A Disease of Past Times Becomes a Current Challenge

Although once thought to be the "disease of royalty" we now know that the disease does not discriminate between commoner or king but rather that the disease is directly related to faulty metabolism.

The most common type of inflammatory arthropathy (joint disease) in the United States is also one of the oldest. Some of the earliest descriptions of the disease date as far as the 5th century B.C. Once called the "disease of kings" for its historical connection to excess and privilege, it was originally thought to be caused by an overindulgence in rich food and alcohol. Hippocrates referred to the disease as the 'arthritis of the rich', as opposed to rheumatism, an arthritis of the poor.

But this "disease of kings" was sorely misunderstood and although diet and lifestyle can predispose a person to develop the disease other factors are equally significant. Once thought of as a disease that mainly affects middle-aged and older men, younger people and postmenopausal women are vulnerable too (1). Alcohol can bring on an attack however genetics and ethnicity are much more important in defining who gets the disease and many who never drink alcohol develop it. Studies show black Americans

having a higher prevalence of the disease compared to white Americans. Some studies show a higher prevalence of the disease among certain Asian populations, including those of Japanese descent and Native Hawaiians. (2) Diuretics (water pills) used to control high blood pressure are another contributing factor (1). There are several other risk factors for the disease however the traditional profile of the disease remains as Tudor King Henry VIII, a corpulent older man with an indulgent sweet tooth and a penchant for fine wine, rich red meat and offal. The disease controlled him for most of his later life.

Other foods that are implicated in the chronic development this disease include beer and alcohol, shellfish, beef, processed food and foods and beverages with high fructose corn syrup. Other established risk factors for the disease include chronic renal disease, hypertension, obesity, and metabolic syndrome. The disease is pervasive and painful and patients with the disease have an increased risk of all-cause mortality, particularly from cardiovascular disease, cancer, and infectious diseases (3).

The disease is gout, also known as gouty arthritis, and although it seems like it should be relegated to a curiosity cabinet this archaic disease is becoming more common.

The term "gout" itself is ancient, derived from the Latin word  gutta, meaning "drop" as it was thought to be caused by a drop-by-drop accumulation of humours (bodily fluids) in the joints.

Current care standards tell us that with early diagnosis, proper treatment and a few doable lifestyle changes, gout is one of the most treatable of diseases. Early recognition is important because left untreated or under treated the disease can develop into a more chronic form leading to gradual progressive joint destruction.

A Disorder of Metabolism

Although once thought to be the "disease of royalty" we now know that gout does not discriminate between commoner or king but rather that the disease is directly related to faulty metabolism. Diseases that are related to metabolic disorders disrupt the body's normal biochemical processes and occur when there's a problem with the body's ability to break down, use, or store nutrients that effect optimum health.

Diabetes is a common type of metabolic disorder. As with diabetes there are new insights and therapeutic interventions with new treatment options (we'll discuss those later).

For example certain characteristics of gout such as painful, disfiguring red, swollen, hot joints, especially in the big toe, along with hard lumps under the skin were scientifically observed as early as the 1600's but it was only in the 20th century that the pathways for their production and growth in the body were understood (4).

Gout is a disorder of metabolic disruption and occurs when the body's ability for processing and distributing nutrients are altered. These nutrients known as purines are natural substances found in the body. They are also found in many foods especially those high in protein. When broken down they produce uric acid. Uric acid is a normal body waste product. Gout is a disorder of metabolism that allows uric acid to accumulate in the blood (hyperuricemia) rather than be excreted. With gout high levels of uric acid can lead to needle-like crystals that deposit in the joints and tissues causing inflammatory arthritis (gouty arthritis) and extreme pain. Over time, if left untreated, uric acid crystals can accumulate and form hard lumps or tophi (TOE-fie) (Latin for stone), crystal-like masses that appear as a lump or hard nodule under the skin that can cause considerable destruction and discomfort.

90% of the time the 1st metatarsal phalangeal joint (MPJ) of the big toe is first effected causing severe joint pain, swelling, redness, and stiffness. Gout occurs most often in the big toe because uric acid is sensitive to temperature changes. At cooler temperatures, uric acid turns into needle-like crystals. Since the toe is the part of the body that is furthest from the heart, it’s also the coolest part of the body and the most likely target of gout.

Other effected areas include the ankles, knees, wrists, fingers and elbows with signs that present as hard nodules that cause the joint to be bulbous and disfigured.

Gout can also occur as a polyneuropathy affecting more than one joint as well as the outer ear and in the skin near the joints and the kidney.

