extensively about aging and what he calls a growing trend in the medical industry to overuse tests and medications to treat patients.
Yet on some basic points about the disease, Hadler and other specialists agree: People who are overweight, have high blood pressure, take diuretics - a common medication for high blood pressure - and have a diet rich in meat and beer are more prone to gout attacks. (Overindulgence in rich food and drink is what earned gout the reputation as a “rich man’s’’ or “king’s’’ disease - King Henry VIII being one of its most prominent representatives.)
Working from that list, Hannoosh was the perfect gout candidate. While he isn’t overweight, Hannoosh has had high blood pressure since his late 20s, had long been on diuretics, and was a big beef-and-beer guy.
“Beer and beef are bad news for me,’’ said Hannoosh, who has struggled to stay away from the stuff.
Gender and age also play a role. Middle-aged men are the typical gout patient, but women start to catch up after menopause, when they gradually lose female hormones that help the body excrete uric acid, a substance produced by the body during digestion.
The disease is caused by a buildup in the blood of uric acid. If the acid levels become too high, crystals may form and trigger an acutely red, hot, and swollen joint - usually starting in a person’s big toe - and excruciating pain.
“Typically it hits you in the middle of the night, and it is so painful, you can’t put the weight of a bed sheet on it,’’ said Dr. Hyon K. Choi, a professor at Boston University School of Medicine and an arthritis specialist who treats patients - including Hannoosh - at Boston Medical Center.
Choi is the lead author of the recent study that analyzed government data to show the increase in gout. It was funded by a company that makes Uloric, a new gout treatment that competes with the generic allopurinol, which has been on the market for decades. Both drugs are designed to lower a patient’s uric acid levels.
Before the new batch of medications hit the market, one of the most common treatments for chronic gout attacks was colchicine, a plant-based therapy that has been used since ancient times and had been available as a generic prescription for more than a century.
When the US Food and Drug Administration in July 2009 approved a new formulation of colchicine, called Colcrys, it gave the manufacturer three years of market exclusivity under rules that encourage compliance with the FDA’s drug-approval process.
The various makers of the older, generic formulation of colchicine were shut out because their products had never been approved by the FDA; they predated agency rules that required such a review but had, until that 2009 action, been allowed to remain on the market.
Dr. Aaron S. Kesselheim, an assistant professor at Harvard Medical School and internist at Brigham and Women’s Hospital, said that since the FDA’s action, some of his patients can’t afford the new drug because their insurance coverage requires them to pay much more for the treatment.
“The same patients didn’t have that issue before, because colchicine was considered a generic drug and was available relatively cheaply,’’ Kesselheim said.
In an article he wrote in the New England Journal of Medicine last year, Kesselheim noted that the price of the new colchicine treatment, compared with the generic, went up by a factor of more than 50, from 9 cents per pill to $4.85.
“It’s really a difficult situation for patients,’’ said Harvard Vanguard family physician Eliza Shulman, who said some patients in her Braintree practice turn to Canada, where the generic medication is still available.
Shulman and other physicians said that despite the new medications, they usually prescribe widely available drugs such as Naproxen or ibuprofen to ease the pain for first-time gout sufferers.
The longer-term strategy, Shulman said, is to help patients lower their uric acid levels to prevent another gout attack.
“We always try to start with nonpharmacologic treatment first, working on the risk factors we can modify,’’ Shulman said. “There are quite a few lifestyle modifications to lower their risk - the big ones are diet and alcohol intake.’’
It’s a hard-learned lesson for Hannoosh, who thought he was a one-and-you’re-done gout sufferer after his first attack in 2001, and had no recurrence for years. He went back to his old beer and beef habits.
“I forgot I ever had gout,’’ he said. “And then all of a sudden, in the fall of 2009, I woke up one night and had the worst attack I ever had. My foot was killing me.’’
That was followed by three more attacks. Today, Hannoosh takes a generic allopurinol medication to keep his uric acid levels in check, eats very little beef, and has sworn off beer.
“I was at a [Red Sox] game at Fenway recently and it killed me not to have beer,’’ he said. “I have a glass or two of wine at the game, but it doesn’t feel right.’’
WHERE
Most initial gout flares start in lower extremities - ankles, heels, knees - and typically in the big toe.
WHY
A buildup in the blood of uric acid, a substance produced by the body during digestion, forms crystals in some people that trigger attacks.
