San Antonio Express-News (Sunday)
Excruciating gout pain can be minimized, systolic, diastolic blood pressure numbers important
Q: I am a 50-year-old female in fair health who was recently diagnosed with gout. I experienced excruciating pain in my left big toe only that came in bursts, then would subside to a dull pain, followed by another burst of pain. This pain was as bad as kidney stones, which were worse than childbirth. Why is gout so painful, and what can be done to minimize recurrences in the future?
A: Gout is caused by crystals deposited in the joints and occasionally in other soft tissues. The crystals are uric acid — strictly speaking, monosodium urate — and they look like needles under the microscope. They cause an intense inflammatory reaction with redness, swelling, pain, warmth and loss of function.
Most people with acute gout agree with you that the pain is exquisite, among the worst they have experienced. Any movement may cause extreme pain, and I have had many patients use a shoebox (or similar) to protect their feet from gout pain being exacerbated by even a sheet on the big toe, which is the most common place to get an acute gout attack. There are lots and lots of nerve endings in the big toe and in and around other joints where gout occurs.
Diet and medications together form the basis of treatment. Uric acid is a product of purine metabolism. Purines are components of DNA and are found in high amounts in meat and seafood. Recent studies have shown that dietary restrictions are most useful in those people with gout who are overweight, and most with well-controlled gout can tolerate meat and seafood without significant risk of a flare. However, legumes such as beans, peas or lentils decrease risk of gout flares. Weight loss is effective in reducing gout attacks in those who are overweight.
Medication treatment of gout is appropriate for people with recurrent (two or more per year) or disabling flares; those with uric acid deposits in soft tissue, called tophi; and those with kidney disease because of gout. Medications such as allopurinol, which lower uric acid levels, are good to prevent gout attacks but paradoxically can cause or worsen an acute attack. Anti-inflammatory drugs or colchicine are more commonly used for acute attacks and sometimes when starting preventive treatment such as allopurinol.
Q: There’s lots of info out there regarding systolic blood pressure, but what about diastolic blood pressure? My top number is always fine, but the bottom goes between 82-88 regularly. I’ve been diagnosed with diastolic dysfunction and would like more info regarding this bottom number that’s not mentioned as much as the top number.
A: The left ventricle, which pumps blood to the body, has two phases: systole, when the chamber squeezes the blood out and the aortic valve is open, and diastole, when the aortic valve is closed and the ventricle refills. The peak blood pressure, represented by the top number, is systolic, while the bottom number (diastolic) is the blood pressure when the left ventricle is filling up. Both systolic and diastolic numbers are important, as elevations in either increase risk of heart disease and stroke.
However, if the systolic number is not elevated and the diastolic number averages around 85, the magnitude of your risk is small.
Diastolic blood pressure elevations mostly represent an issue with the blood vessels in the body, and diastolic dysfunction refers to a decreased ability of the heart to relax, sometimes called a “stiff ventricle.” Longstanding high blood pressure is a major risk for diastolic dysfunction. Diastolic dysfunction and high diastolic blood pressure do not have to be linked but often are.
Q: With cases rising and all the information about COVID-19 out there, I have yet to read what should we be doing for people who have only a mild case. I know of three people in their mid- to late 20s who all tested positive and had only sinus issues and one had a sore throat. Could you please share what treatment they should be receiving, if any?
A: Fortunately, most cases of COVID-19 are mild and will not require hospitalization. The range of symptoms is broad, including a large number of people who have no discernable symptoms at all, to the nasal and throat symptoms you describe, to gastrointestinal symptoms. However, the most common symptoms among those who will ever develop them are fever and cough, often with muscle aches or headaches. Shortness of breath is sometimes present; fatigue is sometimes overwhelming.
In people with newly diagnosed COVID-19 infection, it’s critical for the treating provider to assess risk for severe disease. This includes a review of underlying medical conditions that put a person at risk, especially being older than 65, obesity, chronic kidney disease, diabetes and immunosuppression because of disease or treatment. Any heart or lung disease should be considered a risk factor as well.
Oxygen level has proven to be a very useful tool for assessing risk. Many hospitals provide an oxygen meter for those with COVID-19, and a level below 95 percent is an indication the person needs a face-to-face evaluation. A high degree of shortness of breath is a powerful indicator of more severe disease, as is confusion or lethargy.
Though there are established and emerging treatments for people hospitalized with COVID-19, there are few options for treatment beyond support for people with milder disease managed at home. One new treatment that was approved is called bamlanivimab. It is reserved for people with the risk conditions above and has been shown to reduce the risk of hospitalization. However, there is just not a lot of the drug available at the time of this writing, and most people with milder disease will not receive specific treatment. New treatments are being made available quickly, and it is possible something new will be available even before this is published.
Q: I’m 85 and had been taking my blood pressure medicine in the morning for probably 25 years. I take metoprolol, losartan and a water pill. Lately I’ve been reading that I should take this medicine at night, so that we will be better protected against heart attacks and strokes when we wake up in the morning, when most of them occur. Since I started taking my medicine at night, my readings have been wonderful — for example, 117/70 at the doc’s office! To my surprise, my heart doctor told me to return to taking my meds in the morning because she doesn’t agree with the new suggestions. What is your opinion?
A: A study from Spain in 2019 showed a surprisingly large benefit to taking blood pressure medications at night. People who did had a lower risk of heart attack and stroke. The difference was so large that some experts have difficulty believing how important the time of day was. While waiting for confirmation, I have told my patients to take all blood pressure medication at night; however, some people find taking a diuretic (“water pill”) at nighttime problematic.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell .edu or send mail to 628 Virginia Dr., Orlando, FL 32803.