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Doctors' Answers to "Frequently Asked Questions" - Gout

These comments are made for the purpose of discussion and should NOT be used as recommendations for or against therapies or other treatments. An individual patient is always advised to consult their own physician.

Gout - Low Purine Diet [posted 8/12/98]
Question: I am looking for more information regarding what foods are allowed and recommended for somebody who needs to follow a Low Purine diet. My father is 54, slightly overweight, and has Gout. He hates being on a diet, so I would like to try and find as many foods that he is allowed to eat to keep him happy. I am aware that a Low Purine diet includes foods high in DNA and RNA, and excludes beans, nuts, sardines, animal organs and alcohol. What foods are high in DNA and RNA?

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.

Question: What causes gout?

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
Question: Could you please tell me what a purine diet is? My husband is suffering from gout? in his left wrist I need help. He is taking allopurinol 300 mg now, but he needs help. He has taken aspirin for the pain but found out he shouldn't take that.

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.

Question: Since there is no cure for gout, what can I do to hold down a job if I canít even walk now? Is there any unconventional treatments? Does acupuncture work?

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
Question: About a year ago, I was diagnosed with gout, and I have been taking Allopurinol daily ever since (except for when I took Indocin during the gout attacks). Everyone I talk to who knows anything about gout is usually surprised that I have gout. I am 26 years old, but I believe I've had gout since I was 21. It just remained untreated for a few years. In fact, my gout was originally diagnosed as "turf-toe", which is a very painful inflammation of ligaments in the big toe. People are also surpassed that I have gout because it has been suggested that it only effects larger or overweight people. I am 6 feet tall and weigh about 200 pounds, and although I would like to lose about 15 pounds, I am certainly not overweight. I also have a very good diet, although I do drink a lot of red wine, which is high in purines. My question relates to the drug Allopurinol, which I take 300mg of daily. Everything I read about Allopurinol states that it is a powerful drug and can cause a number of side effects and shouldn't be taken unless you are sure it is the drug for you. Well, I am not sure it is the drug for me as I have experienced a number of side effects in the last few months. I developed a minor skin rash on my hands, mostly between my fingers close to the knuckle. I had this rash off and on for about three weeks. I have also had some pretty severe insomnia every now and then lately which is usually brought on by some pretty severe headaches, which are very difficult to get rid of using Aspirin, Acediminiphin or Ibuprophen. Recently, I have had some problems with nausea after meals. It isn't really bad, no vomiting yet, but I usually have to sit down for a while to let it pass. Sometimes, eating something sweet helps settle things down as well. Some other things that may or may not be connected with the Allopurinol are: extra sensitive extremities (sometimes just bumping my hand into a wall gives me extreme pain), drowsiness, erratic sleep patterns (I'm awake all night and sleepy all day), decreased sexual drive, decreased energy level, and an ever increasing appetite. My question is "is Allopurinol the right drug for my condition?" It does seem to be working on my gout pain (I haven't have an attack in months) which, believe me, is worth all the other side effects. However, I am worried that due to my age (thus I will have to be on the medication much longer) and my side effects, that I might not be on the right medication and that I might have more problems as a result. I am also interested to know if there is any connection between my side effects and my medication. Are these things just associated with getting older?

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.

Question: I'm a 59 year old male. I had my first attack of gout around a year ago. The only medication I'm taking for it now is allopurinol. However, I heard from an acquaintance who also has gout that his doctor told him to soak his feet in cold water every night. No medication was prescribed for him. Is this method of treatment reasonable and effective?

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.

Question: I am currently taking 300 mg daily of Allopurinol for control of gout. I have been pretty good about taking one pill per day, but I occasionally miss a day. I have had gout for about 20 years and have been on and off various medications. During that time I went back on allopurinol about 3 years ago. Lately, I have been having gout attacks in my big toe (the usual place) and also in the Achilles tendon of both legs (but not at the same time). When I have an attack, I take indomethicin which usually helps, but lately it takes longer (several days or a week) to get relief. Should I be taking something different to prevent the gout attacks? Should I be taking a stronger dose of allopurinol? Am I feeling the effects of rheumatoid arthritis? I am 60 years old and weigh 215. I am in otherwise good health except for allergies which have developed in the last 2 years.

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.

Question: What is the basic treatment for pseudogout and what medications are prescribed?

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.

Question: I had a reaction similar to the 35-year old male who reported a severe headache after taking indocin. I am 39 and take Norvasc for blood pressure therapy and recently had a gout attack centered in my foot just back of the big toe. My doctor prescribed indocin for the inflammation but no other drug for pain. After two days of the therapy, I developed a severe headache and vomiting that lasted for 20 to 24 hours. My doctor has advised me to follow a low-purine diet. To my surprise, two of my favorite foods, oatmeal and spinach, that I thought were good for me (and otherwise probably are) likely contributed to my problem.

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.

Question: I have had been diagnosed with gout. I am a 35 year-old male being treated for high blood pressure with tenormin. I have had an attack about 4 -1/2 weeks ago that has affected both my ankle and my knee joint. I began taking indocin for swelling and vicodin for pain. After the 3rd week I was put on allopurinol. Several nights later, I began to get a severe headache which lasted about 12 hrs. I stopped the vicodin, but the pain in my joint has lessened but is still present. A. Why this terrible headache? B. Does gout go on this long normally? and C. When will it end?

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
Question: I am having pain when I walk. The pain is located in my left heel. Once I begin walking, the pain lessens. Could be a spur or gout? What treatments are recommended?

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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