BRUCE ROSEMAN, M.D.
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BRUCE ROSEMAN, M.D.
NICOLE LIVESCU, R.N.

Gout

Definition
You wake up in the middle of the night, and your big toe feels as if it's on fire. It's hot, swollen and so tender that even the weight of a sheet on it seems intolerable. These problems could indicate an acute attack of gout or gouty arthritis a form of arthritis that's characterized by sudden, severe attacks of pain, redness and tenderness in joints.

Gout is a complex disorder that can affect anyone. Men are more likely to get gout than women are, but women become increasingly susceptible to gout after menopause.
Fortunately, gout is treatable, and there are ways to reduce the risk that gout will recur.
Symptoms

The signs and symptoms of gout are almost always acute, occurring suddenly often at night and without warning. They include:
Intense joint pain. Gout usually affects the large joint of your big toe but it can occur in your feet, ankles, knees, hands and wrists. If untreated, the pain typically lasts five to 10 days and then stops. The discomfort subsides gradually over one to two weeks, leaving the joint apparently normal and pain-free.
Inflammation and redness. The affected joint or joints become swollen, tender and red.

Causes
Gout occurs when urate crystals accumulate around your joint, causing the inflammation and intense pain of a gout attack. Urate crystals can form when you have high levels of uric acid in your blood. Your body produces uric acid when it breaks down purines, substances that are found naturally in your body, as well as in certain foods, such as organ meats, anchovies, herring, asparagus and mushrooms.
Normally, uric acid dissolves in your blood and passes through your kidneys into your urine. But sometimes your body either produces too much uric acid or your kidneys excrete too little uric acid. When this happens, uric acid can build up, forming sharp, needle-like urate crystals in a joint or surrounding tissue that cause pain, inflammation and swelling.

Risk factors
You're more likely to develop gout if you have high levels of uric acid in your body. Factors that increase the uric acid level in your body include:
Lifestyle factors. Choices you make in your everyday life may increase your risk of gout. Excessive alcohol use generally more than two drinks a day for men and more than one for women increases the risk of gout.
Medical conditions. Certain diseases and conditions make it more likely that you'll develop gout. These include untreated high blood pressure (hypertension) and chronic conditions, such as diabetes, high levels of fat and cholesterol in the blood (hyperlipidemia), and narrowing of the arteries (arteriosclerosis).
Certain medications. The use of thiazide diuretics commonly used to treat hypertension and low-dose aspirin also can increase uric acid levels. So can the use of anti-rejection drugs prescribed for people who have undergone an organ transplant.
Family history of gout. If other members of your family have had gout, you're more likely to develop the disease.
Age and sex. Gout occurs more often in men than it does in women, primarily because women tend to have lower uric acid levels than men do. After menopause, however, women's uric acid levels approach those of men. Men also are more likely to develop gout earlier usually between the ages of 40 and 50 whereas women generally develop signs and symptoms after menopause.
When to seek medical advice
If you experience sudden, intense pain in a joint, call your doctor. Gout that goes untreated can lead to worsening pain and joint damage.
Seek medical care immediately if you have a fever and a joint is hot and inflamed, which can be a sign of infection.
Tests and diagnosis
Tests to help diagnose gout may include:
Joint fluid test. Your doctor may use a needle to draw fluid from your affected joint. When examined under the microscope, your joint fluid may reveal urate crystals.
Blood test. Your doctor may recommend a blood test to measure the uric acid level in your blood. Blood test results can be misleading, though. Some people have high uric acid levels, but never experience gout. And some people have signs and symptoms of gout, but don't have unusual levels of uric acid in their blood.
Complications
People with gout can develop more-severe conditions, such as:
Recurrent gout. Some people may never experience gout signs and symptoms again. But others may experience gout several times each year. Medications may help prevent gout attacks in people with recurrent gout.
Advanced gout. Untreated gout may cause deposits of urate crystals to form under the skin in nodules called tophi (TOE-fi). Tophi usually aren't painful, but they can become swollen and tender during gout attacks.
Kidney stones. Urate crystals may collect in the urinary tract of people with gout, causing kidney stones. Medications can help reduce the risk of kidney stones.
Treatments and drugs
Treatment for gout usually involves medications. What medications you and your doctor choose will be based on your current health and your own preferences. Medications for gout include:
Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs may control inflammation and pain in people with gout. NSAIDs include over-the-counter options such as ibuprofen (Advil, Motrin, others) and naproxen (Aleve, others), as well as more powerful prescription NSAIDs. NSAIDs carry risks of stomach pain, bleeding and ulcers.
Colchicine. Colchicine controls gout effectively, but may cause uncomfortable side effects, such as nausea, vomiting and diarrhea. If you're unable to take NSAIDs, your doctor may recommend colchicine.
Steroids. Steroid medications, such as the drug prednisone may control gout inflammation and pain. Steroids may be administered in pill form, or they can be injected into your joint. Side effects of steroids may include thinning bones, poor wound healing and a decreased ability to fight infection. Steroids may be reserved for people who can't take either NSAIDs or colchicine.
Prevention

