Established gout treatment raises new controversy

Conway McLEAN, DPM

If you are a 50-year-old male, and you have pain in your big toe, do you have gout? Is that how it works? And if you had a glass of wine in the last year, then the pain in your foot must be caused by gout. Isn’t that how it goes? But this leaves us with one very important question: what is gout?

Gout is a medical condition, recognized for centuries as having an association with the overindulgence OF meat, seafood and alcohol, causing the acute development of pain from some joint of the body, usually of an extremity. Because of this association, the condition was considered a disease of the wealthiest people — those who could afford such eating habits. It was seen as the disease of kings, afflicting only the lazy and gluttonous.

Classified as a type of arthritis, gout occurs when high levels of uric acid in the blood cause crystals to form and accumulate around a joint. Uric acid is a substance produced when the body breaks down a chemical called purine. Purine occurs naturally in your body, but it’s also found in certain foods. An attack results from the precipitation of this material into crystallized deposits of uric acid in and around the joint. These crystals are tremendously irritating to soft tissues and cause severe inflammation presenting as swelling, redness, heat, and intense pain. The classic statement is that the pain is so severe that “even the bed sheets hurt”. Other typical symptoms include stiffness in the joint, with all of these sensations typically developing suddenly, often overnight.

As mentioned, the joint most often involved is the big toe joint. When an acute attack occurs there, the condition is called “Podagra”. But most any joint of the body can be involved. This includes the joints composing the instep of the foot, ankles, heels, knees, wrists, fingers, and elbows. The anatomy of the great toe joint is complex, as is the mechanical functioning of this part of the body, so many painful conditions can occur there. A take-home message would thus be that just because the big toe joint is painful, it does not necessarily mean it is gout. Conversely, if some other foot or lower extremity joint is suddenly painful, it also could be a gout attack.

These days, however, gout is everywhere, meaning it is occurring more commonly. Typically seen in older men, the disease now increasingly afflicts women and younger adults, often accompanied by obesity, diabetes, and high blood pressure. The global burden of gout is substantial and seems to be increasing in many parts of the world over the past 50 years. Developed countries tend to have a higher burden of gout than developing countries, and seem to have an increasing prevalence and incidence of the disease. Some ethnic groups are particularly susceptible to gout, supporting the importance of genetic predisposition. The incidence of gout generally increases with age, reaching a plateau after age 70. In general, gout incidence is 2?6-fold higher in men than in women.

Long before the cause of gout was understood, doctors had observed some benefit of a restricted diet on gout management. For many years, treatment of gout focused on eliminating all foods that had moderate to high amounts of purine. The list of foods to avoid was long, which made the diet difficult to follow. More recent research on gout has created a clearer picture of the role of diet in disease management. Some foods should be avoided, but not all foods with purines should be eliminated. And some foods should be included in your diet to control uric acid levels.

Dietary recommendations include the consumption of more fruits, vegetables and whole grains, which provide complex carbohydrates. Avoid foods such as white bread, cakes, candy, and sugar-sweetened beverages. Keep yourself hydrated by drinking plenty of water. An increase in water consumption has been linked to fewer gout attacks. Some foods of concern on older gout diets included such options as various healthy vegetables that happened to be high in purines. Various studies reveal they do not increase the risk of gout or recurring gout attacks. These include such healthy foods as asparagus, spinach, and mushrooms.

The general principles of a gout diet are essentially the same as the recommendations for a balanced, healthy diet. These include weight loss, since being overweight increases the risk of developing gout, and losing weight lowers the risk of gout. Research suggests that reducing the number of calories and losing weight — even without a purine-restricted diet — lowers uric acid levels and reduces the number of gout attacks. Losing weight also lessens the overall stress on joints.

When the decision is made to put patients with gout on a long-term drug regimen to lower their uric acid, one of several medications can be prescribed. Colchicine, a natural substance originally extracted from the autumn crocus plant, has been used to treat gouty arthritis for centuries. Clinical trial results have demonstrated that low-dose colchicine is effective for the management of acute gout flares as well as for long-term prophylactic maintenance. Regardless, a bitter battle has broken out among physicians about how best to treat this serious affliction.

Gout is known for causing recurrent attacks, and so many physicians have adopted the position that if a relatively safe medication can prevent these episodes, we should not hesitate to prescribe them. But new clinical guidelines published by the American College of Physicians leave many gout experts outraged, saying the guidelines will harm their patients. These new guidelines call for less aggressive pharmaceutical treatment of those suffering from gout attacks. Some gout specialists have formed a group to promote the long-term use of medications to lower uric acid. (To further muddy the waters on the issue, this professional group is backed by a major drug company.)

This exchange highlights the tensions and disagreements over what exactly constitutes ‘scientific evidence’ about appropriate treatment of this, or any other medical condition. There are no published clinical trials demonstrating that patients with gout should be put on a long-term drug regimen to lower their uric acid to any specific level. The need for gold-standard evidence — in the form of randomized, controlled clinical trials — to prove the correct approach to treating any affliction, is a controversial one in medicine. How much should a physician use clinical experience, or his expertise and good judgement, in recommending a treatment regimen?

Rheumatologists argue that the expensive clinical trials that the American College of Physicians wants to see are unlikely to be conducted on already approved drugs. This type of study is quite costly. Many clinicians treating gout believe it makes no sense to wait until a patient suffers from repeated painful flare-ups before treating him or her, since clinical experience demonstrates that lowering uric acid prevents the painful and recurrent flare-ups that bedevil most suffers afflicted with this condition.

The reliance of established medicine on the results of clinical trials remains a controversial one. If a study has not been performed on some particular treatment, does this mean it is not beneficial? Many would say ‘No’, and they continue to treat patients using a combination of clinical acumen, their experience, the results of research on relevant topics, as well as established clinical trials. For those suffering from gout, dietary recommendations have changed. As has the practice of many physicians, who don’t all subscribe to the notion ‘if there hasn’t been a clinical trial, it can’t be so’. Clinical judgement and personal experience should still count for something.

Editor’s note: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.