But rich diet is only one factor in rising rates of ‘the disease of kings’l
Dr. Stephen Vogel should know better than to put chopped chicken livers on his Thanksgiving menu.
As a veteran victim of five years of gout attacks, the retired Gainesville, Fla., surgeon can more or less count on an excruciating flare-up of the acute arthritis that afflicts him and at least 3 million other people in the United States.
But does that mean he’ll steer clear of the savory spread at his brother’s house on Thanksgiving? Not a chance, said Vogel, 69, who is a walking, talking, noshing example of why rates of gout have doubled in the U.S. in recent years.
Organ meats, along with shellfish, beef, beer — and even turkey with gravy — are among foods believed to trigger the searing pain, swelling and inflammation of gout in susceptible people.
“When they break out the vodka bottles and the chopped livers, I can’t resist,” said Vogel. “And then that night, my ankle goes crazy.”
Once regarded as “the disease of kings” — including legendary gluttons such as Charlemagne and King Henry VIII — gout has been democratized, scientists say. Rising rates of obesity, diabetes and the worrisome condition known as metabolic syndrome likely have fueled an unprecedented rise in the joint disorder in an increasingly aging population.
“It’s not just the rich people who are getting it anymore,” said Dr. H. Ralph Schumacher, a gout specialist at the University of Pennsylvania School of Medicine.
Indeed, gout has become the most common form of inflammatory arthritis in men older than 40, and increasingly common in women after menopause, said Dr. John Sundy, director of rheumatology and allergy research at Duke University.
Most long-term treatment of the disorder has relied on a drug developed in the 1960s, but on Monday, an advisory committee of the federal Food and Drug Administration recommended U.S. approval of the first new treatment to manage gout in four decades.
It's not clear exactly how common gout is. A 10-year study of more than 4 million managed care patients in 1999 detected gout in 41 of every 1,000 people older than 75, up from 21 in 1,000 in 1990, according to the Journal of Rheumatology. Rates were more than 31 in 1,000 for people 65 to 74. Current rates have not been pegged, especially in younger people, because recent large studies have not been conducted.
At least one emergency department in Connecticut is keeping track on a small scale, however. At Windham Hospital in Willimantic, Conn., gout diagnoses appear to be up 23 percent over last year, according to Dr. Gregory Shangold, the ED director.
Gout is triggered by high levels of uric acid in the blood, a condition that occurs either when too much of the waste product is produced by eating certain foods, or too little is excreted by the kidneys. In either case, it accumulates, creating concentrations of needlelike uric acid crystals that pile up in the spaces between the joints.
Uric acid typically builds up over time, usually decades. While a single lavish meal isn’t enough to create conditions for gout, a flare can be sparked by a bout of binge drinking, by sudden dehydration or other changes in kidney function, or by trauma such as surgery or a heart attack. In some cases, a stubbed toe on the way to the bathroom in the middle of the night has been enough to send a susceptible patient into an attack.
High uric acid levels form crystals
“It's probably not the sharpness, but the way our inflammatory response reacts to the crystals” that creates a gout flare, Sundy said.
For gout victims, it becomes suddenly and painfully clear when uric acid exceeds normal bounds of less than 6 milligrams per deciliter of blood, often rising to 10 milligrams or higher.
More than 70 percent of gout sufferers experience their first acute attack in a big toe, typically waking up abruptly in the night with a joint so inflamed that the weight of a bedsheet is excruciating.
“It was really horrible. You can't even get air on it,” said Mike Andrews, 66, a restaurant owner who splits his time between Minneapolis and Palm Springs, Calif. He suffered a gout attack eight years ago that started in the middle of a lavish meal.
“It flared up right at the table," he said. "I could hardly walk."
Gout also commonly occurs in the ankle, elbow, shoulder or wrist, with initial bouts lasting about four days and later sessions stretching out a week or more.
“It was like someone cutting off your hand without anesthesia, only it went on for hours and hours and hours,” recalled Vogel, who developed one memorable bout while attending a medical conference in New Orleans.
“I was in a hotel in the French Quarter,” he recalled. “I had them send up four Grey Goose vodka tonics. I actually drank four vodka tonics, curled up in a fetal position.”
That probably was the worst way to treat gout, which often is triggered by alcohol, particularly spirits and beer, said Schumacher.
There’s some debate about whether certain foods actually spur gout attacks, with sufferers swearing they see a pattern and scientists saying they don't.
“A lot of times, people talk about cured meats,” Sundy said. “The strangest one I’ve ever heard is blue Popsicles, so it is far ranging.”
Foods high in purine, a chemical that helps create uric acid, long have been on the list for gout patients to avoid. More recently researchers such as Dr. Hyon K. Choi, a gout expert at the University of British Columbia in Vancouver, Canada, have documented a link between gout and fructose, including the high-fructose corn syrup present in many foods.
“The risk posed by sugary soda per serving was comparable to that caused by liquor intake per serving,” said Choi, who studied 46,000 men for 12 years. “Based on these data, we recommend that gout patients should avoid sugary soda.”
