Table of Contents
Preface to the Second Edition i
Introduction iii
Chapter 1 The Four Stages of Gout 1
Why Do We Get Gout? 1
Asymptomatic Hyperuricemia 3
Acute Attacks 4
Intercritical Periods 7
Advanced Gout 9
Chapter 2 Treating Gout 11
Part 1 Treating Acute Attacks 12
Part 2 Managing Hyperuricemia 23
Part 3 Prophylaxis 32
An Alternative Treatment Method 34
Gout Management at-a-glance 36
Chapter 3 Getting the Right Diagnosis 39
Synovial Fluid Diagnosis 39
Tophi Sampling Diagnosis 41
Clinical Diagnosis 41
Blood Tests 42
Urine Tests 43
Genetic Tests 43
Diagnostic Imaging 44
Other Conditions that Look Can Like Gout 46
Chapter 4 Hyperuricemia 49
What is Hyperuricemia? 49
Why Does Hyperuricemia Occur? 50
Some Causes of Secondary Gout 51
Conditions Associated with Hyperuricemia and Gout 53
Chapter 5 Diet and Lifestyle 61
Weight and Exercise 61
Alcohol 64
Diet 66
Frutose 70
Proteins, Dairy and Fats 72
Other Lifestyle Factors 74
Diet and Lifestyle at-a-glance 76
Chapter 6 Alternative Medicine 79
Alternative Treatments backed by Scientific Evidence 80
Alternative Treatments with Little or no Scientific Evidence 82
Appendix A Purine Content of Food 87
Appendix B Additional Medication Information 93
General Information on NSAIDs 93
Information on Specific NSAIDs 96
Colchicine 107
Uric Acid Lowering Medications 109
Other Uric Acid Lowering Medications 116
Other Medications for Acute Attacks 117
Appendix C For Doctors 119
Glossary 121
References 129
Index 139
Read an Excerpt
Chapter One:
The Four Stages of Gout
"When I have gout, I feel as if I am walking on my eyeballs"
-Sydney Smith
If gout is not treated properly it can become a crippling disease, damaging or destroying joints and resulting in constant pain along with frequent, intense and long-lasting acute attacks. Before we discuss how gout is treated, let's take a look at what causes the disease and how it progresses if untreated.
Gout is a form of arthritis, more formally known as acute gouty arthritis or crystal-related arthropathy. Unlike rheumatoid arthritis, which is caused by the immune system attacking the joint itself and eating away at it, gout is caused by uric acid crystals that form within the joints.
Why Do We Get Gout?
A long time ago - somewhere between when our ancestors were still swinging in trees and when they started to walk upright on land - something happened. Nearly every mammal on earth produces an enzyme called uricase. This enzyme's function is to degrade uric acid, the normal by-product of the metabolization of chemicals called purines.4,6 At some point, while early humans were taking their first tentative upright steps on land, a mutation occurred in their genes, and they stopped producing uricase.7
This lack of uricase didn't seem to cause too much of a problem for early man. Without any form of medicine and only limited intelligence, these early bipeds survived on a sparse diet and were lucky if they made it past the age of 40. However, as man evolved further, developing bigger brains, language, agriculture and civilizations, people began living longer and with more abundance.
As their diet grew richer,their hair grayer and their lives more sedentary, nature's omission of the uricase enzyme came back to haunt them. Initially this omission only affected the wealthy - those who could afford rich foods and wine. The consumption of these rich foods (which contain higher concentrations of purines) resulted in higher levels of uric acid in their blood. Alcohol and lack of exercise made things even worse. Gout became the disease of kings and noblemen.
Over time, as the global economy and wealth grew and complex systems for transporting food products were developed, even common people became able to live with the abundance of the kings of past. Gout could strike anyone, not just the rich. Thus, gout became more common, and the portion of the population suffering from this disease continues to grow today.
Gout occurs in four stages. Not all cases progress to the final stage, but if left unmanaged, many do.
The Four Stages of Gout:
1. Asymptomatic Hyperuricemia
2. Acute Attacks
3. Intercritical Periods
4. Advanced Gout
Asymptomatic Hyperuricemia
Having high levels of uric acid in your body without experiencing any symptoms is called asymptomatic hyperuricemia. Gout will only develop in people who have had asymptomatic hyperuricemia for years or even decades.8 Today, somewhere between 5% and 30% of people living in the developed world are hyperuricemic.6 However, having hyperuricemia does not guarantee that you will get gout; it only predisposes you to it. About 20% of people with this condition go on to develop gout.2,6,9
Hyperuricemia is sometimes caused by a genetic error in the body's metabolism that causes it to produce more uric acid than normal. Or, much more commonly, it can be caused when the kidneys have difficulty removing uric acid from the body. The kidneys are very good at filtering uric acid, but about 90% of it still gets reabsorbed back into the blood before leaving the kidneys.4 Often people can be both "over-producers" and "under-excretors" of uric acid, resulting in exceptionally high levels. This makes gout more frequent and painful, as well as more difficult to manage.
This chapter discusses the direct effects of untreated gout, but untreated hyperuricemia may pose many more health problems. There are a host of disorders associated with hyperuricemia that are much more dangerous than gout. Researchers are just starting to put the pieces of hyperuricemia and these other conditions together, and a frightening picture is developing. In Chapter Four we will discuss hyperuricemia, its causes and the diseases that scientists are now beginning to link with this condition.
Acute Attacks
Uric acid dissolves in blood serum (the liquid part of blood) and other body fluids. In people with hyperuricemia, uric acid concentrations rise to a level where it becomes a super-saturated solution,10 meaning that more uric acid is dissolved in the body than is normally possible.
An acute gout attack occurs when these body fluids can no longer sustain this super-saturation and begin to form urate crystals; like ice crystals that form in freezing water.* These crystals can form anywhere in the body, but in a gout attack they develop in one or more of the joints.11
The body's immune system quickly detects these newly appearing urate crystals and assumes they are disease or infection. In response, white blood cells are sent in to attack the invaders; but when they try to devour them, the large rigid crystals burst the cells, just like popping balloons. As the white blood cells die, they release proteins telling the immune system that the cell has lost its fight with the invader and reinforcements should be sent in.
The released proteins also cause an increase in the acidity of the fluid of the joint. This makes conditions more favorable for even more urate crystals to form. The immune system responds by sending in more white blood cells and by causing inflammation. More white blood cells are killed by the urate crystals, causing even more proteins to be released and more crystals to form. This process perpetuates itself, creating a runaway inflammatory response that directly causes the extreme pain of gout.12
Most men are stricken with their first gout attack between the ages of 30-60, and most women are affected only after reaching menopause,2,14 with gout being 5 to 8 times more common in men than women.4 An acute gout attack typically starts with the rapid development of severe pain in the joint that reaches a peak in 6 to 12 hours. Tenderness, swelling and redness around the affected joint18 are also typical symptoms of an attack. In severe attacks, fever and chills may also be present.1,9,15
A first attack of gout often occurs in the middle of the night and usually only strikes one joint. However, as the disease progresses, attacks involving multiple joints become more likely.8,15 Eventually the inflammation process of an attack will run its course and the pain subsides on its own after a few days, but severe attacks can last weeks.4
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