Dr. Tom:
So today we're talking about gout. And gout is one of the most common problems I see in my office. It's an arthritic inflammatory problem, meaning it's inflammation in the joints. And it affects about 41 million people worldwide. It also affects about 9.2 million people in the US. And it used to be known as the King's disease because a lot of the royalty in medieval times were the only ones to get it. And likely because their diet was a little bit richer and their weight was a little bit higher than the surrounding normal population. And interestingly, we are the only mammals known to spontaneously develop gout. And it's a likely do one to our diet because if we compare it to say other mammals like the gorillas, well, they eat mostly a plant-based diet and they don't develop count. So how does this actually present to my office? Well, usually the patient calls me up and says, doc, my toe really hurts and it's hot, it's red, it feels like it's really warm. And I'll say, well, how long has this been going on? And they'll say, usually they'll say like two to three days. And I'll ask, well, has this happened before? And they'll say, well, no. And I'll ask, well, has it happened with your family? Like has your dad had it? And they'll say, yeah, he's had it, I think. And then I'll ask, well, does it hurt when the bed sheet comes down on top of it? And they'll go, yeah, that really bothers me. There's no way I can do that. So we call that the positive bed sheet sign. And it's just kind of a little. test to see, hey, does it hurt that bad? And I commonly use it in gout to kind of test and see if it is gout. So what else does gout present with, right? Well, at the time of diagnosis, it usually presents with a body mass index of 30.9. It usually can present with high blood pressure as well. And sometimes it can present with heart failure, diabetes, renal complications, because we'll see that the kidney is important in this disease, and as well as coronary artery disease or heart disease, and stroke, and as well as hyperlipidemia. And we'll see that triglycerides can actually affect it as well. So why does this happen, right? Why does it actually... happened or how does it happen in the joint itself? Well, it all starts with a molecule called purine. And purine we consume in our diet and it's made to actually help build our DNA. And eventually the purine gets converted into what's called urate and then uric acid. And then our kidneys kind of get rid of that. But when our kidneys can't get rid of it, it builds up in our system and it can't stay in the water of our blood very well. So it drops out a solution. And you can compare this to, say when you try and make lemonade. Well, you put sugar in there and then the sugar, if you keep adding it, it will come out of that solution and stay on the bottom. And no matter how much you stir it, it just stays there and you can't get rid of it. And so this similar thing happens in gout. And in gout, it's actually the formation of crystals in the joint. And so crystals like sugar crystals, these uric acid crystals form in the joint and it's super painful. And it causes inflammation, it activates our immune system to come and. you know, bring in more little soldiers to attack the area. And so we get this hot red inflamed and swollen joint. Now, why do we get it in the periphery? Why do we get it in our feet, right? Well, our feet are colder than the rest of our body. So if you were to take that lemonade, put it in the refrigerator, well, more of that sugar would drop out. If you heat it up, more of that sugar could be dissolved that lemonade and that's just kind of your basic chemistry there. Um, so what are the risk factors that you should look out for? And there's ones that are modifiable that you can change. And then there's ones that you can't actually change. So the ones that you can't change are like your age. If you're male, you're more likely to get it. Certain ethnicities like Taiwanese are more likely to get it. And then certain people with genetic changes are more likely to get it. So there's two genetic changes that if, let's say you have gout and you're on medication, it's just not going away. Sometimes you can get genetically tested and see if you have a higher predisposition to it. Now, what are the actual modifiable risk factors? Well, one is weight. So if your BMI, starts to get up around 30, you have a more likely chance to get it. And then if your BMI is above 35, you actually have a three times increased risk. In fact, in some of the studies or one of the studies I read, weight represents about 44% of the cause of gout at presentation. Now, it can also present with diabetes and other problems like hypertension. And some of the studies have looked into what's called the Mendelian genetics of this and figured out, hey, does the, or ask the question, does the gout or high uric acid level, does that cause the diabetes or insulin resistance, or does the reverse happen? Does the insulin resistance cause the high levels of uric acid and then gout. Well, when they look at it, they find individuals with genetics that give them insulin resistance. And then they find that at the same time, they do have higher levels of uric acid and repeat attacks of gout. Now, when they look at individuals that have genetics that give them a higher level of uric acid, those individuals