New Study: Women with Gout at Much Higher Risk of Heart Attack

A new study released this month shows that women with gout have a much higher risk of having a heart attack (acute myocardial infarction) then previously thought.  It’s been long known that women with gout are at higher risk of heart attack then men, however, this new study that looked at the history of over 50,000 people shows that the risk is significantly higher than previously thought.  Women with gout are 39% more likely to have a heart attack then women without gout.  However, men only showed an 11% increase in this study.

The authors of this study speculate that this is due to men having higher levels of uric acid in their bodies throughout life than women.  Women’s uric acid levels tend to stay low only to rise suddenly at menopause.  As a result, it is believed that men develop more of a tolerance to the effects of high uric acid.  However, the difference may also be due to the fact that women tend to receive a gout diagnosis much later then men and are often treated with different medications and at different doses.  This is do to the incorrect belief, held by many primary care physicians, that gout is a “men’s disease”.

Regardless of the reason, women with gout, or even women that have passed menopause and have a family history of gout should take note.  Controlling uric acid levels with medication is the best way to reduce the risk.

See also: Gout in Women

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Gout Basics

Since this is a new blog, I thought it would be a good idea to write about the basics of gout.  I am often surprised about just how little some people who have had this condition for years know about this disease that effects their lives so much. The treatments for gout can get complicated, often requiring three different medications on different schedules so understanding what causes gout and the exact process of the disease is key to understanding the role of each of these medications and how to use them effectively.  If you properly treat this disease, there is no reason to ever have to suffer another painful attack.

Gout is cause by having too much uric acid in your body, a condition called hyperuricemia.  Uric acid is a natural substance in the body that is created through metabolism.  People with hyperuricemia either create too much uric acid and/or have trouble eliminating it from their body.  When levels of uric acid get high enough, this uric acid can start to crystalize.
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Questions Being Raised About the Importance of Diet on Gout

An article that will appear in the September Issue of the Journal of the American Dietetic Association calls into question the long held belief that those with gout need to maintain a “purine-restricted” diet.  This article points out that some foods, such as some vegetables are very high in purines, yet research has consistently shown that consumption of these vegetables is strongly correlated with a reduction in uric acid levels and in gout attacks.  Research has also shown that beer is strongly correlated with higher instances of gout even though modern beers often have very low levels of purines.

Although diet has long been assumed to be associated with hyperuricemia, this association remains to be verified. Studies that have reviewed the relationship of diet and hyperuricemia have found it to be a difficult and complex issue.

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FDA Rejects New Gout Drug and Approve an Old One

It was starting to look like 2009 was the year going banner year for new gout drugs.  That all came to a holt on Sunday as the FDA rejected the application for Savient Pharmaceuticals, Inc.’s drug, Krystexxa® (also called puricase or pegloticase).  This new drug used an enzyme not found in humans that breaks down uric acid in the body.  To prevent the body rejecting the foreign enzyme it is “locked up” in a molecular “cage”.  This cage allowed uric acid to flow in but blocks the immune system from attacking the enzyme (see, New Gout Drugs – Coming to a Pharmacy Near You).

Interestingly, the FDA did not have any complaints about the drug itself and found that the drug was safe and effective.  In fact, the FDA’s advisory board voted 14 to 1 to approve the drug.  However, the FDA raised concerns that the drug that was studied was created using a different manufacturing process than the drug that would be released to the public.  Due to concerns that this different manufacturing process could change the safety or effectiveness of the drug, the FDA rejected the drug until the manufacturer proves that the different manufacturing method resulted in a drug that was also safe and effective.
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Yet Another Study Shows Primary Care Doctors Often Do Not Correctly Manage Gout

Another study showing most primary care doctors do not know how to properly manage gout appeared in the journal Rheumatology International this month.  This study found that only 27.5% of patients had their uric acid level measured on, at least, an annual basis.  This means that doctors where unable to evaluate the effectiveness of uric acid lowering treatment, that is, if they even bothered to prescribe one.

