Gout: The 'Disease of Kings'
Sudden, severe big-toe pain after a summer barbecue? A complete guide to gout, its triggers, complications, and prevention.
Summertime poolside barbecues, with burgers, sodas, and alcohol, often precede a familiar complaint: sudden, severe pain, redness, and swelling in the big toe or other joints. For many, the diagnosis is gout, a form of inflammatory arthritis that develops when high levels of uric acid crystallize in a joint, causing intense episodes of pain, warmth, and swelling that can limit activity.
Historically, gout was identified as far back as the Egyptians and Hippocrates and was called the 'unwalkable disease' and the 'disease of kings,' because it was linked to affluent lifestyles and rich food and drink. I've seen it cause debilitating pain, including one father whose uric acid crystals formed nodules ('tophi') in his feet and hands, leaving him unable to lift his child or push a stroller because he had left his gout untreated for years.
Gout occurs when uric acid, produced as purines break down, builds up faster than the kidneys can excrete it, forming needle-like urate crystals in the joints. Risk factors include a diet high in red meat, shellfish, alcohol (especially beer), and high-fructose drinks; conditions like high blood pressure, diabetes, kidney disease, metabolic syndrome, and heart disease; family history; dehydration; male sex; obesity; and certain medications (thiazide diuretics, cyclosporine, low-dose aspirin, and others). Symptoms include severe joint pain (often within the first 12 to 24 hours), warmth, redness, swelling, and reduced mobility.
Uncontrolled uric acid can lead to chronic gouty arthritis with joint destruction, kidney stones, tophi, and possible links to cardiovascular disease and metabolic syndrome. Your rheumatologist will take a history and exam, check uric acid and other blood tests, and may perform joint fluid aspiration (arthrocentesis) to confirm crystals and rule out infection, along with X-rays, ultrasound, or dual-energy CT. Treatment may be started with frequent or worsening attacks or evidence of joint damage.
Medications include colchicine, NSAIDs, and steroids for acute attacks, and uric-acid-lowering agents like allopurinol, febuxostat (Uloric), or uricosurics (probenecid, lesinurad) for prevention, all requiring monitoring by your physician. To prevent attacks: limit alcohol and high-fructose drinks, stay well hydrated, limit red meat and shellfish, add low-fat dairy, maintain a healthy weight and blood pressure, keep moving, and aim for a uric acid level at or below 6 mg/dL. Gout was once called a 'rich man's disease,' but it can affect anyone, of any background and either sex.
Dr. Maggie Cadet, MD