don't always have the same higher levels of insulin resistance. Now, why is that? Well, what happens when you get insulin resistance, it stops the kidneys from getting rid of this uric acid. So then it builds up in the system and then those crystals again, like the lemonade and sugar drop out and collect in the joint. And so the... insulin resistance actually causes the gout. So the main problem though is that we kind of live in this collection of Western lifestyle trends, like eating more calories, we have increased in portion size, and we eat more red and processed meat, as well as sugar and fructose, both of which. contribute to insulin resistance and making bad choices of foods, like higher carbohydrate foods, especially with fructose, as well as we're kind of sedentary. We're sitting here and not doing much, we don't exercise as much, and then that then leads to developing hypertension as well as chronic kidney disease, congestive heart failure, and coronary artery disease, which then contributes to the gout once again overall. And then we're using medications to control the uric acid level. So the main root cause is these lifestyle habits that we have. And if you were like me, growing up, you did not know that nutrition played a significant role. And you... may have learned this along the way, but there are certain good diets to follow, like Mediterranean and DASH diet, and there are bad diets, like the American high carbohydrate diet. Now, oftentimes people will say, well, should I reduce my intake of foods that have purine in it? And I'll say, yeah, that's a good idea. But the problem with that is that when they reduce that, they may be inclined to eat more carbohydrates, which then causes insulin resistance. So it's very important to sit down with a doctor or a dietician that understands these little nutrition nuances and can help guide you in that good direction. One of the diet plans that I tell people to look into is the Mayo Clinic New Diet Plan. And I'll... put reference to that in the show notes. Well, this new diet plan is really cost effective. It's like $20 a month for 12 months. And you get a whole bunch of things, which I'll just read off my notes here. And you get personalized, like approved meal plans. You have a digital platform, which is very easy to access. You have a habit optimizer, a food tracker. You have meal plan options that include keto, higher protein, vegetarian, and Mediterranean. And you actually get access to virtual group video sessions with Mayo Clinic doctors. Plus you can get guidance on behavior change, nutrition, sleep, stress management, and goal setting, which are all extremely important. And then they have a fast track two week phase in the beginning called Lose It. where a lot of the members lose six to 10 pounds in about two weeks. Plus they also give you at home workouts. I mean, there's this whole constellation of good things that have come together and will help you actually lose weight and decrease your chances of getting repeat gout attacks. So oftentimes I'll tell people, you need to go for the Mediterranean diet with the... caveat that you're eating a little bit less fish and red meats in that diet. And then absolutely no alcohol because alcohol will definitely cause it. Now, another thing that I talk to my patients about is bariatric surgery. So there was a good study, there's a meta-analysis which is very high, included 20 studies, 5,000 patients. And most of these had a 12 month follow-up period. What they found was that over that period at three years, their uric acid level had come down by almost two points or two milligrams per deciliter. And so the average level became around 6.5. And so they really lowered their levels and got it well under control and had less repeat count attacks. So going back to that food of high fructose corn syrup, that's a little kind of hidden gem that the food industry has decided to add in and trick people into thinking that, hey, I like this food. When in fact, you just like the sugar that's in it. One of those foods is Pop Tarts. Another one is Ritz crackers. Another one is Baby Rays. This high fructose corn syrup is an unnatural level, unnatural level of fructose. and it increases your risk of obesity and weight gain as well as fatty liver. So it's best to always look on your food label and say, hey, does this have high fructose corn syrup? If it does, swap it out with something that doesn't have it. In fact, they sell baby rays, which is sugar-free, which has sucralose, which you can substitute for the high fructose one. So additionally, foods that are high in purines, reducing those in your diet can reduce the flare-ups themselves. So again, fructose sweetened drinks like fruit drinks that will increase the uric acid production and decrease uric acid secretion and can lead to kidney stone formation. So again, fructose, not good. Other things like yeast, macros, scallops, game meat, organs like kidney and liver, red meat and fish in general can have higher levels compared to other foods. So the diet itself plays some role, but the weight gain and other problems associated with the weight gain have a much higher impact than just the diet alone. Interestingly, people who drink four to five to six cups of coffee have decreased flare ups, which I do not recommend drinking over two to three cups and especially keeping it