The Irish News 11, November, 2022
Cases of gout are on the rise, but the condition is misunderstood, and few patients get the treatment they need, writes Julie Cook
AS an active young man in his 20s, Harry Tyndall was both shocked and scared to wake up one morning with an intense shooting pain in his right foot.
“It was the worst pain ever – I thought I’d broken it. I couldn’t even walk, yet I had done nothing to injure it,” recalls Harry, who was then just 27.
A trip to A&E followed, where Harry was diagnosed with gout, a form of arthritis that causes sudden, severe joint pain and is often associated with elderly men paying the price for over-indulging in rich food and port.
“I thought gout was all about too much good living and older people – not men in their 20s,” admits Harry, who lives in London.
New figures suggest the so-called ‘disease of kings’ is on the rise, with hospital admissions for gout surging. It is thought this increase is largely a result of lack of exercise and poor diet during successive lockdowns.
The number of cases has risen by 20% in three years, with 234,000 patients admitted to hospital with gout in 2021-22, according to figures released last month by the NHS.
About 1.5 million people in the UK are affected by this agonising condition, according to the charity Arthritis UK.
Yet experts say that while lifestyle can trigger flare-ups, genetics play a more significant role in who develops gout in the first place. Harry’s father also had gout, for instance.
And it is feared that outdated perceptions of gout as both self-inflicted and transient are preventing thousands of people from receiving medication to prevent attacks.
“There’s a lack of awareness that it is inherently a genetic disease,” says Dr Alastair Dickson, a GP and trustee of the UK Gout Society, who believes it is still seen as a Victorian condition, caused by excess drink and food.
As such, it is “misunderstood by many health professionals and the public”, he says, adding that, for this reason, fewer than half of people with gout receive the appropriate treatment.
The significance of this was underlined by research published last month in the Journal of the American Medical Association, which found that those with gout were more likely to suffer a heart attack or stroke in the four months following a flare-up than people without gout.
Scientists from Nottingham and Keele Universities, who monitored 62,000 UK gout patients, said this is because the inflammation caused by the condition doesn’t only affect the joints but other parts of the body, including the arteries around the heart.
Gout – the most common form of inflammatory arthritis in the UK – is caused by a build-up in the blood and tissues of uric acid, released as a result of the breakdown of compounds called purines.
These occur naturally in the body but are also found in certain foods, including tuna, beer, bacon and liver.
Gout occurs when the kidneys cannot eliminate this uric acid properly. Uric acid crystals then form inside joints and under the skin, leading to intense pain. Uric acid crystals in the kidneys can also lead to kidney stones and a severe reduction in kidney function.
Dr Dickson says millions of people have excess uric acid in the blood but don’t have gout because they don’t have the genetic susceptibility.
But those who are genetically susceptible can go on to develop full-blown gout if an environmental trigger – such as a virus – causes the immune system to identify the crystals as foreign bodies, launching an inflammatory response.
Once primed, the immune system continues to attack the body, which is why urate-lowering treatment is required long term.
Attacks are usually treated with the anti-inflammatory drug colchicine, or painkillers including ibuprofen.
The preventative medications allopurinol and febuxostat (which reduce uric acid levels) are recommended by the National Institute for Health and Care Excellence (Nice) for ‘multiple or troubling’ flare-ups. Nice also recommends that these drugs, which cost as little as 28p per tablet, are discussed with all gout patients, as most will suffer future attacks without them.
Yet a report in the journal Lancet Regional Health – Europe in May found that only a minority of patients are given preventative medication within 12 months of diagnosis.
One of the report’s authors, Dr Mark Russell, NIHR research fellow at King’s College London, said: “Without preventative treatment, flare-ups tend to become more frequent over time and can develop into a chronic arthritis that never fully settles.
“Long-term treatment with urate-lowering medications such as allopurinol prevents attacks and joint damage in people with gout and improves quality of life.”
Dr Dickson fears that many healthcare professionals don’t appreciate that, far from being a one-off episode which can be addressed by switching to a low-purine diet, gout is for many patients a long-term chronic condition which requires careful management.
Luckily for Harry Tyndall, his doctor promptly prescribed allopurinol after his A&E visit in 2016.
It’s thought that, although Harry’s family history predisposed him to gout and despite being active, his poor diet at the time (he was eating a lot of red meat and weighed 16?stone) triggered a full-blown attack.
The allopurinol helped his symptoms abate, but came too late to prevent him developing kidney stones.
He collapsed several days later with searing stomach pains and was given medicine to dissolve the stones.
Now 34, he has adjusted his diet: he no longer eats red meat and has lost a stone in weight.
“As long as I keep taking my allopurinol and being careful with my diet, there’s no reason to fear another flare-up,” says Harry. “But it makes me angry that people perceive gout as an ‘old person’s’ condition, or something greedy people get.
“Gout can affect anyone and we need to be more aware of it.”
:: ukgoutsociety.org
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