Perhaps the most aggravating arthritis to those afflicted is an acute gouty attack. This condition is quite debilitating to the individual in that even the weight of the bed sheet causes discomfort. This type of arthritic attack is seen in predominately males and usually attacks the patient during a slumber. It has been well documented throughout history. A notable American founding father, Ben Franklin, had been so afflicted that he had to be carried into Congress due to his inability to walk. His chair was in the back of the "House" near a window so that he could allow his burning pain be relieved by the occasional outdoor breeze.

Gout is caused by the elevated levels of uric acid which is a byproduct from the synthesis of the purine type of amino acids. The elevated level of uric acid in the blood is known as hyperuricemia. There are two classifications of hyperuricemia.
"Over producers" and "under excreters" are the kinds of mechanisms that define the cause of hyperuricemia.

An example of an "over producer" would be a psoriatic patient. Psoriasis is condition of the skin in which the cells in certain areas replicate at an accelerated rate thus causing a plaque of scaly skin. Normal skin replaces itself in 28 days as compared to a psoriatic patch which takes 10 days. This rapid turn over of cells increases the synthesis of amino acids. The increase in the purine synthesis likewise increases the level of uric acid. The kidneys are excreting the uric acid but not as fast as it accumulates in the blood.

An example of an under excreter is an individual that has normal levels of uric acid but a restricted amount of uric acid is urinated from the kidney thereby elevating the level in the blood. In the previous example, the kidneys are not eliminating the normal amount of uric acid produced from normal metabolism. This comprises 90% of the hyperuricemic patients and usually have an underlying renal (kidney) disease or failure.

Some drugs likewise may increase the level of uric acid. Low dose aspirin, thiazide and "loop" diuretics are examples of uric acid elevators. High dose aspirin, al-lopurinol, probenecid and sulfinpyrazone are drugs that decease blood levels of uric acid. The normal blood value of uric acid ranges from 2.5 to 7.5 mg/dl depending on the laboratory method of measurement.

During an acute gouty attack, the uric acid (UA) may elevate as high as 10 mg/dl or more . This is seen prior to the attack and the UA level may dip back to a high normal value e.g. 6.9 mg/dl. The explanation is simple . The UA is a crystal that has left the blood and has precipitated into a joint thus decreasing the serum level. Once the UA crystal enters the joint the inflammation begins. This is the painful presentation that gout delivers.

The crystal is a needle like structure that is engulfed by the white blood cells(WBC).
As the WBC tries to digest this foreign invader, it becomes ruptured and enzymes are released from the exploded WBC. This further inflames the joint causing more WBCs to join the battle. Hence, a complete inflammatory attack occurs causing great discomfort. The clinical scenario is a red (rubor), hot (calor), swollen (tumor), painful (dolor) joint that has loss of function. Typically the first metatarsal phalangeal joint (great toe) is involved, however, any joint can be involved in a gouty attack.

Treatments for gout vary. However, the drug of choice is indomethacin (INDOCIN) 50 mg 3x a day (t.i.d.) or 4x a day (q.i.d.) with food (ac). Cholchicine is another alternative. Avoidance of aspirin particularly low doses is necessary. Limited activity is usually driven by the pain the patient experiences. For chronic hyperuricemia, allopurinol (ZYLOPRIM) 100mg 2x a day (b.i.d.) or t.i.d. is recommended. Dietery restrictions of purine rich or uric acid rich foods should be employed. Such foods include sweetbreads (liver, brains etc.) and shellfish (lobster, shrimp etc.). Alcohol does greatly participate in the precipitation of the gouty attack therefore avoidence of alcohol is always recommended.

Dr. Graham has been in private practice in Effingham since 1989 and is on staff at St. Anthony's Memorial Hospital and Effingham Ambulatory Surgical Treatment Center. He is Board Certified by the American Board of Podiatric Surgery and American Board of Podiatric Orthopaedics and Primary Podiatric Medicine. Dr. Graham is a Fellow of the American College of Foot and Ankle Surgeons, the American College of Foot and Ankle Orthopaedics and Medicine, and American Professional Wound Care Association. He is also a member of the American Podiatric Medical Association and the Illinois Podiatric Medical Association.

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