below the 12 noon. So drink it in the morning, not in the afternoon. And so when somebody comes to my office, another thing that I'm concerned they may have, which is called a differential, which is where a doctor looks at a problem and says, It could be these three things. Well, it could be gout, it could be something called septic arthritis, which is an infection in the joint, and it could also be recent trauma to the joint. So that's another question that I'll ask. And so it's important to rule out or to figure out if they have septic arthritis or not. And one of the ways to do that is to take a needle and draw out that fluid that's in the joint. And then this, we can look at under microscope. And I would suggest you look this up, it's very cool. And you can see monosodium urate crystals under the microscopes. They look very cool, but again, very painful. And then I'll add in some lab work that they should get done, especially the uric acid level, which the goal is to bring it back down. below 6.5 and oftentimes they'll present to my office with a uric acid level anywhere from eight to 12. And I'll check their kidney liver function as well as their blood size, shape and color and check is CRP and ESR for a bone infection. So those can be elevated with that. And then I'll get an X-ray to check out if they have what's called a TOEFI or especially if they have had a recent trauma. So TOEFI is where the inflammation and area of damage has kind of been walled off by the body and formed this kind of larger gathering on the joint itself. And what actually happens is that joint is being destroyed. So one of the long-term problems of GAL is that it will go back and destroy that joint and sometimes you have to get it. either fuse back together with some metal pieces by an orthopedic surgeon or a podiatrist. And that's the main problem of having gout besides just the pain itself. And so it's important to get it under control. So how do you get these gout problems under control, these gout flare-ups under control? Well, short term, You can one, get an injection in the joint with a steroid. So you've got to have a physician or doctor that's highly skilled at that and they can inject the joint. You can also begin taking some Motrin or Ibuprofen or Advil with food and start that out even before you go to the doctor. Now the doctor like me will prescribe something like Colchicine and Colchicine is like a really powerful anti-inflammatory. that can be taken and then repeated either later that evening or again, the same dosage maybe two to three days later. I can also prescribe oral steroids. So oral steroids will reduce that inflammatory response, but the problem with that is that it can cause other problems like anxiety and insomnia, and nobody likes to stay up with a hurt toe. They wanna really, really go to sleep. And then after that, so after that initial flare up, usually about anywhere from two to four weeks later, I'll have them get labs and check their uric acid level and then also start at the same time, a long-term urate lowering therapy. And there's certain indications for this. So one, have they had two or more flare-ups in a year? Do they have chronic kidney disease, stage two? Do they have... a kidney stone formation, which uric acid can do, and do they have a presence of the TOEFI or chronic gouty arthritis and some joint damage in there? So all of those will lead me to say, hey, we need to start kind of long-term therapy. And the first line treatment is called allopurinol. Allopurinol inhibits the enzyme that's taking the chemical building blocks like purine and converting it into uric acid or urate. Now, at the same time they start that allopurinol, I'll have them take something like ibuprofen because it can put them at risk for having another flare up. So any change to that chemistry, that pathway can cause a flare up. So also I'll be cautious, especially in people with Korean descent. who are Chinese, hand Chinese or Thai, sometimes if that's the case, then I will ask them to get genetic testing because the problem with allopurinol is it can have these severe side effects in people with certain genetics. And we don't want that to happen. Another treatment is called fibuxostat. Problem with fibuxostat is that it has some cardiovascular mortality and usually is not the first line one that I go with. Now, let's say these don't work. Let's say this person has like in-stage renal disease. Well, then I'll move on to what's called peglotticase. And peglotticase is interestingly made from E. coli. That I was just reading up on this. It's very interesting. It will change the uric acid to something that can be put into water. which is when our blood is made up, and then also excreted out by the kidneys. So very interestingly, it converts that into something that can be absorbed in the water. So that's the majority of the treatment. There's some newer ones called IL antagonists, IL-1 antagonists, which I'm not gonna get into today, but I hope that was helpful to you guys. If you have any questions, you're welcome to leave them in the comments. Let me know down below what you thought of this talk and you can always reach me on my website, www.mycarerocks. I am a family physician who practices also lifestyle medicine in Clinton Township, Michigan. And thanks so much for listening. I hope you have a great and healthy day.