Draft Document/NC/March 02

Draft document/NC/March 02 UK Gout Society Patient Information Booklet

Title page All About Gout!

Page one

Foreword As early as the fourth century BC, Hippocrates wrote about gout as an affliction of old men and a product of high living1,7. During the 17th to 19th centuries the links with rich living caused much humour – we can all picture the caricatures of gout sufferers2. Yet, while the picture of gout today is quite similar – nobody who has suffered from this extremely painful condition will find it in the least bit funny!

Gout occurs mainly in men between the ages of 40 and 60, particularly in those who are either overweight, suffer from high blood pressure or whose diets are high in fatty foods and alcohol4. It is rarely seen in children, pre- menopausal women and men under the age of thirty3.

Sadly, whilst the incidence of gout has increased dramatically over the past two decades4 the public knows very little about this incredibly painful condition. On a more positive note from the medical profession’s perspective gout is a 20th century success story. Attacks can be easily treated, recurrences prevented and damage to joints and kidneys avoided2.

The UK Gout Society is a national charity dedicated to raising public awareness of gout and, in the future, to strengthening scientific knowledge on the causes and treatment of gout. If you would like more information about gout, after reading this booklet, please log-on to our website: www.goutsociety.org.uk or contact the us at PO Box XX, 289–293 High Holborn, London WC1V 7HY or phone 0207 420 32XX.

Professor George Nuki Trustee

Gout comes from the Latin gutta – which means ‘drop’ – with reference to the medieval flowing down of humours2,5 (Information box)

Pages 2 – X Contents  What is gout?  Facts and Figures  What causes gout?

Gout Society Booklet Copy page 1 Draft document/NC/March 02

 Who is at risk?  Can I prevent gout?  How do I know if I have gout?  Does gout recur?  Will my doctor do any tests?  How is gout treated?  How the UK Gout Society can help you  How you can support the UK Gout Society

What is gout? Gout is a metabolic disorder that causes acute, occasional and painful attacks of arthritis in the smaller joints of the knee, ankle, foot, hand and wrist - especially the big toe6,10.

Facts and Figures  Gout is the most common cause of inflammatory joint disease in men over 40 years old4  The big toe is the first joint affected in 70% of cases4,7  Around 10% of patients have what is known as primary gout – caused by the overproduction of uric acid4  Gout may affect more than one joint in about 10% of patients4  In a typical UK general practice of 2000 patients there may be 17 men and fifteen women with gout4

What causes gout? Gout occurs as a result of excess uric acid salts in the blood and tissues. When there is too much uric acid in the blood and tissues, it can form crystals in and around joints. If uric acid crystals enter the joint space, they jab at the surrounding tissue when the body moves and cause inflammation - the affected joint becomes red, swollen and extremely tender2. Most of us naturally pass out enough uric acid in our urine to keep down the amount in our blood. But some people have high levels in their blood either because they don’t pass enough in their urine – which may be as a result of kidney problems or because they are taking certain drugs, which impair excretion - or more rarely because they produce too much uric acid in the first place, owing to an inherited metabolic abnormality8,9.

What is uric acid? Uric acid is a by-product of cell breakdown and some foods. It is normally present in low levels in the blood and tissues since the body is continually breaking down old cells and because some familiar foods contain substances which are the forerunners of uric acid8.

Gout Society Booklet Copy page 2 Draft document/NC/March 02 Who is at risk? Gout is a common joint disease affecting over five times more men than women. In men, it can occur any time after puberty whereas in women it is rare before the menopause. It is rare in children3. In around ten per cent of cases there is a family history of the disorder4. Also at risk are those who are overweight, have high blood pressure, eat diets rich in protein and drink large quantities of alcohol4,7.

Can I prevent gout? Because gout can arise as a result of environmental factors, there are some basic steps you can take to help prevent gout occurring in the first place or prevent recurrent attacks.

Environmental trigger factors These include:  Prolonged stress  Injury  Unusual physical exercise  Minor operations  Severe illness  Excess weight  Dieting  High protein diets  Alcohol – especially beer  Drugs – including diuretics and antibiotics which can interfere with the normal excretion of uric acid4,9.

