Gout – Causes and Treatment – Exploring Ways to Reduce Uric Acid in Joints and Blood
Gout Treatment Is Questioned in New Medical Guidelines
Doctor’s group suggests dropping specific target for uric acid levels in the blood.
You might think of gout as an old-fashioned illness—relevant only, perhaps, to a character in Charles Dickens’ “The Pickwick Papers.”
But almost 4 percent of all adults (yes—women do get gout) in the U.S., or more than 8 million people, have experienced this painful arthritic condition.
The American College of Rheumatology offers guidelines (PDF), most recently updated in 2012, for doctors to follow in treating gout sufferers.
Now, the American College of Physicians has released its own set of guidelines for recurrent gout—meaning attacks that occur twice per year or more. And there are a couple of differences between the two when it comes to treatment.
If you have gout, here’s what these guidelines may mean for you:
In gout, crystals of uric acid, a chemical produced when your body breaks down certain foods, such as organ meats and seafood, collect in and then inflame a joint and some of the structures near it.
These uric acid crystals can cause gout “attacks”—sudden intense pain, swelling, and redness in a joint or tendon that may last three to 10 days.
For many people, the first flare-up of gout occurs in the big toe. But gout can also affect joints and adjacent tendons of ankles, knees, wrists, fingers, and elbows.
Some people who’ve had an attack of gout may go years without having another; others may have the flare-ups with increasing frequency.
To Target or Not?
For years, scientists have generally agreed that for people with recurrent gout, lowering elevated uric acid levels in the blood can reduce the likelihood of painful attacks. Medications such as allopurinol (Aloprim, Zyloprim, and generic) and febuxostat (Uloric), taken daily, can help to do this.
But research published in the Annals of Internal Medicine to support the American College of Physicians’ new recommendations calls into question long-held ideas: that treatment for recurrent gout should target specific uric acid levels in the blood and that doctors should monitor patients’ levels regularly.
That target is usually 6 mg per deciliter (mg/dL) of blood or less. At about 7 mg/dL, the uric acid crystals that cause gout can begin to form.
The authors, who reviewed 28 studies on gout treatment from 2010 to 2016, say research hasn’t yet proved that targeting a specific uric acid level is better for people with gout than other strategies.
Those other strategies include prescribing an uric acid-lowering drug to minimize the likelihood of attacks—but without aiming for a specific uric acid blood level.
The American College of Physicians’ reasoning: Some people who take uric acid-lowering drugs daily may see their gout attacks cease even before their uric acid blood level reaches the target of 6 mg/dL. They may see benefits from less aggressive therapy.
For some people, achieving the 6 mg/dL blood level of uric acid may require ramping up their dose of medication over time, which may increase the risk of side effects.
And uric acid-lowering therapy can have significant side effects (see “What This May Mean for You,” below).
What This Might Mean for You
The American College of Physicians and American College of Rheumatology agree on how doctors should treat the pain of a gout attack and that lowering elevated uric acid blood levels can reduce the risk of future gout attacks. The two groups aren’t in accord, though, on how much to lower those levels.
The American College of Rheumatology hasn’t yet officially responded to the new American College of Physicians guidelines.
Marvin M. Lipman, M.D., Consumer Reports’ chief medical adviser, has some reservations about uric acid-lowering therapy that doesn’t target that 6 mg/dL. “If you treat only to make gout symptoms disappear, people may be still prone to complications like kidney stones, and tendon and joint nodules,” he says.
If you have recurrent gout, have a conversation with your doctor about the risks and benefits of preventive medication, and about whether you need to be targeting a specific level of uric acid in your blood. And make sure you understand the following agreed-upon treatment steps:
For a Gout Attack
To reduce pain and inflammation, your doctor should recommend, usually in this order: steroids, such as prednisone; over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB, and generic) and naproxen (Aleve and generic); or low-dose colchicine (Colcrys and generic). The American College of Physicians emphasizes that low-dose colchicine is as effective as higher doses and can help patients avoid the medication’s side effects, which include diarrhea, nausea, and cramping.
For Recurrent Gout (Two or More Episodes per Year)
Talk with your primary care doctor or rheumatologist about whether you are a candidate for uric acid-lowering therapy. Experts generally agree that taking medication preventively is appropriate for those with repeated gout symptoms and who have an elevated uric acid blood level.
Talk with your doctor about the potential benefits and risks of this therapy, the different medication options, and lifestyle changes you may want to consider.
The two medications that are most frequently prescribed for gout are:
• Allopurinol (Aloprim, Zyloprim, and generic). This drug has been used to treat gout for several decades. Side effects include upset stomach, diarrhea, and drowsiness. If you notice an itchy, red rash while taking allopurinol, call your doctor right away because this may be a sign of an allergic reaction.
• Febuxostat (Uloric). This is a newer and more expensive option for preventing recurrent gout, and it’s sometimes used for people who experience severe side effects with allopurinol. Febuxostat’s side effects include nausea and joint pain. In addition, because of the occurrence of liver test abnormalities in some patients treated with febuxostat, the maker of the drug notes that periodic monitoring of liver function may be warranted.
If Your Doctor Starts You on a Uric Acid-Lowering Drug
He or she will also prescribe an NSAID or colchicine for the first month or so that you’re taking the drug to reduce the likelihood of a gout flare-up. (Beginning uric acid-lowering therapy can paradoxically sometimes provoke an attack of gout.)
If You Also Take a Diuretic for High Blood Pressure
Your doctor may recommend a nondiuretic anti-hypertensive medication. Diuretics can lead to higher blood levels of uric acid by decreasing the urinary excretion of uric acid.
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Does Diet Play a Role?
These include following much of the same advice recommended in the popular DASH diet: consuming less sodium, fewer sugar-sweetened soft drinks, and less red meat and shellfish, and adding more low-fat dairy products, vegetables, and fruits such as cherries to your diet.
Overthinking what you eat, however, may not be necessary, Lipman says. If you consume more than one (for women) or two (for men) alcoholic drinks per day, imbibing less is probably more effective than most dietary strategies said to prevent gout attacks. “If you eat a lot of organ meats, such as liver or kidney, you may want to consider cutting back,” he adds. “Otherwise, a healthy, well-balanced diet is your best bet.”