Gout is out!

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A few commonsense steps can keep your big toe safe from this painful form of arthritis

Gout runs in Tom Lafavore's family. And when he's suffering a gout attack, it also runs--right down to his big toe, where tradition says it has paid back kings, nobles and rich men for thousands of years for their excesses.

Like most of the million other gout sufferers in America, Tom is not a nobleman, nor is he rich. He's a vocational-education teacher in Portland, Maine. But when gout first struck, he experienced a pain so excruciating that only a fellow gout sufferer would understand it, he says. "It's like constantly getting pounded on the toe with a sledgehammer." Twenty-four hours a day, for days on end.

Fortunately for all of you who suffer from this unique form of arthritis, the pain can be controlled--and you don't need a king's ransom to do it.

THE CAUSE OF GOUT IS CRYSTAL CLEAR
All gout attacks can be traced to a single problem: tiny crystals of uric acid that lodge in the lining of the joints and irritate them. Uric acid is one of our body's metabolic by-products. It's a kind of metabolic exhaust fume that the kidneys normally filter out and excrete through urine.

Many Americans have elevated levels of uric acid in their blood, either because there's too much for the kidneys to handle or because the kidneys aren't functioning properly. But only a small percentage of these people will ever have a gout attack. That's because the blood must become saturated with uric acid before crystal deposits begin to form in the joints.

"Think of what happens when you put too much sugar in a glass of iced tea," says Jeffrey R. Lisse, M.D., director of the division of rheumatology at the University of Texas Medical Branch, in Galveston. "The sugar will dissolve up to a point. Beyond that point the liquid can hold no more, and the remaining crystals pile up at the bottom. In gout, the excess crystals may pile up in the joints. What's not clear is why attacks are only intermittent although the crystals may be there for years."

YOUR FIRST BOUT WITH GOUT
So you've just felt the first not-so-gentle twinges of stabbing joint pain. Is it gout? Or another form of arthritis? Check out these three distinctive warning signs of a gout attack. If you experience any of the signs and symptoms, be sure to pass the information on to your doctor.

Sign #1: Sudden onset Gout strikes without warning--generally over-night--and quickly becomes very painful. Most other forms of arthritis begin gradually and get worse over several weeks or months, not several hours like gout.

Sign #2: Location, or 'The Big-Toe Mystery' The first attack of gout strikes a single joint. More than half the time it wallops the big toe. In some cases, an ankle or knee is the initial battleground.

Scientists speculate that the lower joints are usually the ones to get hit because of gravity. Like sugar crystals in that glass of iced tea, the uric-acid crystals settle to the bottom--and there's no place lower to go than your big toe. Previously injured joints are also more likely to be affected by gout. And there again, the big toe, ankle and knee, with all the banging about they get, remain likely candidates for a gout attack. (Exception: In older women who take diuretics, the first twinges may be felt in an elbow, wrist or finger.)

The affected joint usually looks swollen, and the skin turns deep red, as if it were infected. Later gout attacks may involve two or more joints, but the first attack rarely does.

Sign #3: Intensity Although the first attack may be relatively mild, sufferers swear there's no pain on earth like gout. "Older women with gout have told me that natural childbirth is less painful," says Robert Wortmann, M.D., professor of medicine and interim chairman of the department of medicine at the Medical College of Wisconsin.

Other forms of arthritis can be extraordinarily painful, too. But a little rest usually reduces the pain. Not so with gout. "It hurts constantly during an attack, no matter what I do," reports Tom. In fact, most people can't even tolerate the weight of a bed sheet on the affected area.

GETTING THE GOUT TEST
Gout or not, any sudden joint pain is cause for concern. Call your family physician or go to a hospital emergency room. The doctor will ask about your risks and may order a blood test to check for high levels of uric acid. If your big toe is the affected spot, that may strongly suggest the diagnosis. But the only way to say for certain if it's gout is to check the inflamed joint for uric-acid crystals.

The test is mercifully quick. After numbing the area with a supercold spray, the doctor removes fluid from the joint with a needle. The fluid is examined under a microscope for telltale crystals. Once the diagnosis is certain, treatment can begin pronto!

