Uric acid's the enemy for those who suffer from the severe pain and swelling of gout
Chris Bauer's right hand shows symptoms of an attack of gout.
Chris Bauer, 45, has chronic gout in his elbows, hands, knees and feet.
Chris Bauer's elbow after an attack of gout. The lump is tophi, an accumulation of uric acid under the skin.
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Chris Bauer, 45, of Shaler, had to take disability from his position as a registered nurse at Allegheny General Hospital. He doesn't have the strength to lift patients anymore. He can't even push a lawn mower, and the sharp pains he gets in his feet and knees cause frequent falls.
The joints of his feet, knees, elbows and right hand often are painfully swollen, reddened and warm to the touch, and he has big, unsightly lumps of crystallized uric acid under the skin of both elbows and left knee called tophi.
Mr. Bauer has gout, a complex form of arthritis caused when the level of uric acid in the bloodstream gets too high and crystallizes within a joint or joints, causing severe pain and swelling along with red, warm skin.
The incidence of this disease has risen significantly over the past 20 years, according to researchers from the Boston University School of Medicine, and now affects 8.3 million Americans, or 4 percent of the population.
"Probably [the increase] is related to health status, in that gout can be seen in all kinds of individuals, from skinny to not-so-skinny," said Larry W. Moreland, UPMC rheumatologist and chief of the Division of Rheumatology and Clinical Immunology at the University of Pittsburgh School of Medicine.
While most gout is episodic, Mr. Bauer's is chronic. Since his first flare five years ago, he estimates he's had more than 150 attacks. "It never goes away. I'm chronically in pain. It wakes me up at night," he said. "It's just progressively getting worse."
Dr. Moreland said he tells his patients "that gout is one of the three or four most painful things you can have happen to you. You can have a baby, have a kidney stone or have gout."
Though gout can occur in any joint or, less commonly, in multiple joints, the most common gout attack is in the big toe, where it's called podagra. "The classic description of podagra is exquisite pain of the toe in the middle of the night where even the touch of a sheet is very painful, similar to an infected joint," said Fotios Koumpouras of the West Penn Allegheny Health System, medical director of the Lupus Center of Excellence and associate chief, division of rheumatology.
The body produces uric acid when it breaks down purines, which are the building blocks for DNA and which occur naturally in the body and in foods.
"There are two general reasons your uric acid level gets elevated," Dr. Moreland said. "One is you're making too much uric acid, or you're not getting rid of enough of it through your kidneys. The biggest reason is you're not excreting enough of it through your kidneys, but sometimes with certain medical conditions you're making too much uric acid."
For example, taking diuretics can lead to increased levels of uric acid; so can chemotherapy, which results in a flood of protein and purines, Dr. Koumpouras said.
Men are more likely to get gout, though it's uncommon in males under 30, but women become more prone to get it after menopause.
Genetics can play a role in who gets it, Dr. Koumpouras said. So do medical conditions such as "kidney problems, heart problems, medication for those conditions and high blood pressure, dehydration," he added. "Those are the main ones, and of course, certain drugs. Gout is more common in individuals who are obese and in individuals who eat indiscriminately." Diabetes, high levels of fat and cholesterol in the blood and arteriosclerosis, or narrowing of the arteries, also make it more likely you'll develop gout.
But gout is treatable and, "it can be cured ... if you can identify the factors that is causing it," Dr. Moreland said.
For example, if someone is obese, eating a diet high in purines and drinking alcohol who then loses weight, changes his eating habits and gives up alcohol, his gout may be cured. If gout is caused by a diuretic and the medication can be changed, it can be cured.
"But many people have high uric acid. They do well on medication. Then they stop the medication, and the gout comes back," Dr. Koumpouras said. "If it's in your genes, [the gout] has to be managed."
Gout management means a combination of diet and medications.
Certain foods are high in purines and can precipitate a flare: red meats, organ meat, shellfish, small silvery fish like sardines and anchovies, asparagus, mushrooms and alcohol, especially beer.
Some medications are used to treat flares: over-the-counter nonsteroidal anti-inflammatory drugs such as ibuprofen (Advil, Motrin) or naproxen (Aleve) or prescription medications like indomethacin (Indocin). A pain relief option for patients who can't take NSAIDS is colchicine (Colcrys).
Steroids such as cortisone or prednisone also sometimes are used for inflammation and pain. They can be administered as pills or injected into the joint.
There also are medications that block uric acid production for patients who have several gout attacks a year or if, though less frequent, they are particularly painful. One group called xanthine oxidase inhibitors include allopurinol (Aloprim, Lopurin, Zyloprim) and febuxostat (Uloric).
Probenecid (Probalan) improves the kidneys' ability to remove uric acid from the body.
"The treatment is to avoid food that can precipitate gout and to use medications that can help treat flares," Dr. Koumpouras said. "You get them once a year, you only treat the flares. You get three or four a year, then you put them on everyday drugs to prevent gout, which reduce the ability to make uric acid in the body."
There are possible complications from gout and high uric acid levels, or hyperurecemia. Tophi, the collections of uric acid crystals under the skin, can rupture and get infected. Joints can be destroyed. Kidneys can develop stones or be damaged.
If medications cause unwanted side effects, doctors will try to substitute a prescription. Mr. Bauer said over the years he has had to stop taking colchicine because of diarrhea, Uloric because it caused him to go into liver failure, and Indocin because of diarrhea, nausea and vomiting.
Dr. Koumpouras emphasized treatment is ongoing:
"It's important if you do have gout and are on medications to take them regularly and see your doctor regularly because the medications have significant side effects."
First Published July 30, 2012 12:00 am