Gout Questions
Arthritis Today Medical Experts Answer Your Questions About Gout
One of the most popular features in Arthritis Today, "On Call" finds answers to your most puzzling arthritis questions by asking a variety of healthcare experts. Just click on the question or title you'd like to see.
Is It RA or Gout?
A New Gout Therapy?
Pseudogout Defined
Can Fasting Cause Gout?
Safety of Fish Oil Supplements in Gout
Whey Protein Supplements in Gout
A: Gout is a condition caused by an excess of uric acid crystals depositing in tissues of the body. This excess can lead to the formation of uric acid crystals in and around the joints, causing pain and inflammation.
Is It RA or Gout?
Q: I am a 50-year-old man recently diagnosed with rheumatoid arthritis (RA). But based on some previous, isolated joint problems, I suspect I have had RA for some time. Two years ago, after a day of vigorous exercise, I experienced swelling and excruciating pain in my left toe, which lasted a few days. Then, while recuperating from a heart attack last year, I had a similar problem in the opposite foot and knee. My doctor suspected an infection and prescribed antibiotics, which seemed to clear up the problem. Three months later, though, the problem returned in the same knee. It soon went away, but later returned in both feet and knees and now my wrists. Do you think these incidents were early signs of RA?
A: I definitely think these events are related, but they probably were not due to RA. It sounds to me like you have gouty arthritis, or gout, an inflammatory disease that occurs when excess uric acid (a bodily waste product) circulating in the bloodstream is deposited as sodium urate crystals in certain joints. The excess uric acid may be caused by genetic factors or kidney disease. The condition may be aggravated by certain drugs such as diuretics and low doses of aspirin or by consuming too much alcohol or foods rich in purines, which are broken down into uric acid.
If your physician didn't know about your previous problems, it's not surprising that he diagnosed your condition as RA, probably without even suspecting gout. In its later stages gout can look a lot like RA, causing pain and inflammation in multiple joints. In some cases, untreated gout can be associated with a positive rheumatoid factor, an antibody often detected in the blood of people with rheumatoid arthritis. And build-ups of sodium urate can form lumps under the skin that resemble the nodules that are fairly common in RA.
But that's pretty much where the similarity ends. The causes and treatments are entirely different. Unlike gouty arthritis, RA is caused by an abnormality of immune function that causes the immune system to attack the membrane lining the joints. RA may begin acutely in many joints or may start gradually, involving several joints and progressing. Initially, the involved joints are the knuckles, middle joints of the fingers, wrists, and joints that attach the toes to the feet.
Gout, on the other hand, often starts as your problem did -- with excruciating pain and swelling in the big toe -- and often follows a trauma such as an illness or injury. Subsequent attacks may occur off and on in other joints -- primarily those of the foot and knee -- before becoming chronic. In its chronic stage, gout can affect many joints, including those of the hands. But this can take a few years to happen.
Unlike rheumatoid arthritis, gout is a well-understood and highly treatable disease -- and it has been for almost three decades. Medications are available to stabilize uric acid levels and relieve acute pain and inflammation. With appropriate treatment gout can be controlled and future attacks can be prevented. The biggest obstacles in controlling gout are improper diagnosis and noncompliance. If a doctor doesn't diagnose it properly, he cannot treat it properly. Like some other forms of arthritis, gout requires a medical regimen all its own. Taking the proper medications and taking them faithfully -- even during periods that you feel absolutely fine -- is essential to controlling gout. Maintaining a reasonable weight and limiting alcohol consumption can help control gout as well.
If you haven't already had a joint fluid sample examined for urate crystals, I would recommend that you speak to your doctor about having one at your next visit. Or if the medication he has prescribed for your RA (and I assume he has prescribed one or more) doesn't seem to be helping, schedule a visit sooner. If, in fact, you have gout, the sooner you know and begin proper treatment, the sooner you will experience relief.
Doyt Conn, MD, Rheumatologist
Back to Top
A New Gout Therapy?
Q: I have had gout for more than 15 years with consistently high uric acid levels. Recently, however, I began taking 2 mg of folic acid daily, and I have since had two blood tests showing normal uric acid levels. What is the recent research concerning folic acid and gout?
A: High uric acid levels -- due either to excess production of uric acid or to abnormally low excretion of this waste product in the urine -- are the cause of gout. In recent years there have been a few studies examining the effect of folic acid on uric acid production and excretion. These studies have shown that folic acid has no effect on uric acid levels. It is interesting that in your case folic acid appears to have lowered uric acid, but appears may be the key word here. Is it possible that you have made other changes that might have affected your uric acid level, such as switching medications for another health problem? I am glad your uric acid levels have stabilized, for whatever reason. For the moment, I cannot recommend folic acid as a therapy for patients with gout, but it does appear that the issue should be studied further.
Jeffrey N. Katz, MD, MS, Rheumatologist
Back to Top
Pseudogout Defined
Q: I hear and read a lot about gout, but I have been diagnosed with pseudogout. Can you please tell me what this is and how it is treated?
A: Pseudogout often resembles gout and, like gout, is caused by the formation of crystals in the joints, thus the name. But instead of being composed of uric acid, as true gout crystals are, the crystals in pseudogout are composed of a salt called calcium pyrophosophate dihydrate (CPPD). The condition is also called CPPD disease. Pseudogout is the most frequent cause of acute arthritis in one joint among older people. Although any joint may be involved, the knee is most commonly affected. A typical attack begins rapidly with severe pain, redness and swelling of the affected joint or joints. The attacks often resolve within a few weeks whether treated or not.
To limit pain and swelling, your doctor may prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) or remove fluid from the infected joint and inject it with a glucocorticoid compound.
