Ask the Pharmacist

Q: My gout keeps reoccurring and I’m finding that the anti-inflammatories and colchicines just don’t work as well or as quickly as they once did. Is there another alternative that can relieve my discomfort?

A: Gout is one of the most painful forms of arthritis. It occurs when the uric acid levels in your blood get so high that they start to solidify into hard crystals within your joints. A fitting analogy would be adding sugar to a cup of water. Initially all the sugar will be dissolved, but if the sugar is continually added, eventually a point is reached that the sugar will crystallize.

The most common initial symptom is a night-time attack of swelling, tenderness, heat, redness and a very sharp pain, usually within the big toe. Attacks can also occur within other joints and tend to as the disease progresses. These joints include the insteps, ankles, heels, knees, wrists, fingers and elbows.

Uric acid comes from the breakdown of our cells which is a normal process that occurs within us all constantly. When a cell dies, the DNA is broken down into its constituent amino acids, some of which are called purines. The purines are, in turn, converted into other chemicals, one of which is uric acid.

Uric acid levels can get too high when one (or more) of three mechanisms gets out of balance. The first is excessive cell death which leads to an overproduction of uric acid. The second happens when the kidneys fail to excrete enough uric acid which is essentially a waste product.

Lastly, gout can occur when purines are ingested in our diet in excessive amounts. Purines are found in such foods as red meat (particularly organs), seafood (especially crustaceans), alcohol, dried beans, peas and many other foods. It is estimated that 10 to 15 per cent of our uric acid levels come from our diet.

Gout affects two to four per cent of Canadians and the prevalence seems to be increasing. Reasons behind this are thought to include the fact that the incidence of conditions, such as hypertension, metabolic syndrome, obesity, Type 2 diabetes and kidney disease, are also rising, and this collection of disparate diseases all acts to increase the risk of gout occurring.

While early attacks usually get better in three to 10 days (later ones tend to last much longer) even without treatment, the pain can be debilitating and some suffer for much longer.

Traditionally first-line treatment has been the drug colchicine or one of the many NSAIDs, such as indomethacin, naproxen or ibuprofen. For mild to moderate attacks, one of these has been used and the choice has been based on prior history, patient preference or other diseased states that may also be affecting the patient.

Colchicine, while often quite effective, should only be used if it is started within 36 hours of an attack and is probably even then a less-desirable option due to side effects (mainly), cost, difficult dosing and multiple drug interactions.
NSAIDs are a great option for many and should be continued at their full prescribed dose until at least two days after the resolution of all symptoms.

While indomethacin seems to be the most frequently prescribed member for this disease, there is little evidence to support that it is any more effective than the other drugs, and it is associated with a greater risk of side effects especially with regards to the stomach.

Now, doctors are considering a short course of a corticosteroid (such as prednisone) as another first-line option to treat an acute case of gout. Steroids seem to work at least as well for pain as the NSAIDs, and are a safer option for many patients, such as those with kidney disease, liver disease, heart failure, those on blood thinners or in seniors due to the risk of a stomach bleed associated with the NSAIDs.

Usually a five-day course of prednisone, at 30-40 milligrams (mg) per day, should suffice for most acute cases of gout. For those who do not tolerate the possible side effects of oral steroids (emotional roller-coaster, upset stomach, water retention), a single injection of a steroid right into the joint can be considered if there are only one or two joints affected.

For patients in severe pain, or when multiple small joints or more than one large joint are involved, or for those who fail to respond adequately to the above initial treatments (i.e. a less than 25-per-cent improvement in pain within 24 hours, or less than a 50-per-cent improvement after that), a combination therapy can be tried.

All of the above classes can be tried with one of the others for an increased therapeutic effect with the exception of an NSAID with a corticosteroid due to the high risk of a gastrointestinal bleed.

For those who get more than two gout attacks per year, have a history of kidney stones made out of uric acid, or have tophi (a permanent lump made of uric acid crystals found around a joint), preventative medication and lifestyle measures should be considered.

For more information about this or any other health-related questions, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination. Also check the website at www.gordon-pharmasave.com/ and the Facebook page at www.facebook.com/GordonPharmasave/?fref=ts