Signs and Symptoms of Gout

An attack of gout can be miserable with

• Intense pain that comes on suddenly often in the middle of the night or upon rising.

• Red, tender, hot areas with swelling over the joint - inflammation.

Joint destruction is due to the crystalized tophi deposits around a joint that can cause it to become swollen and misshapen and the skin that covers it to become stretched and taut, sometimes to the point of ulceration. Tophi crystallization in the joints erodes bone and destroys cartilage, leading to chronic inflammation and debilitating pain. Uric acid is usually considered high when it’s over 7 milligrams per deciliter (mg/dL) for men (and those who were male at birth) and over 6 mg/dL for women (and those who were female at birth).

Causes of and Misconceptions about Gout

There are many variables that contribute to metabolic disorders and the worsening of symptoms. In the case of gout

• We known there is a correlation between certain foods and beverages (red meat, alcohol, beer and shellfish) that contain high levels of purines resulting in gout flare-ups and attacks.

• We know some people develop gout because their kidneys have difficulty eliminating normal amounts of uric acid, while others produce too much uric acid.

• We know that the tendency to accumulate uric acid is often inherited and that there are certain genes that control how much uric acid gets “reabsorbed” by the kidneys, which leads to higher levels of uric acid in the blood.

• We know there are other biological influences that put a person at risk for developing gout including high blood pressure, diabetes, obesity, metabolic syndrome and certain medications and vitamins that influence the risk of developing the disease. For example, the body’s ability to remove uric acid can be negatively affected by taking aspirin.

• We know some diuretic medications (water pills) and the vitamin niacin effect that risk.

• We know there is a prevalent age range. While gout is more common in men aged 40 to 60 years, it can occur in younger men and also occurs in women.

However the general misconceptions about gout have given it the reputation of being a disease of past times. A disease of revelry caused by too much food, wine and the excesses of the "gouty elite". Because of this there was and still is a tendency to trivialize the impact of the disease despite its severity and lack of class distinction. A recent survey conducted by the Alliance for Gout Awareness revealed some very interesting facts about the disease:

• 9 million Americans have gout

• 52% of people with gout feel embarrassed of their condition so they don’t talk about it.

• 40% of people look down on people with gout.

• 93% say they didn’t know that gout is actually a form of arthritis.

• 46% of gout patients believe that diet alone causes the disease.

Although diet does have a significant role in managing gout, there is a misconception that only people who eat poorly or drink alcohol in excess suffer from gout. In fact, people who eat healthy food and refrain from alcohol can still develop the condition. Most experts including rheumatologist Larry Edwards, MD, a professor of medicine at the University of Florida and chair of the Gout Education Society believes that although food plans for gout control such as the Mediterranean diet and DASH diet are important, diet alone is not enough to stop gout flares for most people.

There are other variables that contribute to the disease such as the gout genetic; the hereditary risk of developing gout. According to a 2022 study published in BMC Medicine

people who were least likely to develop gout had a low genetic risk and a healthy lifestyle; those more likely to develop it had a high genetic risk combined with a lifestyle that wasn’t so healthy. But even high-risk patients could reduce their risk by changing unhealthy factors to healthier ones, including choosing anti-inflammatory foods instead of gout triggers like red meat, beer and sugary drinks. The general consensus was that a healthy lifestyle, regular exercise, moderate alcohol consumption, not smoking and healthy eating were enough to override the genetic risk by at least one-third.

Diagnosing and Medical Management of Gout

In diagnosing gout, laboratory tests and x-rays are often ordered to determine if the inflammation is caused by something other than gout. If confirmed initial treatment of an attack of gout typically includes the following:

• Medications. Prescription medications or injections are used to treat the pain, swelling, and inflammation.

• Dietary restrictions. Foods and beverages that are high in purines should be avoided, since purines are converted in the body to uric acid.

• Fluids. Drink plenty of water and other fluids each day, while also avoiding alcoholic beverages, which cause dehydration.

• Immobilize and elevate the foot. Avoid standing and walking to give your foot a rest. Also, elevate your foot (level with or slightly above the heart) to help reduce the swelling.

Because high levels of uric acid (hyperuricemia) are a significant marker of gout it is important to recognize that periodic evaluation as part of an annual screening can avoid disease progression and joint destruction. A healthy benchmark for control of gout is a serum uric acid level (SUA) of 6.0 mg/dL or below.