WHO
People who are overweight, have high blood pressure, take diuretics (a common medication for high blood pressure), and have a diet rich in certain red meats and beer are more prone to gout attacks.
WHAT
Gout is a type of arthritis that is characterized by red, hot, and swollen joints.
WHEN
Middle-aged men are the typical gout patient, but women start to catch up after menopause, when they gradually lose female hormones that helped their bodies excrete uric acid.
Sources: Centers for Disease Control and Prevention; National Institute of Arthritis and Musculoskeletal and Skin Diseases.
Once called ‘the disease of kings,’ it can hit anyone — and it’s on the rise
Kay Lazar : Boston Globe : August 29, 2011
The sudden pain in Greg Hannoosh’s left big toe was so intense one night he thought his entire foot was going to “blow up.’’
The West Newbury public relations executive hung on until morning, then hobbled in to see his doctor, who took one look at Hannoosh’s swollen, angry foot and concluded that the 41-year-old had gout.
“I didn’t even know what that was,’’ recalled Hannoosh, now 51. “I thought it was an old man’s disease.’’
Gout, long known as “the disease of kings’’ or “rich man’s disease,’’ is a form of arthritis, first identified centuries ago, that is becoming more common as Americans age and pile on the pounds, say researchers and health care providers.
Over the past two decades, the prevalence has risen from an estimated 2.7 percent of the population to 3.9 percent in 2008, and is estimated to affect more than 8 million Americans, according to a study published last month in the journal Arthritis & Rheumatism.
Along with the increase has appeared a crop of new gout medications; federal regulators have approved three new drugs since 2009. They are the first new gout medications after a 40-year drought, and come with a flurry of recent advertisements from pharmaceutical companies touting them.
The promotions have raised questions among health care providers about whether the new therapies, which can be significantly more expensive, are any better than the conventional ones at treating the age-old disease.
“If you convince a lot of people that there is this terrible disease lurking, then it is hard for Americans not to say, ‘Gee, that new medicine sounds good to me,’ ’’ said Dr. Nortin M. Hadler, an arthritis specialist and professor at the University of North Carolina School of Medicine.
Hadler said that in his experience, the new drugs don’t seem to be more effective than those that have been on the market for decades. A self-described skeptic, Hadler has written extensively about aging and what he calls a growing trend in the medical industry to overuse tests and medications to treat patients.
Yet on some basic points about the disease, Hadler and other specialists agree: People who are overweight, have high blood pressure, take diuretics - a common medication for high blood pressure - and have a diet rich in meat and beer are more prone to gout attacks. (Overindulgence in rich food and drink is what earned gout the reputation as a “rich man’s’’ or “king’s’’ disease - King Henry VIII being one of its most prominent representatives.)
Working from that list, Hannoosh was the perfect gout candidate. While he isn’t overweight, Hannoosh has had high blood pressure since his late 20s, had long been on diuretics, and was a big beef-and-beer guy.
“Beer and beef are bad news for me,’’ said Hannoosh, who has struggled to stay away from the stuff.
Gender and age also play a role. Middle-aged men are the typical gout patient, but women start to catch up after menopause, when they gradually lose female hormones that help the body excrete uric acid, a substance produced by the body during digestion.
The disease is caused by a buildup in the blood of uric acid. If the acid levels become too high, crystals may form and trigger an acutely red, hot, and swollen joint - usually starting in a person’s big toe - and excruciating pain.
“Typically it hits you in the middle of the night, and it is so painful, you can’t put the weight of a bed sheet on it,’’ said Dr. Hyon K. Choi, a professor at Boston University School of Medicine and an arthritis specialist who treats patients - including Hannoosh - at Boston Medical Center.
Choi is the lead author of the recent study that analyzed government data to show the increase in gout. It was funded by a company that makes Uloric, a new gout treatment that competes with the generic allopurinol, which has been on the market for decades. Both drugs are designed to lower a patient’s uric acid levels.
Before the new batch of medications hit the market, one of the most common treatments for chronic gout attacks was colchicine, a plant-based therapy that has been used since ancient times and had been available as a generic prescription for more than a century.
When the US Food and Drug Administration in July 2009 approved a new formulation of colchicine, called Colcrys, it gave the manufacturer three years of market exclusivity under rules that encourage compliance with the FDA’s drug-approval process.
