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ASK THE DOCTOR: Out with gout
By DR. JIM MITTERANDO
The Patriot Ledger

Q - My big toe occasionally aches and I wonder whether I have gout. Tylenol and aspirin do not help. What medicine helps? What foods should I avoid? I hear wine is bad. Is beer OK?

A - A gout attack often will make your big toe feel as though it's on fire. It is also swollen and so tender that pulling the bed sheets over your feet can be intolerable. Gout sometimes also affects the feet, ankles, knees, hands and wrists. The pain typically lasts one to two weeks.

In people with gout, uric acid crystals collect in the joints causing joint pain and swelling. Uric acid is a substance that forms when your body breaks down proteins called purines. Red meats, fish and alcohol are high in purines that can contribute to gout attacks. Contrary to popular belief, a recent study showed that beer was more likely to cause gout than wine. Moderation is the key; limiting alcohol to two or less drinks per day reduces the risk of gout. People will often find their own individual triggers for gout attacks and should limit those foods.

Diagnosing gout may involve inserting a needle into the affected joint to withdraw fluid that is microscopically analyzed for uric acid crystals. Blood tests are not helpful in diagnosing gout because people frequently have elevated uric acid levels without having gout. Frequent gout episodes can lead to joint destruction and lumps (uric acid deposits) on the hands and feet called tophi.

Treating a gout attack

During an attack, avoid alcohol and drink plenty of water. Apply ice. Rest and elevate the affected joint; prolonged standing or walking on the affected foot will worsen and prolong symptoms.

NSAIDs (nonsteroidal anti-inflammatory drugs) such as ibuprofen, naproxen and indomethacin are most helpful for treating the initial pain and swelling. These medications can cause stomach upset or ulcers and should be taken with food. Indomethacin is particularly hard on the stomach. If you have a history of kidney disease or congestive heart failure, check with your doctor before taking NSAIDs. People taking the blood thinner, warfarin (Coumadin) or people with ulcers may need to avoid NSAIDs but may take the similar acting but more expensive COX-2 drugs: Celebrex, Vioxx or Bextra.

Sometimes, Colchicine, is added to relieve severe symptoms. This drug is notorious for causing diarrhea. Occasionally, steroids such as prednisone can be used for gout attacks as well. Avoid taking aspirin for gout pain since aspirin interferes with uric acid elimination and can worsen gout. Tylenol does not help much since it has no anti-inflammatory effects.

Prevention

If you get frequent gout attacks, consider:

  • Moderating your intake of red meats and fish. High purine vegetables are not a problem, as previously thought.
  • Consuming more milk and dairy products may reduce attacks.
  • Limit alcohol to no more than two drinks daily.
  • Avoid niacin, aspirin and diuretics (water pills) such as hydrochlorothiazide or furosemide.
  • Losing weight. Overweight people tend to have higher levels of uric acid.
  • Take preventative medications that lower uric acid such as allopurinol or probenicid if you have three or more attacks per year. The benefits of the these medications need to be weighed against their possible side effects. Allopurinol can cause rare life-threatening reactions, including rashes and liver failure. Probenicid can cause kidney stones. Probenicid cannot be used if you have kidney disease or take aspirin or diuretics. Allopurinol and probenicid can cause a flare up of gout when first started.

Dr. Jim Mitterando is a family doctor at Cohasset Family Practice and a staff member at South Shore Hospital in Weymouth.

Readers should send questions to: Ask the Doctor, The Patriot Ledger, P.O. Box 699159, Quincy, MA 02269-9159, or by E-mail to his attention at features@ledger.com.

Questions of general interest will be answered in this column. The information in this column is not intended to diagnose individual conditions, and individual replies are not possible. Readers should see their own doctors about specific problems.

Copyright 2004 The Patriot Ledger
Transmitted Tuesday, June 22, 2004