Dietary measures There are several things sufferers can do to help prevent a recurrence of gout. Uric acid is a by-product of purine and a low-purine diet is advisable. Foods that are high in purine should be avoided including:  Meat – particularly red and organ meats, such as liver and kidneys  game  seafood – especially mussels, herrings, sardines  alcoholic beverages – especially beer  asparagus

In addition, yeast products, white flour, oatmeal, sugar, mushrooms, spinach, cauliflower and even some pulses – especially lentils – can all increase the level of uric acid in the body and should be eaten in moderate quantities3,7.

Quick fix slimming regimes, particularly crash and ‘yo-yo’ dieting and fasting, should be avoided as they also increase the production of uric acid7.

Sufferers should drink plenty of water since uric acid crystals can be secreted by the kidneys as calculi (stones) Drinking 8-10 glasses of water each day

Gout Society Booklet Copy page 3 Draft document/NC/March 02 washes out the urinary system and helps to prevent any stones from developing9.

How do I know if I have gout? Gout is usually diagnosed on the basis of its distinctive symptoms and an examination of the joint – few things are as painful as a severe attack of gout7,8. An acute attack of gout often develops during the night or early hours of the morning and reaches a peak within a few hours so that, with an infected foot, it is impossible to tolerate even the touch of bed linen. The skin is red and shiny and may peel8,9,10. A mild fever and a feeling of tiredness may also accompany acute attacks of gout. The attack generally lasts for a few days, then dies down and the joint gradually returns to normal.8,9,12

Does gout recur? Some people never experience another attack, but most have a second attack between six months and two years after the first. After the second attack, more joints may become involved and there may be constant pain due to damage to the joint from chronic inflammation8,9,10.

Will the doctor do any tests? A blood test may be performed to help clarify the diagnosis as a high level of uric acid suggests gout – however the level is often normal during an acute attack4,7,8. Blood concentrations cannot therefore be relied upon to confirm or exclude gout.

A better test that may be performed is the aspiration of the affected joint. Fluid from the joint space is aspirated (removed through a needle into a syringe) and examined under a special type of microscope that uses polarised light4,7. The presence of needle-shaped, uric acid crystals confirms the diagnosis of gout11.

How is gout treated?

The goals of treatment are threefold: The first step is to reduce the pain and inflammation of the acute attack, the second to prevent future attacks and the third to lower uric acid levels and so reverse the complications of joint and kidney damage1,9,12.

Step one – treatment of the acute attack During the actual attack, the most important thing to do is relieve pain by controlling the inflammation and immobilising the joint. Currently non- steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen or indomethacin are used as first-line therapy and all are effective.4 NSAIDS with a short half-life, such as Indomethacin and Ibuprofen are most popular

Gout Society Booklet Copy page 4 Draft document/NC/March 02 because of their rapid onset of action – although their use should be avoided in patients with a history of ulcers1,13. Cox-2 selective inhibitors were designed specifically to be as effective but better tolerated. Colchicine therapy was the old treatment of choice and still has a part to play where NSAIDS are contraindicated, although it too may cause gastrointestinal side effects and has to be used carefully. If only one or two joints are affected and patients have multiple medical problems or are unable to take oral medications, a corticosteroid crystal suspension may be injected through a needle into the joint space in order to reduce inflammation 1,4,7,8,10,12.

Step two – preventing recurrences Once the attack has passed, the next step is to prevent recurrences by addressing trigger factors that can be modified. Patients are advised to lose weight, drink plenty of fluids (at least eight glasses of liquids a day), avoid alcohol (especially beer) and eat smaller amounts of protein-rich and calorie- rich foods1,2,7,8,10,11.

Step three – lowering uric acid levels Finally, for some people – especially those who have repeated, severe attacks – long-term drug treatment to lower the level of uric acid in the blood can be started when symptoms of the attack have disappeared. This treatment is then continued between attacks and includes:  Uricosuric drugs, such as probenecid, lower the uric acid level in the blood by increasing the excretion of uric acid in the urine1,2,7,13.  Allopurinol, a drug that blocks production of uric acid in the body, is especially helpful to people who have an abnormally high uric acid level and kidney stones or damage, although it has to be used with caution as it can have unwanted side effects1,4,7,8,10,11,13.

