Why the ‘Disease of Kings’ can be so debilitating - and how to treat it

Published on Tuesday, June 1, 2021

By: Bruce Coleman

American cartoonists’ traditional depiction of someone stricken with gout usually involves a portly gentleman with a heavily bandaged toe hobbling about with the assistance of a cane.

Think Benjamin Franklin or King Henry VIII, for example.

The correlation has become so fixed that the metabolic condition has been nicknamed the “Disease of Kings” or the “Rich Man’s Disease.”

Those suffering from gout hardly think it’s a laughing matter, however.

So what is gout, exactly?

“Gout is a metabolic condition in which uric acid - one of the byproducts of cell metabolism - is produced in excessive amounts,” said Dr. Vikas Majithia, division chief of rheumatology at the University of Mississippi Medical Center, “which ultimately leads to it being deposited in various tissues, particularly in joints, where it can cause inflammation. Most commonly, it results in pain in the foot.

“But uric acid involves not only the joints, where it causes the most pain, but it can be deposited into the kidneys and other places in the body, where it can cause symptoms.”

The sudden onset of pain and swelling in the big toe or foot and difficulty in walking or moving the affected joint can be intermittent, according to Dr. Cathy Lee-Ching, assistant professor of medicine in the Department of Rheumatology at UMMC.

“These episodes come and go, even without treatment, but do tend to recur if the cause is not addressed,” Lee-Ching said. “In severe cases, gout can cause kidney stones, skin nodules or masses, destruction of the bones and joints and could get complicated with serious infections of the bones, requiring amputation.”

The exact causes of this potentially debilitating disease remain frustratingly unknown, but Majithia said uric acid is definitely the culprit.

“Generally, as we age, we can produce so much uric acid that it overwhelms our ability to remove it,” he said. “Increased uric acid kind of accumulates as we get older, and the kidneys do not clear it as well as we need them to. People may also have other conditions in which they produce more uric acid than their kidneys and gut can handle, such as cancer - especially leukemia and lymphoma - diabetes, heart disease, psoriasis and with certain medications.

“And sometimes gout appears in younger people because of genetics.”

Lee-Ching said certain foods and drinks are known to increase uric acid levels in the body as well, such as seafood, red meat, alcohol, sodas, sugary drinks and diuretics. Taken as a whole, these contributing medical conditions and dietary habits are no more prevalent anywhere in the United States than in Mississippi.

“We feel patients who have gout and increased uric acid levels are part of the Metabolic Syndrome, in which they have high blood pressure, obesity, elevated blood glucose levels, diabetes and elevated cholesterol,” Majithia said. “It seems all of those conditions feed off each other, and they all may lead to gout.”

According to a National Health and Nutrition Examination Survey, the incidence of gout in the U.S. in 2015 and 2016 was 3.9 percent, which corresponds to an estimated 9.2 million adults with gout. Along with increasing age, Majithia said other factors, including gender and ethnicity, can factor into the gout equation: Men are much more likely to develop gout - almost 3 to 1 - and minorities, such as African Americans, indigenous Taiwanese, Pacific Islanders and New Zealand Maori, have a higher incidence of it.

While gout may remain asymptomatic in most patients, others can encounter nasty flare-ups.

“They will experience pain with swelling and stiffness of one or multiple joints,” Lee-Ching said. “The joint will look red and feel hot. Some cannot even tolerate a slight touch due to the severe pain, for example from clothes or bed sheets.

“If the affected joints are your feet or your knees, you can have difficulty standing up or walking. Fever can also be a symptom.”

Majithia said there is some truth in all those humorists’ drawings.

“There is a strong predilection with acute inflammation of joint pain in the first big toe,” he said. “Two out of three patients will have that; one out of three will have pain in their ankles or wrists. Gout can cause problems with any joint in the body, but there’s just a higher incidence in the big toe.” 

While flare-ups may last one or two weeks, Majithia said left untreated, painful attacks of gout tend to become more and more frequent and increase in severity. Many joints can also be affected at the same time. Furthermore, it leads to permanent damage and deformities.

Effective treatment for gout involves a two-pronged approach: medications to control inflammation during an acute attack and uric acid-lowering therapies to prevent incidence in the future. He emphasized patients who have severe disease need to take serious measures to decrease the uric acid in their bodies.

“It’s something patients don’t do, and it’s why they keep on having attacks and having problems,” Majithia said. “Not treating it effectively can lead to permanent joint damage. If the uric acid is being deposited in other organs and tissues, that can lead to other organ and tissue damage, especially kidney disease.”

Although there are no specific medical recommendations to prevent the development of gout in individuals with risk factors, those who already have been diagnosed and who meet certain criteria are strongly urged to maintain a healthy weight and manage any contributing conditions.

“We do recommend lifestyle modifications and, often, lifelong therapy with a medication that will reduce the uric acid accumulation in your body,” Lee-Ching said. “These will prevent flare-ups and other complications from gout.”

She said lifestyle modifications to decrease the incidence of gout may include:

• Losing weight
• Avoiding food and drinks that can precipitate gout
• Drinking low fat or skim milk, coffee or cherry juice
• Taking Vitamin C

She said prescription medications that can reduce uric acid levels if taken uninterruptedly may include:

• allopurinol
• febuxostat

“Your doctor can also review with you the list of medications you may be taking that could potentially trigger gout and consider switching to alternative therapies,” Lee-Ching said.

The onset of the COVID-19 pandemic and its accompanying limitations have contributed to a more sedentary lifestyle for many Americans. That, in turn, has supported an increase in gout throughout the pandemic, and unfortunately, many of these patients are more susceptible to severe symptoms from COVID-19 infection. 

“Gout patients share the same risk factors that make someone with COVID-19 have worse disease and poorer outcomes,” Lee-Ching said. “It is not that gout directly increases your risk for severe COVID-19 infection, but because gout patients are usually older men, African Americans, obese, diabetic, hypertensive, with heart disease, they have worse prognosis when or if they get this viral infection.”       

Therefore, Majithia is a strong proponent of gout patients receiving a COVID-19 vaccine.

“Patients with gout have so many more comorbid conditions that put them at such high risk for severe COVID and having a high mortality from it,” he said. “These patients would particularly benefit from having the vaccination to prevent COVID and decrease their risk.”

The good news about gout? It is a very treatable condition, Majithia said.

“Adding diet, self-management and medication, we can prevent complications from it,” he said. “Being a very treatable and, in some cases, a very preventable disease, it’s important to know that people who have gout can have consequences from it, but it can be treated effectively.”

“Gout can be a disabling and very painful condition,” Lee-Ching said. “But when adequately treated, you can avoid flares and improve your quality of life and overall health. Therefore, it’s important to seek the help of an expert, usually a rheumatologist, for proper evaluation and counseling.

Majithia said while primary care physicians can manage routine cases, more complicated gout cases can be referred to UMMC rheumatologists. To contact UMMC’s Rheumatology Clinic, call (601) 984-5540.

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