What can be done to minimize gout pain?

DEAR DR. ROACH

» I am a 50-yearold 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?

— C.C.

DEAR READER » Gout is caused by crystals deposited in the joints and occasionally in other soft tissues. The crystal is uric acid — strictly speaking, it’s 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 most painful 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 gouty 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 due to 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.