Unfortunately, recurrent attacks of pseudogout are not uncommon. Chronic attacks are likely to affect several joints at once, most commonly the wrists, fingers and knees. Like gout, pseudogout primarily involves the body's metabolism (for instance, a problem with iron or calcium metabolism) rather than the immune system. However, there is no specific therapy for the underlying metabolic disorder.
Bernard Rubin, DO, Rheumatologist
Back to Top
Can Fasting Cause Gout
Q: I have read that fasting can lead to gout. Is this true? If so, why?
A: Yes, fasting can cause gout - if fasting causes you to become dehydrated, which raises the level of uric acid in your blood. In fact, high blood levels of uric acid are the single most important factor in determining the risk of a gout attack. A form of arthritis that primarily affects middle aged men, gout is associated with obesity, heavy alcohol intake, hypertension, decreased kidney function and diuretic use. Acute gout is caused by uric acid crystals in the joint, which trigger inflammation and cause severe pain and swelling of the joint. If this condition is not treated effectively, inflammation can smolder in a number of joints and eventually cause joint damage.
Bernard Rubin, DO, Rheumatologist
Back to Top
Safety of Fish Oil Supplements in Gout
Q: A doctor advised me to take fish oil supplements to improve my cholesterol level. But the source of fish oil in many preparations includes sardines, trout and herring – fish that are high in purines and on the list of foods I should avoid because I have gout. How much purine is in fish oil supplements? Should I take them or not?
A: Purines are found in the meat of the fish but not in highly purified, molecularly distilled fish oil, so it should not affect your gout. I recommend everyone consume at least 2,000 milligrams (mg) per day of EPA and DHA (two fatty acids in fish oil crucial to human health). Those with autoimmune disorders and arthritis should consume 3,000 to 6,000 mg in divided doses with meals.
Buy only pharmaceutical-grade, molecularly distilled fish oil supplements. And go to the supplement company’s Web site and make sure you research what you’re getting. Also, know that using fish oil supplements to bring down your cholesterol level may thin your blood. If you have any bleeding disorders or already are taking medications to thin your blood, such as clopidogrel (Plavix) or warfarin (Coumadin), please talk to your doctor.
James McKoy, MD, Rheumatologist
Whey Protein Supplements and Gout
Q: Is it safe for someone with gout to take whey protein supplements?
A: Whey protein supplements are popular among athletes and bodybuilders because the supplements often are marketed as a means of building and maintaining muscle following workouts during which amino acids are depleted.
Whey proteins are a mixture of proteins that can be isolated from whey, a by-product of cheese making. Whey proteins are considered complete proteins – that is, they include all the essential amino acids.
Gout is a form of arthritis stemming from an inborn error in the metabolism of the bodily waste product uric acid. Excess uric acid circulating in the blood seeps out and forms crystals in and around the joints. Historically, gout has been associated with a number of factors, including the consumption of a “rich” diet and the presence of a high level of purines. Purines, like proteins, include nitrogen and ultimately are excreted by the kidney as uric acid.
Whey proteins may not be linked directly with gout. However, people with gout should exercise caution before increasing the protein load from whey. The burden on the kidneys to excrete or clear the whey products might become excessive, especially if the kidneys already are compromised.
When deciding whether to use nutritional supplements, including whey protein supplements, discuss the pros and cons with your doctor. He or she will have the information needed about your kidney status, is familiar with the medications you are taking to treat gout and can evaluate your muscle status.
Mary Fran Sowers, PhD, RD, Registered Dietitian and Epidemiologist
Safe Foods for Gout
Q: I have gout and have heard that alcohol and some foods can aggravate the condition. Can you tell me which fruits, vegetables, meats or seafoods I should eat - or avoid? Is there any type of alcohol - wine, beer, spirits - that is better or worse for me than the others?
A: Because dietary management of gout is so restrictive and of limited benefit, medication is the best way to treat gout. In addition to medications that treat the inflammation and other symptoms that occur during a gout attack, medications exist that can treat the underlying metabolic condition of hyperuricemia - too much uric acid in the blood. Hyperuricemia can occur either when the body produces too much uric acid or when the body does not excrete enough uric acid. Drugs exist to treat both causes of hyperuricemia.
Purine compounds produce uric acid crystals, which then build up in soft tissues and joints, causing the painful symptoms of gout. Dietary management focuses on reducing the amount of uric acid in the system, and managing the disorders that occur frequently among patients with gout, including diabetes mellitus, obesity, hyperlipidemia (high blood levels of fats), hypertension and atherosclerosis (hardening of the arteries).
The primary dietary modification traditionally recommended is a low-purine diet. Avoiding purines completely is impossible, but strive to limit them. People with gout should learn by trial and error what their personal limit is and which foods cause problems.
Laura Rall, PhD, nutrition researcher at Tufts University in Boston, says, "Begin by eliminating foods in the 'high-purine' category, while reducing your intake of foods in the 'moderate-purine' category. If you don't have gout attacks after trying this, you may add more foods from the 'moderate' category, or occasionally try a food from the 'high' category. Using these guidelines, you may be able to determine a safe level of purine consumption and enjoy some of your favorite foods without experiencing attacks."
Foods considered high in purine content include:
* Alcoholic beverages (all types).
* Some fish, seafood and shellfish, including anchovies, sardines, herring, mussels, codfish, scallops, trout and haddock.
* Some meats, such as bacon, turkey, veal, venison and organ meats like liver.
Foods considered moderate in purine content include:
* Meats such as beef, chicken, duck, pork and ham.
* Crab, lobster, oysters and shrimp.
* Vegetables and beans such as asparagus, kidney beans, lentils, lima beans, mushrooms and spinach.
RONENN ROUBENOFF, MD
Rheumatologist