This is another shining example of why it’s important to arm yourself with the facts on how this disease is managed.  There is a lot of very bad information out there and this misinformation results in you being in pain! That’s a pretty compelling reason why you should become familiar with the proper and scientifically backed methods of managing this disease.  Not to replace your doctor, but to complement his care.
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Is Febuxostat (Uloric®) Really Better Than Allopurinol?

UK’s National Institute of Health and Clinical Excellence doesn’t think so.  In December it issued guidance that the benefits febuxostat (sold in the US under the brand name Uloric®) have not been clearly demonstrated.

The argument is that the pharmaceutical companies tested febuxostat against a fixed dose of 300mg of allopurinol per day.  Even though this is the way most doctors prescribe allopurinol, it is not the best way to use it according the expert “best practices” guidelines.   The appropriate way is to adjust the dose of allopurinol until uric acid levels are lowered to below 6mg/dL (333µm/L).  Allopurinol can safely be prescribed up to 900mg/day.

Because the pharmaceutical companies did not show that febuxostat was more effective than allopurinol when allopurinol is used this way, and because of the cost and other risks, they concluded that for most people it best to just stick with allopurinol.
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New Research: Allopurinol Can Help You Live Longer

New research published in the medical journal, Rheumatology, has shown that lowering uric acid levels using the medication allopurinol can result in a significant decrease in the risk of death.

Recent research has shown that high levels of uric acid have been strongly associated with diseases such as heart disease, high blood pressure, kidney disease, liver disease, diabetes, stroke and obesity.  However, little is known about the effects of lowering uric acid levels on the risk of these diseases and even less is known about whether or not lowering uric acid levels can actually extend life.  This is one of the first research studies that has shown a strong correlation between lowering uric acid levels and living a longer life.

This study, that followed almost 10,000 people, showed an average reduction in uric acid levels of 1.86mg/dL (111µmol/L).  This resulted in an overall reduction in the risk of death by about 22%.

Unfortunately, we do not yet understand the mechanisms by which uric acid causes disease.  The current theory is that uric acid, when it reaches high levels, is constantly forming crystals in all parts of the body, not just the joints as in gout.  These crystals are spotted by the immune system and spark an immune response that increases inflammation.  This inflammation has been identified as a leading cause of some of the most deadly diseases mentioned above.

Hopefully, researchers will soon find proof as to exactly how uric acid causes disease.  This information will is the next step in finding the best means of dealing with high uric acid levels.

In the meantime, this new research shows us that fighting gout by lowering uric acid levels is not only the best way of stopping gout attacks, but may also be helping us live a longer and healthier life.

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Gout: The Forgotten Disease

I think what’s most amazing about medical science is how small it’s focus has become. I’m not talking about the scale of medical science, or the focus on making people healthy, but on the scale at which it is studying the complex mechanisms of the human body.

Over the past few hundred years medical science has gone from looking at the structure of the body, to its organs, down to the cells that make up those organs and now down to the most tiny and intricate molecular machines that make everything actually work. Molecules so small and sophisticated that ever the most advanced microscopes in the world can only view them dimly and we are only just beginning to grasp how they actually function.

However, this all seems to be changing. This focus on the very small has obscured a larger reality – that the human body is a large, unimaginably complex and integrated machine – a single machine. If something is broken in one part of that machine, the function of the whole suffers.

I think that more and more researchers are starting to get their heads out of their microscopes and starting to look at what happens to the whole machine when those microscopic machines misbehave. And I think this will be the next great step forward for medical science.

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Gout and High Fructose Corn Syrup

Last week I sent out a press release announcing my new, Beating Gout Starter Kit and got some surprising feedback. I received a letter from Audrae Erickson, President of the Corn Refiners Association criticizing my characterization of high-fructose corn syrup as a leading cause of gout, so I thought I would address the subject here.

The scientific research clearly shows that fructose has a direct metabolization path to uric acid. There have been several studies that have looking at soft drink consumption, both in it relationship to it ability to create uric acid in the body and directly as a cause of gout. These studies have shown a strong links between consumption of fructose and higher levels of uric acid and more frequent gout.

