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Interviewer: Gout. What causes it, what can you do to prevent it, and what can you do if it's so unbearable and nothing seems to work?
Dr. Tom Miller, I'm going to make a quick confession here. My father had gout. I don't think it was ever anything too bad. He just had some minor flare-ups. But I'm concerned could I get gout because I hear there is a big genetic component to it.
Genetic Predisposition to Gout
Dr. Miller: There is in fact, and you may indeed be predisposed to gout. So the question is, where did your father first have his gout attack?
Interviewer: I don't even remember. Like his feet maybe.
Dr. Miller: You know they used to call it podagra, the big toe. That was where people usually developed gout attacks. In the old days, you'll see pictures of sort of portly men in 17th-century English garb with their feet up on a pedestal. And they have a bright red toe in the painting. And that's classic podagra, that's gouty inflammation of the first toe.
Interviewer: Which interesting side note, I actually did read about that. It was known as a disease of royalty because only the royalty could afford to get a disease like that, that could keep them, you know, not be able to move for two or three days.
Dr. Miller: Right. So gout is essentially an overproduction of uric acid that crystallizes in the joints. The reason that you would sometimes get a higher concentration of uric acid is that you would take in large amounts of protein. So if the wealthy person was on a big meat diet from that hunt that they were just on, and they were portly, to begin with, and they were washing it down with their favorite port, or Bordeaux, that was sort of push them over the limit and they would then develop crystals in their joints. And that would cause intense pain and inflammation, redness, and swelling.
Symptoms and Severity of Gout
Interviewer: Yeah. Not a lot of fun, though. I hear that there are varying levels of pain caused by gout. Do you in the medical community define what those levels are?
Dr. Miller: Well, generally speaking, when someone has an attack, we call an acute attack, gouty attack, it's very painful. What happens is that all of a sudden you have crystals deposited in your joints. And that sets up an inflammatory reaction where you have all the mediators of inflammation focusing in on those crystals to try to eat them, if you will. That causes tremendous pain, redness, and infusion of blood into that area, and it is very painful. And you'll read some of these descriptions about people who have gout, gouty attacks, and they can't even put a sheet over that toe. It's so painful.
Interviewer: Yeah, and it can go to other joints too, right?
Dr. Miller: It is.
Interviewer: Is that the differentiation between somebody who is mildly suffering and really suffering?
Dr. Miller: Right. So someone who has recurrent gout attacks and they don't always have to start in the extremities in the big toe, for instance. They can start in the knees and the other large joints as well. So some people are predisposed to have high uric acid levels and those are the folks who will develop multiple joints with inflammation due to the crystallization of uric acid.
Interviewer: And it is genetically caused, it's not necessarily . . .
Dr. Miller: You are predisposed by genetics so you have a higher likelihood of developing gout if you have family members who have had gout.
Interviewer: And then the things you eat can cause those flare-ups to be worse if you're predisposed.
Treatment Approaches for Gout
Diet
Dr. Miller: You can, you can. Now sometimes, it's not fair to say that, you know, a person that does everything right won't get gout, because they will. They'll have a very strong predisposition for it. And in fact, on a on a diet, a low purine diet, they may still develop gout. But for some, you know, weight control, cutting back on the high protein intake, those kinds of things may moderate the attacks, the number of attacks. The frequency. But nowadays, we have medicines for these things that are actually very effective.
Interviewer: Is that in lieu of controlling your diet or is controlling your diet kind of the first step?
Dr. Miller: Of course, we would do both. Now, I will tell you that if someone has an acute flare of gout, we treat that with medicine. We don't wait for that to go away because resolution can take quite a while. And we generally don't screen for high uric acid levels. So someone who develops gout then we get after them with diet, but we also treat that initial attack with medication because it resolves much more quickly.
Medication
Interviewer: And at what point does it become a little bit more elevated?
Dr. Miller: In terms of recurrence, you mean?
Interviewer: Yeah.
Dr. Miller: Well, again, what you do is you treat the acute attack, it goes away, and you wait and then you check the uric acid levels. If they are significantly elevated, you may put that person on chronic therapy to suppress the level of uric acid. There are over-execrators and under-execrators of uric acid. So that is to say some people produce more uric acid because of their metabolism than others and some people under excrete it in the urine. And so, there are two mechanisms and you can attack either one with medications long-term to prevent recurrent attacks. Generally, if someone has one attack, you'll treat that acutely, and then you'll follow up and see how they're doing. So I wouldn't rush to put somebody on chronic therapy.
Chronic Gout Therapy: Long-Term Management and Preventive Measures
Interviewer: And how many people end up going on chronic therapy? Because I have to talk to people since I found out my dad has it that they suffer quite often in a lot of joints.
Dr. Miller: Anyone who joins anyone who has more than a couple of attacks in the setting of watching their protein intake and diet probably could use, you know, some suppressive therapy. That is therapy to reduce the level of uric acid and if you reduce the level of uric acid, you reduce the risk of crystallization in the joints.
Seeking Help from Rheumatologists
Interviewer: And what about somebody whose treatments don't seem to be working? I have talked to a couple of people, and they seem to suffer from it and it doesn't seem like the medication is working, the diet's working. What could possibly be going on in those situations?
Dr. Miller: Those are complicated cases, and sometimes they occur in the setting of people who have gout and deformative joints. So the crystallization sets up in the joints and because of the abnormalities in the joints, they continue to be predisposed to the attacks. Those require the care of a rheumatologist long term to monitor how they're doing and to . . . there are different treatments. But yes, there are some people that have recurrent attacks and they need special treatment and usually we'll send them to the specialist.
Interviewer: So if somebody is suffering from gout, it sounds like it's very painful and they're probably, they're going to seek out some help to alleviate pain.
Dr. Miller: It's quite painful. They will seek out some help. And I would say to those who are listening that if it happens in the large toe, it becomes red and inflamed and you're over 30, you probably should think about gout. It's a possibility there's an infection there so you don't want to you know, could be an infection other than a gouty attack but that's unless you've had trauma to the toe or the feet. That would be less likely
Interviewer: Come and see a primary care physician. They can generally treat it if it becomes more complicated than a rheumatologist
Dr. Miller: Correct.
updated: May 14, 2024
originally published: July 9, 2019