GOUT / SWOLLEN – PAINFUL JOINT
By: Corinne Gehegan, DPM
Gout is a painful, inflammatory condition that occurs about joints with the highest incidence in the foot. The condition results from high levels of uric acid in the body. Uric acid is a by-product produced by the natural break down of purines. Purines are found within the cells of the body as well as in many foods. Uric acid is carried through the blood to the kidneys where it is eliminated in the urine. Gout can occur if the body produces excess uric acid or the kidneys do not eliminate it adequately or efficiently. In these cases the uric acid forms needle like crystals which precipitate from the blood and collect within soft tissue structures or within joint fluid. This collection of crystals is very painful and is associated with redness, swelling, and warmth about the affected area. The pain may be so severe that even the slightest touch can intensify the pain.
Men are more likely to experience gout attacks, but women may be just as susceptible after the onset of menopause. Other risk factors include family history, consumption of alcohol, hypertension (high blood pressure), diabetes, increased cholesterol levels, and arteriosclerosis (narrowing of the arteries). Certain medications may increase the risk of gout. Examples of these medications are thiazide diuretics (water pills), low dose aspirin, and anti-rejection medications for post organ implant patients. Do not discontinue these medications or change their dose/frequency without first discussing this with your doctor.
Gout is most often diagnosed after taking a thorough history in addition to examining the area in question. X-rays may be performed to rule out other conditions that can mimic gout. Some of the conditions that may have similar presentations are infection, acute diabetic Charcot neuroarthropathy, trauma, insect bites, and other types of arthritis. Arthritis due to repeated gout attacks may not be evident on x-ray until several years have passed since the first attack. A blood test may be performed to determine the level of uric acid in the blood; however, the level may be normal even in the midst of a gout attack. On the contrary, some individuals have high levels of uric acid in the blood, but have never experienced a gout attack. Therefore, the test is not reliable. Tophi are deposits of uric acid crystals under the skin. They appear to be nodules and are usually not painful. Typical locations are the ears, elbows and hands.
A gout attack is typically treated with oral medication, particularly anti-inflammatory medication. Within a day or two symptoms should diminish. NSAIDS (non-steroidal anti-inflammatory drugs) are often recommended in either over the counter varieties such as ibuprofen or prescription strength such as indomethicin. Steroids may be indicated and are available in an oral form or by injection. Colchicine effectively blocks the inflammation caused by uric acid crystals and can be used to treat an attack and prevent future attacks. If gout attacks occur several times a year other medications may be prescribed to manage the condition. Allopurinol is an example of a medication that works to lower the production of uric acid. Probenecid is an example of a medication that promotes elimination of uric acid. All of the above classes of medications have side effects as well as the ability to complicate existing health problems. Your doctor can discuss which are optimal for you and your individual case.
Prevention is an important and possible means of managing gout and high levels of uric acid. Below is a guideline for managing gout with diet modification.
High Purine Foods (should be avoided)
Anchovies, Sardines, Scallops, Herring, Mackerel, Liver, Kidneys, Brains, Game meats, Gravy
Moderate-Low Purine Foods (eat in moderation)
Asparagus, Cauliflower, Spinach, Mushrooms, Green peas, Lentils, Beans, Oatmeal, Wheat bran, Wheat germ.
Alcohol, particularly beer, should be avoided.
Water helps to dilute urinary uric acid.
In general, a well balanced diet following the above guidelines and maintaining a healthy body weight will significantly help to prevent gout attacks if you are prone to developing them.
Article written by Dr. Corinne Gehegan
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