“My father is in his early 70s and recently moved in with me because he didn’t want to live alone due to a recent fall. He has gout and seems to be having a really bad flare-up. I want to help him get this under control, but I don’t know anything about gout.My father is a very proud man and says he can do it all by himself. You won’t let me be at your appointment. What exactly is gout? Are there lifestyle modifications I can implement at home to prevent attacks (along with taking prescription medications, of course)?
Answer from Dr Colm Kirby, Consultant Rheumatologist at Beacon Hospital
Gout is the most common form of acute joint inflammation and is caused by crystal deposits within the joints. The origin of the term “gout” comes from the Latin word “gutta”, meaning “drop”. Approximately 6% of men and 2% of women are affected. Due to hormonal factors, older men and postmenopausal women are most often affected.
The crystals that cause gout attacks form and are deposited when blood levels of uric acid increase beyond insolubility (>360 μmol/L). In other species, uric acid is metabolized to more soluble compounds that do not result in crystal formation, but humans do not have the enzyme to carry out this process. As uric acid levels rise, the risk of gout attacks also increases.
Elevated uric acid can occur due to overproduction or insufficient excretion by the kidneys. Overproduction of uric acid is usually caused by excessive intake of dietary purines, alcohol, and fructose. Certain foods and drinks to avoid include those high in fructose (fruit juices, sugary drinks, energy drinks), beer, red meat, shellfish, and seafood such as sardines and anchovies. Poor excretion in gout is usually caused by chronic kidney disease and certain medications, such as diuretics, commonly called “water tablets.”
Fortunately, there are highly effective drugs available to lower uric acid, so-called uric acid-lowering therapy (ULT). These drugs work by inhibiting the production of uric acid, lowering its concentration to the point where it can dissolve in the blood again and crystals no longer form. The magic number to aim for is a uric acid concentration <360 µmol/L, but a more aggressive strategy targeting levels <300 is recommended for patients with frequent flare-ups.
A major challenge in the treatment of gout is the paradoxical risk that ULT causes gout flare-ups. As these drugs take effect and begin to reduce uric acid levels, previously formed clumps of crystals begin to dissolve and travel through the bloodstream, often depositing in joints elsewhere and It causes acute, painful gout attacks. This risk exists for approximately 6 months after starting ULT. This makes patients generally reluctant to take ULT and gout is never optimally treated.
To overcome this, whenever you start ULT, make sure your doctor also starts the treatments normally prescribed for acute attacks of gout. This drug must be used in conjunction with an ULT drug for 6 months. After this 6-month period, use can be discontinued and ULT is safe to use on its own.
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