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Doctors' Answers to "Frequently Asked Questions" - Gout
Gout - Low Purine Diet [posted 8/12/98]
Answer: A low purine looks to avoid those foods that are high in DNA/RNA - you have it reversed. The foods are low in DNA to be included in a low purine diet. Diet plays a minor role in the current treatment of gout. Weight loss is long term more important to the chronic gout patient than the specifics of diet. However, any food high in DNA/RNA can elevate uric acid levels.
Answer: Uric acid is the culprit. This is a breakdown product of DNA and RNA. High levels (generally above 7 or 8) will cause crystals to form in cooler parts of the body (hence the toes and feet). Once these crystals form, the bodies immune system thinks they are foreign and attacks them. The gout is really your immune system attacking the crystals. This causes the pain and swelling. Cutting back on the uric acid level (low purine diet) or using antiinflammatories (indocin seems to be preferred) will decrease the attacks. Losing weight is a great way to get ones uric acid down.
Gout - Purine Diet
Answer: A low purine diet focuses on those foods that are high in DNA and RNA. These chemicals are broken down to form uric acid and a low diet will decrease gouty attacks. Also, I have patients who will treat themselves after they "indulge" although I don't advocate this. A low purine diet will eliminate all beans, nuts, sardines, animal organs, etc. You can get a more complete list form your doctor. This diet helps, but is a minor factor in gout prevention.
Answer: First you can try to lose weight. Second, get a list of high purine foods from your doctor or dietitian. These are drugs which will precipitate gout and the foods are usually surprising to many patients. These include beans, sardines, etc. The common thread being high DNA content. Lastly, allopurinol is very effective. Some patients will develop an allergy, but it will prevent gout.
Allopurinol and Gout
Answer: Gout is unusual before the age of 35 or so unless it is familial. There are several types of familial gout that cause the uric acid to be very elevated. These types are important to know since early treatment may be necessary. In general, Allopurinol is not given for one attack of gout but reserved for those who have in excess of 3-4 attacks a year. Allopurinol can result in a hypersensitivity syndrome-- otherwise it is fairly symptom free. The hypersensitivity syndrome can be severe and occasional patients have died. It is usually preceded by a rash and fever. I doubt the other side effects are from Allopurinol after the time you have been on it. Also, long term use doesn't seem to have any major consequences other than the hypersensitivity syndrome, I'd ask about the level of your uric acid, if it is above 10-12 you probably have an inherited enzyme deficiency responsible for your elevated uric acid.
Answer: Gout is caused by the formation of uric acid crystals in the joints and joint spaces. This commonly occurs in the great toe as it is the farthest from the body and the coolest joint. Consequently, cooling the feet would not have any benefit and actually might increase the risk. Other things that one might consider in addition to allopurinol are a low purine diet(available from your physician or a dietitian) and weight loss.
Answer: Gout is one of the oldest medical diagnosis known. It was first described by the ancient Greeks. Its name derives from the Greek gutta-for drop-from the theory that "bad humors" were dropping into the joints from the body causing the distress. This is preserved in pharmacy parlance as gtt which is medical shorthand for drop on a prescription. Gout occurs when uric acid crystals form in joints. These form in supersaturated fluid with uric acid levels above 7 or so and form much as rock candy forms when the liquid is cooled forming crystals. This is why the feet are the usual source of initial attacks because they are cooler. The pain from gout is not from the crystals-they are inert, but from the body attacking the crystals. Apparently, the white blood cells recognize these crystals as invaders and attack. Consequently, decreasing the antiinflammatory response will "cure" a gout attack. Uric acid is formed as the break down products of DNA and RNA. Interestingly, man and the guinea pig are the only animals that get gout since we lack an enzyme that will process uric acid to a soluble end product. For years, the only treatment was dietary. Avoiding foods high in DNA like brains, organs of any type-especially liver, sardines, beans, etc. Alcohol is also likely to set off an attack, particularly wine or beer. In 1790, colchicine was "discovered" by a French doctor with Napoleons army in Egypt and used until the advent of non-steroidal anti-inflammatory agents such as indocin, etc. Allopurinol was discovered in the 1950s and is used as a preventive medicine - not a treatment of an acute attack. Allopurinol is very useful in preventing attacks if the level of uric acid is kept below 7 or so. If recurrent attacks occur, the dose may need to be adjusted. Usually 200-300 mg will suffice depending on ones weight. Allopurinol is very well tolerated except for an occasional allergic reaction. These are peculiar and can occur months or years after starting allopurinol. They can result in death in occasional cases. Different drugs are notorious for inducing gout attacks and particularly diuretics. Avoidance of diuretics is necessary for those predisposed to gout, as well as those taking allopurinol. A low purine diet is also still of use.
Answer: Pseudogout refers to the inflammation causes in joints by the attack of the bodyís immune system against calcium crystals. This is termed pseudogout because it tends to look similar. However, it is more common in the knees (gout in the toes and feet). Treatment is similar to gout (anti-inflammatories), but some gout medicine is ineffective (colchicine, allopurinol, etc.). Consequently, it is important to make the diagnosis by joint aspiration to tailor the treatment to the disease.
Answer: Following a low purine diet can be very helpful. However, you are fairly young to get gout. If your uric acid level is above 9 or so, a special work up might be in order to rule out familial causes of gout. This is especially true if other members of the family have gout.
Answer: Gout is caused by the formation of uric acid crystals in joints and body parts. Uric acid is accumulated by the breakdown of DNA in the diet and normal breakdown of body cells. The pain and inflammation of gout are caused by the body's own white cells attacking these crystals as if they were foreign bodies. Conseqently, turning off this attack or inflammatory response is critical to treating gout once it starts. Gout is best treated at the early stages before the inflammatory response gets really turned on. Consequently, taking non-steroidal anti-inflammatories(NSAIDS) such as indocin at the first signs of gout is very important. Once white blood cells get turned on, turning them off is very difficult and pain for several weeks is common. Often, a diet called a "low purine diet" is helpful. This seeks to decrease the DNA in one's diet to reduce the uric acid. Allopurinol is very useful in preventing gout. However, it is of no use during an acute attack. Indeed, allopurinol can produce gout when initially started. Allopurinol is an extremely useful drug - one word of caution - some individuals will become allergic to allopurinol. This reaction can be severe and result in loss of skin and long term (3 to 6 months) there have been deaths from this drug in the 1 to 2% with this severe reaction. The reaction is usually delayed and not on the initial taking of the drug. It is difficult to tell any particular cause for the headache. I would discuss this with your physician.
Pain In Left Heel
Answer: This is a condition called plantar fascititis. There is a large strong tendon like structure which connects your toes to the heel. This fascia is to keep your foot from falling apart when you run. However, it is prone to inflammation. This is usually best felt over the heel and after repeated inflammations it will develop a calcium spur at the site of inflammation-called a heel spur. Heel cups(purchased at a drug store ) will help. Also, walking shoes with built in heel cups(check Consumer Reports for good walking shoes) will also help. Antiinflammatories(Aleve, Motrin taken in large doses for 10 days or so) will also help. Injections are a last resort.
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