Gout was believed to be a disease that afflicted only the rich but with an increase in risk factors, it’s now a possibility for just about anyone
Gout is one of the world’s oldest forms of arthritis and it is known as podagra when it affects the big toe joint. It is believed that the first evidence of gout appeared in a description of arthritis of the big toe, dating back to 2600 BC, in Egypt!
Thanks to King Henry VIII of England, who was thought to have suffered from gout and frequently pictured holding a morsel of food or guzzling wine, this disease became associated with a ‘rich man’s’ diet. However, gout has been known to attack seemingly healthy people who eat balanced meals.
We spoke to Sunway Medical Centre’s consultant physician and rheumatologist, Dr. Amir Azlan Zain about gout in the big toe.
Crystals in Your Body
Gout is a form of arthritis caused by hyperuricaemia, which is essentially elevated levels of uric acid (a product of the metabolic breakdown of protein that contain purines) in the blood. Hyperuricaemia happens because of a host of reasons including genetics and obesity. In healthy people, excess uric acid is excreted in the urine but for those with hyperuricaemia, this doesn’t happen. So excess uric acid crystallises and collects in joints, tendons and surrounding tissues, causing inflammation. This is when the base of the big toe joint can become red, swollen and warm or hot to the touch. As much as 50% of first-time gout cases, occur in the big toe joint.
Uric acid crystals form easily in cool temperatures, which is why gout attacks also tend to occur in the big toe. The feet and the toes are considered to be a cooler part of the body as it takes longer for blood to circulate to the area. Our heels, ankles, knees and wrists are also cooler zones and this explains why these areas are also more susceptible to gout. Other than that, external trauma plays a role in gout attacks and the big toe, which is at risk for trauma, is very vulnerable. A sprain or even stubbing your toe could trigger an episode of gout
Gender, Food and Family History
According to Dr. Amir, “Uric acid is a product of cellular breakdown thus, 70% of gout attacks are due to cellular turnover. The higher the cellular turnover, the higher the chance of contracting gout.” This is why men are predisposed to gout as they have higher cellular turnover.
Having a family history of gout also increases a person’s risk for gout attacks. This is especially true for men who do not eat a balanced diet and who smoke. Dr. Amir says that 30% of gout attacks are attributed to a diet high in purines. “Food such as red meat and shellfish are food that are rich in purines along with organ meats such as brains and liver. Alcohol in the form of beer and stout elevate uric acid levels as well.”
Other factors including pre-existing conditions such as hypertension, metabolic syndrome and insulin are seen in more than half the cases. Dr. Amir has observed that in recent years in Malaysia, gout is being diagnosed in people who don’t fit the profile such as men in their late teens to twenties and young women too.
Intense Pain, Swelling and Redness
According to Dr. Amir, gout attacks follow a pattern. “There is a sudden onset of pain, swelling and redness in the toe. This goes on for about two to three days and the pain is intense. It goes away just as quickly as it hits. In between episodes, the toe feels completely normal.”
If you experience these symptoms, it is best to either see a physician or a rheumatologist. They can advise you on lifestyle changes and also prescribe medication that may help. Dr. Amir mentions that with recent advancements in ultrasound techniques, uric acid crystals can now be accurately detected in the joint.
The medication prescribed depends on the stage of gout attack. “During acute episodes, colchicine which is a type of pain reliever, anti-inflammatory medication and sometimes — although rarely —steroids will be prescribed. For patients with the potential for joint damage, I would advise considering a treatment that lowers uric acid, which involves enzyme inhibitors such as allopurinol.”
For relief at home or if you’re nowhere near a pharmacy or a doctor, ice cold water may help. “The most effective way to find relief is to use non-steroidal anti-inflammatory drugs (NSAIDs) which will sort the pain out within a few hours,” says Dr. Amir. Most importantly, rest until the attack subsides.
Diet and exercise plays an important part in managing gout symptoms. Contrary to popular belief, exercise is beneficial to people with gout. “During an attack, it is too painful to exercise so it is best to rest during this time. In between attacks, exercise won’t harm the toe at all,” explains Dr. Amir. Exercise is especially good for people who are overweight because being overweight increases the chances of experiencing a gout attack.
As for food, it is best to stick to a diet low in purines. “Practice moderation with red meat, shellfish and organ meats such as brains, kidneys and liver. Purine levels in plants are much lower than in animal by-products but different people have different food triggers. Alcohol can contribute to gout attacks but the least contributory would be white wine and spirits,” shares Dr. Amir adding that you should see a doctor if you have recurrent episodes of gout. Ask about the suitability of long-term uric acid treatment for relief. “Gout remains the most treatable form of arthritis,” assures Dr. Amir.
Did you know?
- Great apes (chimpanzees, gorillas and orang utans) do not have the ability to produce uricase which breaks down uric acid. This is why they can suffer from gout as well.
- A Tyrannosaurus rex specimen known as ‘Sue’ is believed to have suffered from gout.
- Sir Isaac Newton had gout.
Arthritis Foundation Malaysia; Footdoc.ca; Mayo Clinic; Malaysian Society of Rheumatology;