The symptoms of gout and the inflammatory process usually resolve in three to ten days with treatment. If gout symptoms continue despite the initial treatment, or if repeated attacks occur you may be placed on a maintenance treatment that may involve daily medication. If diagnosed early, most people with gout can live a normal life. Lowering urid acid levels can improve joint function and resolve tophi. Medication, lifestyle and dietary changes can also help ease symptoms and reduce the frequency and severity of gout attacks.

Self-Management of Gout

Medicine is an important tool for managing gout but lifestyle and fitness changes can significantly contribute to the long-term success of gout management. Self-management includes

• avoiding high-purine foods as they can increase the amount of uric acid in the blood and may trigger an attack of gout.

• avoiding foods containing high fructose corn syrup, which are also associated with gout flare up. Fructose is a naturally occurring simple sugar found in fruits, vegetables and honey. In the form of high fructose corn syrup, it has become an additive in many foods and drinks. There is a correlation between a diet high in fructose content and gout. In the typical American diet, high-fructose corn syrup is added to many foods. All sweetened soft drinks, juices and foods with added high fructose corn syrup on the label, especially sodas, fruit drinks, many breakfast cereals, many store-bought baked goods, ice creams and candy and processed foods such as those found at “fast food” restaurants should be kept under control.
  

High-purine foods to avoid include

• organ meats, such as brain, sweetbreads, heart, kidney, and liver

• bacon

• turkey

• lamb

• venison

• herring, anchovies, smelt, and sardines

• mackerel, tuna, trout, haddock, and codfish

• mussels and scallops

• yeast

• beer, wine, and liquor

The Impact of Gout on People and Society

Not treating gout can result in attacks that are more frequent or longer in duration with implications to the cost in community health and quality of life. Patients with gout who are untreated or under treated may develop chronic tophaceous gout over several years, leading to gradual progressive joint destruction.

According to a 2013 study from the Arthritis Research Centre of Canada, the University of British Columbia and Boston University, there is a $2,021 annual work productivity loss per gout patient suffering from more than 3 gout attacks per year. For those patients that suffer 6 or more gout attacks per year, direct gout-related health care costs top $12,020. Patients with gout who fail to achieve optimal levels of serum uric acid are at increased risk for premature mortality with a risk twice as high in patients with serum uric acid levels of 6 mg/dL or higher than in those with levels below 6 mg/dL (5).

In recent years, a concerning increase in metabolic disorders has been observed worldwide (7). Time, stress and a greater preference for high-fat and high-sugar foods, as well as a decrease in physical activity can increase the risk of metabolic diseases. Health-driven modifications to meals are more challenging. All these factors require a more proactive partnership between patient and provider.

Gout is a Treatable Disease

Gout is a treatable disease. If diagnosed and treated properly it is one of the most controllable forms of arthritis. Many people can avoid gout flare ups, decrease the severity of their symptoms and can even become gout free.

Include a gout check-up in your annual exam, question your doctor if you are experiencing any symptoms of gouty arthritis or if anyone in your family is being treated for gout. Your doctor may recommend a blood test to check uric acid levels,

a joint fluid analysis or imaging tests if gout is suspected.

1. Harvard Health Publishing. “All About Gout”, May 5 2033. Reviewed by Robert H. Shmerling, MD, Senior Faculty Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health.  

2. JAMA Netw Open. Aug 1, 2022.”Racial and Sex Disparities in Gout Prevalence Among US Adults”. 

Natalie McCormick 1,2,3,4,✉, Na Lu 4, Chio Yokose 1,2,3, Amit D Joshi 2,3,5, Shanshan Sheehy 6, Lynn Rosenberg 6, Erica T Warner 2,3,5,7, Nicola Dalbeth 8, Tony R Merriman 9,10, Kenneth G Saag 9, Yuqing Zhang 1,2,3, Hyon K Choi 1,2

3. The National Kidney Foundation. “The Circular Connection Between Kidney Disease and Gout”. November 30, 2022. 

Jennifer Cramer-Miller

4. HSS.edu. “Gout In Depth: Risk Factors, Diagnosis and Treatment”. October 23, 2024 Theodore R. Fields, MD, FACP

5.Fernando Pérez-Ruiz, MD, PhD, from Hospital Universitario Cruces in Vizcaya, Spain, reported during a news conference here at the American College of Rheumatology 2018 Annual Meeting)

6. National Institute of Arthritis and Musculoskeletal and Skin Diseases December 2023

7. Int J Mol Sci. 2023 Jun 26;24(13):10672. doi: 10.3390/ijms241310672. New Insights and Potential Therapeutic Interventions in Metabolic Disease