Gout: A Big Pain in the Big Toe

Dr. Brown is an assistant professor of pharmacy practice at Palm Beach Atlantic University, Lloyd L. Gregory School of Pharmacy, West Palm Beach, Florida.

Gout is a condition in which there is too much uric acid in the joints, tissues, and sometimes, even the kidneys. When this acid builds up, crystals are formed, often causing pain in the affected areas.

Gout occurs much more frequently in men—approximately 10 times as common—than in women.As you age, the risk for having gout increases. Additionally, having a family history of gout is linked to the development of the condition.

Risk Factors

Other risk factors for gout include being overweight or obese; drinking alcohol; heart failure; history of kidney disease; lead toxicity; high cholesterol; high blood pressure; and medications such as diuretics (fluid pills), niacin, aspirin (>2000 mg/day), levodopa, and cyclosporine. Eating certain foods high in purines, a natural substance found in cells, is also a risk factor. For the most part, high-purine foods are also high in protein, and these foods include organ meats like liver, and some fish, such as herring, salmon, and sardines.

Symptoms

The most common symptoms associated with gout include pain, redness, warmth, and swelling in the affected joint(s). Patients commonly describe a worsening of pain with touch. Although gout attacks may be slightly different from patient to patient, they typically come on suddenly, occur during the night, and affect the big toe. Other joints and tissues that may have a buildup of these crystals include the insteps, heels, ankles, knees, fingers, wrists, and elbows.

How is gout treated? Lifestyle changes, such as losing weight, reducing alcohol intake, avoiding foods high in purines, and controlling blood pressure and cholesterol, can help to lower the buildup of these crystals in the body; however, when used alone, these methods are often ineffective in bringing levels back to normal. Thus, medications are often used to help.

Treating Gout Attacks

Treating a gout attack early is important to reduce the pain as quickly as possible. Hot pads and/or cold packs may provide additional pain relief. In addition, several medications are available to treat gout attacks.

Nonsteroidal Anti-inflammatory Drugs

This class of drugs works quickly to relieve pain and is a cost-effective option. The data do not suggest, however, that these medications are better than any other treatment option for gout attacks. Indomethacin, a prescription medicine, is commonly used; however, other anti-inflammatory medications may be used, such as ibuprofen and naproxen (available over the counter), and sulindac, by prescription. This class of medications should be used cautiously in patients with a history of peptic ulcers, kidney disease, heart failure, or coronary heart disease. Side effects of anti-inflammatory medications may include increased risk for bleeding, rash, nausea, diarrhea, and heartburn.

Other Prescription Options

An alternative to anti-inflammatory drugs for the immediate treatment of gout attacks is colchicine. This drug is most effective when given as quickly as possible; within 24 to 48 hours is best. Beginning treatment after 48 hours of symptoms does not tend to be as successful, when compared with starting it earlier. If you are prescribed this drug, instructions commonly include taking it every 2 hours until diarrhea occurs, symptoms have gone away, or a total of 8 mg has been taken. Side effects include nausea, vomiting, and diarrhea.

Steroids are reserved for patients who cannot tolerate or who do not respond well to anti-inflammatory medications or colchicine. If you are prescribed steroids to relieve the pain of a gout attack, they may be given either by injection into the affected joint or taken by mouth. Steroids generally are used for the shortest period of time possible, due to the risk of side effects, such as osteoporosis, cataracts, diabetes, high blood pressure, and many others.

Pain from gout attacks usually resolves within a few days of treatment. Patients may never have another attack, or a second attack may occur as late as 5 to 10 years after the first episode.

Preventing Recurrent Attacks

Patients who have frequent gout attacks, certain softtissue swellings, or kidney stones from the build up of uric acid are often considered for beginning treatment to prevent gout attacks. This decision should be discussed with your doctor, who should take into consideration how well your kidneys are working, as well as your uric acid level.

Commonly Prescribed Medications

Colchicine is commonly used to prevent recurrent attacks of gout. Taking low doses of this drug once or twice daily has been shown to prevent gout attacks, especially in patients who have normal or slightly increased uric acid levels.

Another option available by prescription is allopurinol. When given once daily, allopurinol is effective in reducing the production of uric acid. This is the treatment of choice for patients who have kidney stones from gout and for patients who have kidney problems and/or disease.

It is important to note that allopurinol is not used to treat gout attacks; in fact, an attack may occur when beginning therapy, and the attack can be managed with anti-inflammatory medications or colchicine. Side effects of allopurinol may include nausea and diarrhea. Patients who develop a skin rash, hives, itching, swelling, blood in the urine, or trouble breathing should stop taking the medication and seek immediate medical attention, as this may indicate a potentially fatal allergic reaction.

Another class of drug is available by prescription to help prevent gout attacks from recurring. These medications, which include probenecid and sulfinpyrazone, work by reducing uric acid levels through urination. They should not be used if you do not have normal kidney function. Patients taking these medications should drink at least 8 to 10 full glasses (8 oz each) of water every day to prevent the development of kidney stones. These drugs may interact with other drugs, such as penicillin, indomethacin and other aspirin-like products, and other antibiotics. The use of low-dose aspirin for the prevention of coronary heart disease is generally acceptable, however.

Side effects associated with this therapy may include nausea, vomiting, headache, dizziness, sore gums, or flushing. As with allopurinol, the presence of shortness of breath, blood in the urine, rash, hives, and/or swelling may indicate an allergic reaction. Immediate medical attention should be sought.

Conclusion

You may want to consider stopping preventive medication if you have been symptom-free for about 1 year. Stopping therapy presents a risk for an attack of gout, however. All health care practitioners involved in your care should have a full understanding of any underlying diseases or health conditions you may have as well as all of the medications you are taking, in order to develop the best treatment plan and stop gout from being a big pain in the big toe.