The various makers of the older, generic formulation of colchicine were shut out because their products had never been approved by the FDA; they predated agency rules that required such a review but had, until that 2009 action, been allowed to remain on the market.
Dr. Aaron S. Kesselheim, an assistant professor at Harvard Medical School and internist at Brigham and Women’s Hospital, said that since the FDA’s action, some of his patients can’t afford the new drug because their insurance coverage requires them to pay much more for the treatment.
“The same patients didn’t have that issue before, because colchicine was considered a generic drug and was available relatively cheaply,’’ Kesselheim said.
In an article he wrote in the New England Journal of Medicine last year, Kesselheim noted that the price of the new colchicine treatment, compared with the generic, went up by a factor of more than 50, from 9 cents per pill to $4.85.
“It’s really a difficult situation for patients,’’ said Harvard Vanguard family physician Eliza Shulman, who said some patients in her Braintree practice turn to Canada, where the generic medication is still available.
Shulman and other physicians said that despite the new medications, they usually prescribe widely available drugs such as Naproxen or ibuprofen to ease the pain for first-time gout sufferers.
The longer-term strategy, Shulman said, is to help patients lower their uric acid levels to prevent another gout attack.
“We always try to start with nonpharmacologic treatment first, working on the risk factors we can modify,’’ Shulman said. “There are quite a few lifestyle modifications to lower their risk - the big ones are diet and alcohol intake.’’
It’s a hard-learned lesson for Hannoosh, who thought he was a one-and-you’re-done gout sufferer after his first attack in 2001, and had no recurrence for years. He went back to his old beer and beef habits.
“I forgot I ever had gout,’’ he said. “And then all of a sudden, in the fall of 2009, I woke up one night and had the worst attack I ever had. My foot was killing me.’’
That was followed by three more attacks. Today, Hannoosh takes a generic allopurinol medication to keep his uric acid levels in check, eats very little beef, and has sworn off beer.
“I was at a [Red Sox] game at Fenway recently and it killed me not to have beer,’’ he said. “I have a glass or two of wine at the game, but it doesn’t feel right.’’
WHERE
Most initial gout flares start in lower extremities - ankles, heels, knees - and typically in the big toe.
WHY
A buildup in the blood of uric acid, a substance produced by the body during digestion, forms crystals in some people that trigger attacks.
WHO
People who are overweight, have high blood pressure, take diuretics (a common medication for high blood pressure), and have a diet rich in certain red meats and beer are more prone to gout attacks.
WHAT
Gout is a type of arthritis that is characterized by red, hot, and swollen joints.
WHEN
Middle-aged men are the typical gout patient, but women start to catch up after menopause, when they gradually lose female hormones that helped their bodies excrete uric acid.
Sources: Centers for Disease Control and Prevention; National Institute of Arthritis and Musculoskeletal and Skin Diseases.
Gout Guidelines Issued
October 1, 2012
The American College of Rheumatology has published new gout management guidelines in Arthritis Care & Research.
Among the recommendations with the highest levels of evidence for pharmacologic treatment of hyperuricemia:
Among the recommendations for preventing and treating acute gouty arthritis:
Arthritis Care & Research guidelines on hyperuricemia
October 1, 2012
The American College of Rheumatology has published new gout management guidelines in Arthritis Care & Research.
Among the recommendations with the highest levels of evidence for pharmacologic treatment of hyperuricemia:
- Allopurinol or febuxostat (Uloric) should be first-line therapy. If these are contraindicated, probenecid is an alternative.
- Serum urate levels should be targeted to at least <6 mg/dL.
- When the target hasn't been met, treatment should be titrated upward to the maximum appropriate dose (up to 800 mg/day for allopurinol, 120 mg for febuxostat).
- HLA-B*5801 allele testing is recommended for patients at high risk for severe allopurinol sensitivity (e.g., those of Hans Chinese or Thai descent). Patients who test positive may receive an alternative to allopurinol.
Among the recommendations for preventing and treating acute gouty arthritis:
- Monotherapy with NSAIDs, corticosteroids, or oral colchicine is recommended for mild-to-moderate gout attacks.
- Colchicine should be the first-line therapy for attack prophylaxis (with, or just before initiating, urate-lowering therapy).
- Prophylaxis should continue for the greater of: 6 months, 3 months after achieving target urate levels without tophi, or 6 months after achieving target levels with resolution of tophi.
Arthritis Care & Research guidelines on hyperuricemia