On the positive side, Choi has found that low-fat dairy products and lots of coffee — more than four cups a day — seem to protect against gout. Some sufferers swear by cherries or cherry juice.
Drugs more important than diet
Modifying diet, however, is not the sole or even the primary way to treat gout, experts say. Far more important are uric acid-lowering drugs, which last year accounted for 16.2 million prescriptions in the U.S., a 25 percent increase from nearly 13 million issued in 2003, according to IMS Health, a healthcare information and consulting company.
Top among those was allopurinol, a drug first approved more than 40 years ago, which accounted for 12.3 million prescriptions in 2007.
“I don’t leave the house without my allopurinol,” said Andrews, who has not suffered a gout attack since he began taking the daily 300-milligram peach-colored pill.
Many gout patients will suffer one attack and then not another for months or even years.
For the acute flare-ups, doctors rely on nonsteroidal anti-inflammatory drugs such as such as naproxen and ibuprofen, or on a drug called colchicine to immediately ease the inflammation and pain, said Joan McTigue, a physician assistant in the rheumatology division at the University of Florida College of Medicine in Gainesville.
In some cases, that might be enough.
“If you get some guy who comes in and says he drank beer and ate shrimp all weekend, but he doesn’t normally do that, we might say, ‘Don’t do that again,’ and he might get by,” McTigue said.
Many gout patients, however, will need long-term treatment with allopurinol or other uric-acid lowering drugs to prevent repeated attacks.
One problem with gout is that people often seek initial care from emergency room or primary care doctors, who may not properly diagnose or treat the disease. Either they don't recognize gout as the problem, thinking it's a bacterial infection, for instance, or they do detect gout, curb the initial attack and, if warranted later, start allopurinol therapy, but at a dose too low to completely dissolve the crystals, McTigue said.
Underdosing with allopurinol doesn’t lower the uric acid to optimum levels, allowing crystals to continue to accumulate and setting the stage for future pain and joint destruction, McTigue said.
Gout that is left undetected, or cases that don’t respond to treatment can lead to severe, life-altering disease, including joint deformities called tophi. Tophi occur when crystallized uric acid forms stonelike bumps that can swell and burst.
That happened to Janet Wheeless, 63, of Nashville, N.C., who took allopurinol for gout for 15 years, but had to stop when she developed kidney trouble. One morning, she noticed a tiny knot on one thumb, followed quickly by several larger growths.
“It just seemed like all my fingers were infected with the tophi overnight,” said Wheeless, a pharmacy technician who struggled to type with gnarled, knobby fingers.
‘A terrible, terrible disease’
She finally found relief after joining a clinical trial now being conducted by Sundy for a drug called pegloticase, which is showing success with treatment-resistant gout.
“It’s a terrible, terrible disease,” Wheeless said. “People just don’t realize what it can do.”
Sundy receives research funds from Savient Pharmaceuticals, which makes pegloticase. He’s also a consultant for the firm, but does not take payment. In addition, Duke holds some patent rights to the drug.
High levels of uric acid don’t necessarily cause gout, scientists said. In fact, only 20 percent of people with very elevated levels ever develop the disease, while many people with low levels of uric acid — including Vogel and Wheeless, for instance — do.
That’s one reason uric acid was dropped from a standard blood chemical screening panel more than a decade ago: The measure wasn’t a reliable indicator of disease.
Now, however, some researchers are finding links between high levels of uric acid and other problems, such as cardiovascular disease and kidney disease. Choi and Schumacher both have led research that finds a significantly elevated risk of cardiac disease among gout sufferers, even when other risk factors have been accounted for.
Choi has received funding in the past from Tap Pharmaceuticals, now merged with Takeda Pharmaceutical Company Limited, which makes gout drugs, including febuxostat, a uric acid-lowering drug that has been billed as the first alternative to allopurinol in decades. Schumacher also has received grants from Takeda and has served as a paid consultant to Savient.
An arthritis advisory committee of the federal Food and Drug Administration on Monday recommended approval of febuxostat to treat hyperuricemia in the U.S., a move that could dramatically alter the gout drug market.
Privately, however, some scientists said that while they welcome new treatments for gout, they'd like to see results of large clinical trials before expanding uric acid-lowering drugs to people who don't suffer from the acute disorder.
Do holiday meals mean more gout?
In the meantime, gout sufferers should be aware that some hospital emergency rooms report spikes in gout cases in the days after heavy holiday meals, although others say they see no connection.
“We usually see an increase in gout attacks during the holidays,” said Dr. Shay Bintliff, medical director of the emergency department at Hale Ho’ola Hamakua Hospital in Honokaa, Hawaii. “Patients will say that they know they should not eat certain foods or drink alcohol, but just cannot resist.”
It’s the big picture that’s most important, said Schumacher.
“I don’t think a few nice meals are what makes or breaks gout,” he said. “Our dietary expectations have to be more on chronic weight loss and healthy diets rather than one nice turkey dinner.”l
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