How the UK Gout Society can help you The UK Gout Society raises awareness about the challenges of living with gout. It also provides educational materials for people with gout and their families. In time, once fundraising efforts have been established, the UK Gout Society will support scientific research into the causes, prevention and treatment of gout. For further information on the work of the Society, and information on gout, please contact: PO Box XX, 289–293 High Holborn, London WC1V 7HY or phone 0207 XXX XXXX.

How you can support the UK Gout Society If you want to help us make a difference there are several ways you can get involved in the work of the UK Gout Society:

 Hold fundraising events - ever wanted to do anything adventurous? Parachute jumping, running the London marathon or running a local sports day. Well, now here’s your chance to realise that dream and raise vital funds for gout research at the same time. We will be delighted to

help you run an event of your own – giving you plenty of advice, ideas, and support.

 Simply make a donation by completing the form below and choosing how you wish to pay. The UK Gout Society relies on the generosity of the general public to continue its vital work. With your help we can start to fund groundbreaking research into the causes, prevention and treatment of gout, whatever you decide to give – no matter how small – you will be helping to make a difference to the lives of people with gout. There are several ways you can make a donation to the UK Gout Society. Donate now by credit card, cheque, and charities aid foundation or by standing order. Or find out more about how you can donate through leaving a legacy or becoming a member of the UK UK Gout Society by phoning 0207 XXX XXXX

o Title o First name o Surname o Address o Postcode o Daytime telephone no. o E-mail address o Date of birth o I would like to make a donation of £5, 10, 15, 20 o Gift Aid declaration It is now possible to claim tax on your membership subscriptions and donations through Gift Aid if you are a UK taxpayer. This means that the UK Gout Society can claim an additional 28p on every £1 you pay. You must have paid an amount of income tax and/or capital gains equal to the tax deducted from your donations. If you would like the UK Gout Society to reclaim tax on your donation, making your gift to us even more valuable, please fill in the Gift Aid declaration below: I would like the UK Gout Society to treat as Gift Aid all donations I make from the date of this declaration until I notify the GS otherwise.

Signature Today’s date

Please find enclosed my payment of £ Payment by cheque postal order

Please complete and return to the UK Gout Society, PO Box XX, 289-293 High Holborn, London WC1V 7HY

End of booklet

References:

1. Davis JC Jr; A practical approach to gout: Current management of an ‘old’ disease; Postgraduate Medicine, 1999, Vol 106/4, p115-123

2. Snaith M; Over and Gout; Arthritis Care Today, January 2002; Arthritis Research Campaign

3. Van Doorum S, Ryan PFJ; Clinical manifestations of gout and their management; Medical Journal of Australia, 15 May 2000, Vol 172/10, p493-497

4. Nuki G; Gout; Medicine 1998, Vol 26 p54-59; Medicine Publishing Company

5. Gout; Concise Oxford English Dictionary, 9th Edition. BCA London with the Oxford University Press

6. Gout; Pocket Medical Dictionary, p120, 14th Edition; Churchill Livingstone

7. Snaith ML; ABC of Rheumatology: Gout, hyperuricaemia, and crystal arthritis; BMJ 1995; 310:521-524 (25 February)

8. Gout Chapter 52, p267-269, Merck Manual of Medical Information, Home Edition 1997; Simon & Schutter Inc.

9. Pal B; Gout; Diseases and Conditions, NetDoctor.co.uk

10. BMA Complete A-Z Family Health Encyclopaedia 1999; Dorling Kindersley

11. Jelley MJ, Wortmann R; Practical steps in the diagnosis and management of gout; Biodrugs, 2000 Vol14/2, p99-107

12. Wood, J; Gout and its management; Pharmaceutical journal, 5 June 1999, Vol 262/7048

13. Scott JT; Gout: The last 50 years; Journal of the Royal Society of medicine, 1996,Vol 89/11, p634-637

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