Gout no longer strikes only wealthy

Medical Matters: What do Michelangelo, Alexander the Great, Kubla Khan and Henry VIII have in common? They all suffered from gout, one of the oldest disorders known to humans.

Traditionally associated with the excesses of the ruling classes - it was once known as the disease of kings - gout was believed to be brought on by high living and gluttony.

In 1705, Thomas Sydenham wrote: "The gout most commonly seizes such old men, as have liv'd the most part of their lives tenderly and delicately, allowing themselves freely banquets, wine and other spirituous liquors, and at length by reason of the sloth that always attends old-age, have quite omitted such exercise as young men are wont to use. Moreover they who are subject to this disease have large skulls, and most commonly one of gross Habit of Body, moist and lax, and of strong and lusty Constitution, the best and richest Foundation for Life."

Scientific knowledge has modified our understanding of the disease compared with the somewhat disparaging, if colourful, description by Sydenham. Gout is more common in men with a prevalence of 5 per cent in men over 65, and is associated with obesity and a high alcohol intake. But not all types of alcohol are bad: one study found that men who drank two glasses of wine per day did not have a higher risk of developing gout, whereas those who drank two glasses of beer had a two and a half times greater risk of having an attack than if they drank no beer at all.

Classified as a form of arthritis, gout typically affects the joint at the base of the big toe. A severe pain usually comes on without warning, often early in the morning. The joint becomes so tender that the patient cannot even bear the weight of bedsheets. The skin over the big toe joint becomes red and shiny. Fortunately, the excruciating pain responds fairly quickly to non-steroidal anti-inflammatory drugs, bed rest and the application of ice.

What causes this acute inflammation? Crystals of uric acid are deposited in the space between the affected joints. Uric acid is a natural waste product which usually passes out of the body via the kidneys. However, if the load of uric acid becomes too great, then it builds up in the bloodstream before being deposited in a joint. The elbows, knees and finger joints are other, less common, targets for the uric acid crystals.

Proteins called purines are the chemical bricks that make uric acid, which is where the link with food and alcohol comes in. If you are prone to gout and you load your body with purine-rich foods, then an acute attack is likely. Some of the foods to steer clear of include rich red meats, shellfish and oily fish such as mackerel. For many people, gout may only strike once so no further treatment is needed apart from following certain "rules of moderation" (see below), which will ensure that purine and uric acid levels stay within a range that the kidneys can manage.

However, some people develop intermittent gout. In a small number of patients the attacks become so frequent that chronic gouty arthritis results, in which the joints may resemble the appearance of wear and tear arthritis. For anyone getting more than three attacks a year and in whom a blood test has shown elevated levels of uric acid, then preventative treatment will be needed. A drug called allopurinol blocks the production of uric acid by interfering with the enzyme xanthine oxidase. Patients taking the drug should report the development of a skin rash to their doctors as it can cause a severe skin allergy. The only complication of gout is the development of kidney stones, as uric acid builds up in the kidney. Otherwise, it is a curable disease.

But the key to controlling gout, whether taking medication or not, is to follow these "rules of moderation":

restrict your intake of foods high in purine such as liver,

kidneys, sweet bread, shellfish and tinned fish;

reduce your alcohol intake to not more than two standard

drinks a day;

eat a normal well-balanced diet;

drink plenty of water;

keep weight down but avoid crash diets;

take regular exercise, but do not exercise too strenuously;

avoid excessively cold temperatures.

Looking at this list, perhaps Sydenham and his contemporaries were right to refer to gout as a "patrician malady" and a "disease of plenty". But times have changed: gout no longer shows any socioeconomic preferences.