Dear Dr. Garner,

About two months ago, I had the worst pain in my life in my big toe. My wife wanted me to see the doctor. I decided to tough it out, and took Tylenol, rested and the pain was gone in about three days. At first I thought I might have stubbed it, as it was red and swollen, but everything is normal now.

Now my wife wants me to see a doctor, because she says I have gout and she pesters me almost every day. I feel that if I had gout, there should at least be some symptoms. Do you think I need to see a doctor about this? I read your column every week, and will go, if you think I should.

Man with Pain in the Toe Wife in Williamsburg

 

Dear Man with Toe Pain,

Your wife is very smart to insist you see a doctor. One of the most common misconceptions about gout is that if you don’t have any pain, then you must be well.

Unfortunately, this is not the case. Let’s review a little bit about gout. It is sometimes referred to as the “disease of kings” because it has long been associated erroneously with the kind of overindulgence in food and wine only the rich and powerful could afford. In fact, anyone can be affected with gout.

Gout is a very painful form of arthritis. If left untreated, it can be disabling, with destruction of joints throughout the body. The initial symptoms consist of episodes of painful swelling in single joints, most often the feet, especially the big toe.

It occurs when a waste product, known as uric acid, builds up in the body. When it gets too high, crystals are deposited in the joints. The buildup may be due to the fact that the kidneys are not working properly to remove the waste product. The other reason is that the body may produce too much of the uric acid.

Gout affects about one in 100 people, and is much more common in men over 60 with men affected about nine times more than women.

Some predisposing factors for developing gout include:

• Obesity
• High alcohol intake
• A genetic predisposition
• High intake of foods rich in purines (a chemical that contributes to increased uric acid)
• Certain medicine such as diuretics for blood pressure
• Injury to a joint
• Long-standing kidney disease
• Crash diets
• Chemotherapy
• Diabetes

Gout can be diagnosed by a physical exam and medical history, as well as blood tests to measure uric acid. The definitive test is removing fluid from a joint to demonstrate the uric acid crystals.

People with gout can have destruction of their joints, even if they are not having pain. It is therefore a critical part of the treatment to keep the uric acid as low as possible.

Uric acid levels may be high, either due to failure of the kidneys to remove it properly, or from the body producing too much of it.
This is where diet becomes important. There are foods that are known to increase the uric acid level in the body. These should be consumed in moderation, or avoided altogether in those with gout. These foods include:

• Beer and other alcoholic beverages
• Anchovies, sardines in oil, fish roe, herring
• Yeast
• Organ meats (liver, kidney, sweetbreads)
• Legumes (dried beans, peas)
• Meat extracts, consommé, gravies
• Mushrooms, spinach, asparagus, cauliflower
• Shellfish, and
• Wild game, such as duck, mutton, and venison.
On the other hand, there are foods which may be good for people with gout. These include:
• Dark berries, which may contain chemicals that lower uric acid and reduce swelling.
• Tofu, which is made from soybeans and may be a better choice than meat.
• Certain fatty acids found in fish (such as salmon and flax), olive oil, and nuts, may reduce inflammation.

While I do not advocate going crazy with diet, a well-balanced diet, high in whole grains, fruits and vegetables, that is low in protein (soy, lean meats and poultry are good) and derives no more than 30% of calories from fat, is a good model to follow. Gradual weight loss and decrease in consumption of alcohol, especially beer, has been shown to help.

Aside from diet, the treatment for gout is directed at reducing pain and inflammation from acute attacks as well as keeping the uric acid levels low, to reduce the number of acute attacks, and reduce destruction of the joints.

An attack of gout cannot always be prevented, but medication and self-care can help to reduce symptoms and damage to the joints.

Medications to reduce pain, such as Motrin or Aleve, taken early in the attack, can reduce the duration and severity of an attack.

There are also medications your doctor can give you to stop inflammation and are most effective when taken early in the attack. Steroids, either by injection or pill, may also be useful.

There are medications which help keep the uric acid level low and are taken all the time. Your doctor will need to monitor certain blood tests if you take this medication, but it can be effective in reducing attacks and joint destruction.

An ice pack may be helpful for acute attacks, as well as bed rest.

Your question was whether or not you should see your doctor since the pain has gone away, the answer is a definite YES!!
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Dr. Steven Garner is a Fidelis Care provider who is affiliated with New York Methodist Hospital, Park Slope. He also hosts “Ask the Doctor” on The NET, Tuesdays at 8 p.m. on Channel 97 Time Warner and Channel 30 Cablevision.