Why do doctors insist on a proper diagnosis? Because it can save you a lot of pain--and perhaps the use of a limb. Certain drugs given for gout won't relieve other forms of arthritis. Delaying the proper treatment could cause permanent damage.

FOUR STEPS THAT LOWER YOUR RISK OF GOUT
No single risk factor is likely to put your big toe on red alert. But a combination of risk-raisers can trigger an all-out gout attack. Fortunately, you can lower some of those risks by taking the following steps.

Lose weight, yes . . . Doctors say that more than half of all gout patients are overweight. And the greater your girth, the more susceptible you are to chronic diseases that can alter uric-acid concentrations in the blood. Tom Lafavore's experience bears this out: He's a diet-controlled diabetic, a factor doctors say increases his risk.

. . . but don't crash diet! If you have some weight to lose, don't go on a crash diet. The shock to your metabolism can raise uric-acid levels and trigger gout. "Twice, I've had gout attacks while I was trying to lose a lot of weight," says Tom. "Even my antigout medication didn't prevent one of the episodes." The moral: Lose weight gradually with a sensible low-fat diet and exercise.

Don't overindulge Purine is a protein by-product that is used by the body during cell growth or repair. When purines are burned up, the end product is uric acid. People prone to gout are often told to go on a low-purine diet to reduce uric-acid buildup.

"That's been overrated. The best diet for most gout sufferers is a weight-loss diet," says Herbert S.Diamond, M.D., clinical professorof medicine at the University of Pittsburgh and chairman of the department of medicine at Western Pennsylvania Hospital. Purine-rich foods--like organ meats, gravies, anchovies, herring and sardines--may trigger an attack in people with high uric-acid levels, but others can tolerate them in small portions.

Cut the alcohol In gout, what you drink is more important than what you eat. Alcohol is doubly bad: It increases uric-acid production and interferes with the kidneys' ability to filter it out--no matter how much urine you may pass on a drinking spree. People at risk don't have to give up the occasional New Year's toast, but overdoing it only tempts fate.

Drink water instead Water can help flush uric acid out of your system. That old H2O also helps maintain the fluid volume in your bloodstream. (Gout attacks can be triggered by dehydration in high-risk people.) You can easily maintain your fluid intake by drinking a 12-ounce glass of water or juice with every meal.

Actually, any shock that reduces the volume of blood or revs up the body's repair systems can raise uric-acid levels and cause gout: sudden serious illness, surgery, even too much exercise. Fixing the primary problem will clear up the gout. Some beneficial medicines can trigger gout, too. The most common culprits are diuretics, often prescribed for high blood pressure, heart failure or fluid retention. It's important to consult your doctor at the first sign of diuretic-induced gout. Don't stop taking the medication on your own!

PUT THAT GOUT TO ROUT
If left untreated, your first attack of gout can last 5 to 10 days. After that, it goes away on its own. But there's no reason to wait. Quick intervention with anti-inflammatory drugs can parry an attack within 24 hours.

First line of defense The treatment of choice for an acute gout attack is any one of the many non-steroidal anti-inflammatory drugs (NSAIDs). Most NSAIDs are extremely effective and cause only mild side effects: stomach upset, headache, skin rashes and, on rare occasion, ulcers. The most popular antigout NSAIDs are indomethacin and naproxen. Both are available only by prescription. Nonprescription ibuprofen is also used.

Ancient remedy The great-great-grandpa of antigout medicines is an anti-inflammatory called colchicine (COAL-chih-seen). Plant extracts containing colchicine were used to fight gout over 1,500 years ago. In all that time, no one has figured out exactly how it works. But work it does, especially when taken during the first two days of an attack.

Colchicine has lost ground to the NSAIDs because it takes a toll on people's digestive tracts: About 80 percent of patients will experience diarrhea, nausea and stomach cramps as side effects. Injecting colchicine into a vein can bypass stomach problems, but it requires a trip to the doctor. Despite these drawbacks, colchicine is still prescribed for those who don't respond well to the NSAIDs. It comes in a prescription-only tablet, usually taken in several small daily doses.

