Big Toe, Big Pain: The Science of Gout
I've always found chemistry fascinating. I loved those times in the school chemistry lab with the Bunsen Burners, beakers, and flasks. The best labs I can remember produced colorful, geometric crystals.
Given my affinity for chemistry, I took a similar fascination with the study of gout in medical school. As gout is caused by the precipitation of uric acid crystals in the joints and tissues of our body, I got to see that crystal experiment occurring right inside the body!
I'd like to take a moment to discuss gout from a scientific standpoint and what can be done for this painful condition.
Gout 101- Basic Chemistry
The formation of uric acid crystals in the joints and tissues of the body can cause a wicked syndrome of pain and swelling. Generally, the crystals are produced when there is an elevated level of uric acid in the body.
Uric acid is a byproduct of the metabolism of purines from our diet. Purines are contained in most everything, but they are more prevalent in rich foods like sausage, sardines, organ meat, and beer. The byproduct, uric acid, is unhealthy for the body and needs to be released. It leaves the body in… you guessed it: the urine. The kidneys filter uric acid from the blood, and it is urinated out.
In a beaker or a body, crystals form when the liquid state system of a dissolved substance is overwhelmed. With gout, the dissolved uric acid may rise via increased intake or decreased output. Cooling of the body may further strain the uric acid’s ability to remain dissolved. These factors may come about through the following:
- Exposure to cold temperatures
- Purine-rich diet
- A genetic pre-disposition affecting metabolism
- Kidney disease
- Cancer therapy (destroying tumors loads the body with uric acid).
The big toe is the most common site for a gout attack because it is the coolest area of the body. Aside from the big toe though, gout can affect most any joint including the hands, ankles, and knees. It can also form as ulcers in the skin or painful bumps in the ear lobes.
Deer Camp - The Perfect Gout Environment
I see a LOT of gout in the late fall and the trend is directly related to hunting. The typical patient returns hobbling in from deer camp, a poor soul who set out for a time of recreation with his buddies, drank a bunch of beer, ate a bunch of meat, and then went out and sat in the cold - the perfect environment for the creation of uric acid crystals. As a result, instead of a big buck, this poor guy finds a painful, throbbing big toe.
The History of Gout
Gout has been around for ages. In fact, it was more common centuries ago than it is today! This is due mainly to the fact that, long ago, water purity was not regulated and contamination was widespread, leading to regular outbreaks of cholera and other forms of dysentery. As such, alcohol was one of the safest things to drink and, being naturally high in the purines that uric acid crystals love, excessive consumption led to a lot of gout. Gout was considered a disease of the rich because the wealthy combined a high degree of alcohol consumption with a diet full of purine-rich foods like sausage and organ meats.
Most people with an acute gout attack are most interested in controlling their pain. Once the attack subsides, your doctor will order a blood uric acid level to see if there is the potential for more attacks. If it's determined that you're at higher risk for repeated gout attacks, medication can help lower uric acid in the long-term, and is usually accomplished with anti-inflammatory medications and possibly a narcotic pain medication such as Allopurinol and Uloric. A medication called colchicine can also be used to help in the acute setting. However, while colchicine is effective, diarrhea and upset stomach are common side effects.
On a more conservative and practical home care level, incorporate the following tips to avoid gout:
- Drink Plenty of Water: Pushing fluids through the body is important to get the uric acid out of the body. This dilutes the uric acid and helps the kidneys.
- Avoid the Cold: Even though there is a lot of inflammation with gout, don't apply ice. This actually lowers the temperature and promotes the formation of more crystals! If anything, keep the area warm; cover up those feet with warm socks.
- Eat Right: Avoid foods that are high in purine content.
- Avoid Drugs: Caffeine and alcohol are common causes of dehydration. Also, take a look at the medication you are on. For instance, Diuretics, medications commonly used to regulate blood pressure, can promote gout.
- Try Bing Cherries: Extracts and concentrations of Bing cherries have been reported to treat gout in various forms, but there aren't many quality studies to support efficacy. I have heard some anecdotal positive reports from my patients, however.
- Consider a Supplement or Natural Medicine: A number of gout sufferers have found supplements or natural medicines helpful. HelloLife offers a dietary supplement called Uricinex and a natural homeopathic medicine called Goutenex which have some pretty impressive reviews!
Knowledge is Power
If you have gout, arm yourself with knowledge. There are a few pitfalls out there that you should be aware of.
For one, the appearance of gout can be ambiguous. Joints that are hot and red can look infected. Many people with acute gout wind up in the emergency room. Often, healthcare providers fail to diagnose gout because blood uric acid level is normal. Uric acid levels are often normal in acute gout because the uric acid is, by and large, located in the joints, not the blood. Levels needs to be reevaluated weeks after the resolution of the attack.
Once therapy has begun, “mobilization flares” are common. The medicine releases a huge amount of uric acid from the tissues and joints only to deposit it in another joint if the conditions are right. These flares can be prevented by taking an anti-inflammatory medication along with other gout medicines for a few months. Patients with mobilization flares often see them as a sign that the medication does not work and give it up on it.
Finally, gout nodules in the joints called tophi (especially the hand) can be mistaken for osteoarthritis. It's always a good idea to check uric acid levels because tophi can amazingly “melt away” with aggressive gout treatment.
Gout is a common condition that can be extremely painful. As such, those who have had a gout attack usually want to avoid any future occurrences. Consider the chemistry causing those gout crystals to form in the body, and work toward lowering this potential. If you have a family history of gout or any nodules around painful joints, consider getting a blood uric acid level.