Medications
If you experience several gout attacks each year or if your gout attacks are less frequent but particularly painful, your doctor may recommend medication to reduce your risk of future gout attacks. You usually begin taking preventive medications once your acute gout attack has subsided. Options include:
Medication that blocks uric acid production. Allopurinol (Zyloprim, Aloprim) limits the amount of uric acid your body makes. This may lower your blood's uric acid level and reduce your risk of gout. Side effects include a rash and low blood counts.
Medication that improves uric acid removal. Probenecid improves your kidneys' ability to remove uric acid from your body. This may lower your uric acid levels and reduce your risk of gout, but the level of uric acid in your urine is increased. Side effects include a rash, stomach pain and kidney stones.

Gout diet
No specific dietary changes are proved to reduce your risk of gout. However, it may make sense to eat foods that contain fewer purines. If you want to try a gout diet, try to:
Cut back on the amount of red meat and seafood you eat.
Avoid alcoholic beverages.
Eat more low-fat dairy products.
Eat more complex carbohydrates, such as whole-grain breads.
Choose portions that allow you to maintain a healthy weight. Losing weight may decrease uric acid levels in your body. But avoid fasting or rapid weight loss, since doing so may temporarily raise uric acid levels.
Lifestyle and home remedies
Take care of your body during a gout attack. While you're waiting for your medications to take effect, you may find it easier to cope with pain and inflammation if you:
Reduce the amount of animal protein you eat. Government guidelines advise eating no more than 5 to 6 ounces of lean meat, poultry or fish a day for nearly everyone especially people who have gout, because high-protein foods increase the blood level of uric acid. Organ meats (liver, brains, kidney and sweetbreads), anchovies, herring and mackerel are particularly high in purines.
Avoid alcohol. Alcohol can inhibit the excretion of uric acid. If you're having a gout attack, it's best to avoid alcohol completely.
Drink plenty of liquids. Fluids help dilute uric acid in your blood and urine, so be sure you get enough water and other fluids every day.
Alternative medicine
If gout treatments aren't working as well as you'd hoped, you may be interested in trying complementary and alternative treatments for your gout. Discuss these treatments with your doctor first. Your doctor can help you weigh the benefits and risks and tell you if the treatments will interfere with your gout medications.
Though you may be reluctant to discuss complementary and alternative medicine with your doctor, many mainstream doctors are becoming more open to discussing these options. But, since few of these treatments have been extensively studied in clinical trials, it's difficult to assess whether these treatments are helpful for gout pain. In some cases, the risks of these treatments aren't known.
Some complementary and alternative treatments that have been studied include:
Coffee. Studies have found an association between coffee drinking both regular and decaffeinated and lower uric acid levels, though no study has proved how or why coffee may have an influence on uric acid in your body. The available evidence isn't enough to encourage noncoffee drinkers to start, but it may give researchers clues to new ways of treating gout in the future.
Vitamin C. Supplements containing vitamin C may reduce the levels of uric acid in your blood. However, vitamin C hasn't been studied as a treatment for gout. Don't assume that if a little vitamin C is good for you, then lots is better. Megadoses of vitamin C may increase your body's uric acid levels. Talk to your doctor about what a reasonable dose of vitamin C may be. And don't forget that you can increase your vitamin C intake by eating more fruits and vegetables, especially oranges.
Cherries. Cherries have been associated with lower levels of uric acid in studies, but it isn't clear if they have any effect on gout signs and symptoms. Adding cherries and other dark-colored fruits, such as blackberries, blueberries, purple grapes and raspberries, to your diet may be a safe way to supplement your gout treatment, but discuss it with your doctor first.
Other complementary and alternative medicine treatments may help you cope until your gout pain subsides or your medications take effect. For instance, relaxation techniques, such as deep-breathing exercises and meditation, may help take your mind off your pain.


By Mayo Clinic Staff
Nov. 14, 2007
1998-2009 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "EmbodyHealth," "Reliable tools for healthier lives," "Enhance your life," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research.
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VITAMIN C MAY PREVENT GOUT
Study finds that every 500 milligrams cuts risk of condition by 17 percent
CHICAGO - Men with a higher intake of vitamin C from food or supplements have a lower risk of developing gout, a form of arthritis from uric acid build-up that causes inflamed joints, researchers said on Monday.
"Vitamin C intake may provide a useful option in the prevention of gout," Dr. Hyon Choi and colleagues at the University of British Columbia in Vancouver said in a paper published in the Archives of Internal Medicine.
Gout victims are typically men age 40 and older, although the malady can also strike women. Vitamin C appears to lower the levels of uric acid in the blood, the research team said.
 
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