Last resort In some cases, doctors will inject a corticosteroid directly into the affected joint to reduce pain and swelling. But one major side effect severely limits the usefulness of this treatment: If a single joint undergoes more than three injections, there's a risk of tendon and ligament damage. So corticosteroids are a last resort.

FIGHTING FUTURE ATTACKS
First-time gout patients should be optimistic. A majority of these people will never suffer another attack. You can increase your odds of being in that majority by following some of the preventive measures mentioned earlier: Lose weight slowly, and drink more water and much less alcohol.

Some patients at high risk of a second gout attack won't actually have one until years later. Formerly, these people would be put on antigout drugs for life. But now doctors tend to take a wait-and-see attitude. Patients are given a bottle of colchicine or prescription nonsteroidal anti-inflammatory drugs, with instructions to take some at the first sign of an attack.

ATTACKING GOUT AT ITS ROOTS
Ultimately, only 25 percent of people who get gout will need a permanent prescription to prevent or reduce future attacks. Patients aren't generally put in this category until they've had three or more gout attacks within a year. The drugs used for long-term management fight the cause of gout, not the symptoms: These drugs are useless against pain and swelling during an attack. The preferred drug for the veteran of gout is allopurinol. It actually slows the rate at which your body produces uric acid.

Allopurinol is the best medicine for people with uric-acid stones or other kidney problems because it reduces the kidneys' work load. It may reduce your work load, too, since it makes a minority of patients drowsy or less alert.

Patients who can't tolerate allopurinol are given an older class of medicine, the uricosuric drugs. The best-known of these drugs is probenecid. Kidneys get no breaks here: Uricosurics work by increasing the amount of uric acid passed in the urine. Early on, people taking these drugs must drink liberal amounts of fluid to keep their urine diluted, or they'll get kidney stones.

Uricosurics are preferred in some cases for their ability to help dissolve painful deposits of uric-acid crystals that accumulate over time. In uncontrolled gout, these deposits can cause irreversible damage to the joints and form disfiguring lumps under the skin and in the cartilage of the ear.

Both allopurinol and uricosurics are taken orally, and they have similar side effects. Both can cause stomach upset, which generally goes away after the body becomes accustomed to the drug. They also can cause skin rashes, which in rare cases can become a serious problem.

Ironically, both drugs can increase the frequency of gout attacks during the first six months of use. Doctors think that reducing blood uric-acid levels so quickly causes the crystals to move around inside the joints. To control this cruel twist of fate, most patients take low doses of colchicine or NSAIDs for several months after starting treatment.

Once begun, allopurinol or a uricosuric must usually be taken for life. (New research suggests that some people--particularly those of normal weight--may be able to decrease their need for medication over time.) Talk over your medication options with your doctor. Tom Lafavore did. "I'm currently taking allopurinol, and for me it's worth it.

"In six years I've had only two additional gout attacks. And at least one of those attacks was caused by skipping my medicine. So stick with it," he advises.

For more information about gout or any other form of arthritis, and to receive a free copy of a 12-page booklet on gout, contact your local Arthritis Foundation chapter, or write to the national office at P.O. Box 19000, Atlanta, GA 30326. You may also call the Arthritis Foundation Information Line toll-free at (800) 283-7800. The toll-free phone line is staffed from 9 a.m. to 7 p.m. EST, Monday through Friday.

ILLUSTRATION: Ouch! This little piggy has gout! The big toe is usually the first target of this arthritic disease.

DIAGRAM: Left: Swelling, needlelike crystals and joint damage are the recipe for pain in a gout-ridden toe. Right: A normal toe joint.

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By Steven Lally

MEET MR. GOUT
The average gout sufferer is an overweight, middle-aged man. The first attack can hit by age 30, although it's more common in the 40s, 50s and beyond. Premeno-pausal women rarely get gout. For every woman there are 10 men afflicted, though either sex may inherit this painful legacy if there are gouty roots on the family tree.

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