From Dr Theo’s Desk

Gout Attack: Frank’s Story

Frank, a 37-year-old man, was woken up at around 3 am by a sudden sharp pain on his right big toe. The pain was so intense that he could not sleep for the remainder of that night. Even a slight brush of his toe against the bed sheets caused a lot of pain, which worried him a lot. He had attended an event that evening where there was plenty of “nyama choma” (roast meat). The party was fun and it was an unforgettable evening with alcohol flowing freely.

Needless to say, Frank had had more bottles of beer than his body could handle. Additionally, he had only drank two glasses of water the previous day. By morning, Frank’s big toe was swollen, warm to touch, and very red. The pain was so intense Frank could barely walk and was not able to wear his shoes. Fortunately for him it was a Saturday morning so he didn’t have to go to work as he could not imagine stepping out of the house.

By 10 am, the pain was unbearable. He called a cab to take him to hospital and he was assisted to get to the car from the house. At the hospital, the doctor found out that his uric acid level was very high and he was diagnosed with an acute gout attack. He was given a jab and was advised by the doctor on lifestyle modification such as dramatically cutting down on alcohol, reducing his red meat intake and reducing his weight, as he was overweight.

What is gout?

Gout is a type of arthritis. Arthritis can be defined as the inflammation of the joints of the human body. In cases where someone has gout, the inflammation of the joints is caused by a chemical in the blood called uric acid (urate).  Usually, uric acid is a harmless chemical made in the body, which is mostly passed out with urine and some with the stool.

However, when the amount of uric acid in the blood builds up, tiny grit-like crystals of uric acid may form, which typically collect in a joint. The crystals irritate the tissues in the joint to cause inflammation, swelling and pain… and that is what is known as a gout attack. It is, however, possible to have a high level of uric acid without developing gout. It is also possible to have a gout attack with a normal uric acid level. However, the higher the levels of uric acid the greater the chances of developing gout.

What are the signs and symptoms of gout?

The main symptom of gout is often a sudden excruciating pain in one joint, in most cases it is often the big toe. Sometimes, it is possible to have other joints affected such as the knee, the wrist, and the shoulder joints. Pain caused by gout is so excruciating that even a slight touch by your beddings causes pain. Usually, it makes walking a very painful exercise. The affected joints become swollen and the skin around becomes red. If gout is not treated quickly, these signs and symptoms may persist for about 10 days before resolving completely.

What are the risk factors for gout?

Several factors make the uric acid levels to build up in the body and thus cause gout:

Food and lifestyle choices

• Alcohol: Drinking a lot of alcohol, especially beer, interferes with the removal of uric acid from the body hence increasing the risk of getting gout. Beer is, especially risky because of both alcohol and purine (derived from brewer’s yeast) content.
• Diet: Eating a diet rich in purines, especially of animal origin increases the risk of getting gout. High purine diets include; all meats, organ meats (such as kidney, liver, heart and ‘matumbo’), meat extracts and gravies, yeast and yeast extracts and certain types of seafood.

The good news is plant sources of purines such as beans, peas, lentils, oatmeal, spinach, asparagus, cauliflower, and mushrooms do not seem to increase uric acid levels as much as the animal sources and are thus safer.

• Fructose rich fruits: Certain fruits and juiceare rich in fructose, a naturally-occurring form of sugar. Such fructose rich fruits, fruit juices and beverages increase the levels of uric acid, which increase your risk of gout. High fructose corn syrup that is added as a sweetener to some soft drinks is also a culprit. Lack of vitamin C is associated with an increased risk of gout.
• Obesity. If you’re overweight, your body produces more uric acid and your kidneys have a more difficult time eliminating uric acid.
• Chronic medical conditions: Kidney disease increases the risk of developing gout because of the reduction in the rate of removal of uric acid from the body.
• Other medical conditions: Such as diabetes mellitus, hypertension, lipid disorders, and blood vessel disease add onto this risk.
• Family history of gout: There are certain families which due to their genetic make-up are pre-disposed to gout.
• Medications: Some medications such as diuretics and salicylates may cause gout.
• Age: The adult population is more prone to gout.
• Gender: Men get gout attacks more than women due to their higher uric acid levels in their body.

What are the complications of gout?

Frequent gout attacks can result in complications. The pain from gout affects the quality of life of the patient. With repeated attacks the joints get damaged. Accumulation of the crystals may damage the kidneys. The crystals may accumulate under the skin causing bumps called tophi. These tophi can be disfiguring and require surgery.

How is gout diagnosed?

The diagnosis of gout is typically done clinically and by laboratory tests. Clinically, gout is diagnosed by the typical gout symptoms that a patient comes with to the hospital. Blood tests may show a raised blood level of uric acid (urate). Joint fluid analysis under the microscope may show crystals of uric acid.

How is gout treated?

The treatment of gout involves both supportive and medical aspects.

Supportive management

Involves raising the affected limb under a pillow to reduce the pain and swelling. Additionally, an icepack gently compressed against the joint may relieve the symptoms.

Medical management of gout

This entails taking anti-inflammatory drugs such as diclofenac, meloxicam etc. The main side effect of these drugs is acidity and sometimes stomach ulcers. These drugs should also be carefully used in patients with asthma, hypertension and heart failure.

Other alternative medical treatments for gout are colchicine, probenecid, allopurinol and steroids. Allopurinol is a common medicine for prevention of gout attacks. Surgery may be needed to remove the uric acid crystals or to repair a destroyed joint.

How is gout prevented?

Lifestyle modification is important: 

• Avoid or reduce your alcohol consumption, especially beer and hard liquor.
• Stop binge drinking.
• Limit the amount of red meat and organ meats.
• Eat less of poultry, especially turkey. Also, moderate your diet on eggs and chicken.
• Reduce your intake of sugary soft drinks, processed foods, refined carbohydrates and foods high in fructose.
• Avoid eating seafood like tuna, mackerel, herring, lobsters and shrimps.
• Drink a lot of water.

Embrace a healthy diet:

• You should drink at least eight glasses of water in a day.

• Eat whole grains and low fat dairy products.

• One should also consume fruits low in fructose for example strawberries and cherries. Additionally, eat lemon, kiwi, sweet lime, tomatoes, and oranges to boost your Vitamin C levels.

 • Use vegetable oils like sunflower and olive oil.

• Maintain a healthy weight by doing regular exercises and avoiding sedentary lifestyle.