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The Most Misused Gout Drug, Colchicine

Gout is a disease that medical science obsessed over for, well, since medical science came into being.  Only in the last fifty years has gout become a “forgotten” disease.  Through this long and amazing history, gout has had a more or less faithful companion: the autumn crocus flower.  It’s from the bulb of this flower that colchicine comes.

Some reports say that colchicine has been in use for over 6000 years while other reports say its a much newer drug that has only been in use for 2000 years.  Regardless, it is still considered to be a first line drug by many doctors.  Unfortunately, those doctors are grossly out-of-date.  Not only in using colchicine first, but also in how they use it…

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Uric Acid Levels and Gout

If you have gout, it is important to get your uric acid levels tested regularly.  This is important for a couple of reasons.  First, if you are taking medication, or even natural remedies to lower uric acid levels, you want to make sure that they are actually working.  You also want to make sure that you are maintaining a healthy uric acid level – too much uric acid and gout can occur (bad) – too little uric acid and neurological issues can occur (rare, but worse).

Second, uric acid levels can fluctuate wildly, from day to day, even hour to hour.  A blood test gives you a snapshot of what your uric acid level is at that moment.  You could be having a good day and your uric acid level is low.  This might make you feel as though you do not need to take so much medication and scale back.  Unfortunately, this will likely result in a gout attack.
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Swine Flu and Gout

I have been sitting in my office this morning with the television on, watching the coverage of the swine flu outbreak.  I am always impress at how much panic an infections disease can generate.  Personally, if the swine flu does become pandemic, I hope I am one of the first to come down with the disease.  Why?  With a disease as virulent as the flu, the odds are very good that I will develop the disease eventually and if that happens, I want to get it before the medical system is overloaded and drugs like Tamiflu run out. Beside, I am a healthy 38 year old and the risk of serious complications, let alone death, are small.  This way, I would get the best care, medications, will get it over with quickly, and be healthy (and immune to the disease) when the disease hits it’s peak so I can help care for others.  So you won’t find me walking around with a mask on – which really doesn’t provide much protection anyway.

What does swine flu have to do with gout?

Not much really, however some medications used to treat gout can suppress the immune system which can make you more susceptible to disease including the flu and can make the flu worse if you should get it.  If you are unlucky enough to develop the flu just as you are being treated with corticosteroids or colchicine for a gout attack, it could make it much worse - particularly if you are elderly.  Note that NSAIDs and medications to lower uric acid levels do not suppress the immune system.

Of course, if you manage gout properly by lowering uric acid levels, there is no need to ever treat a gout attack because you will not get them.

Update: NYC Assistant Principal in Critical Condition

In New York City an Assistant Principal has come down with the N1H1 flu and is now in critical condition.  It has been reported in the media that the only preexisting health condition he had was gout.  As a result I have seen a lot of interest in any possible connection between gout and swine flu.  It has been reported in the media that this Assistant Principal is suffering from kidney failure.  As I have written previously (see,Is Gout Dangerous) that gout is strongly associated with kidney failure.  If fact, nearly all people suffering from gout have significant kidney damage at the time of death.

So, did gout combine with swine flu contribute to this man’s kidney failure?  That remains to be seen, but I would not be surprised if this turns out to be the case.  The flu could have found a comfortable home in the already damaged kidneys.  As the disease spreads, we will see if more people suffering from gout develop serious kidney complications.

Update 2: NYC Assistant Principal Passes Away

Unfortunately, NYC Assistant Principal Matthew Wiener passed away Sunday, May 17th.  Our sympathies go out to his family.

As for the connection between gout and swine flu…  Its unlikely that gout played a role, but it is possible.  I hope that the CDC takes a close look to see if there was a connection.  If they can find a connection, then I hope that they will at least advise the public of the risk and advise the medical community to treat those that have gout and develop swine flu more aggressively.

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The Impact of Gout on Your Quality-of-Life, Finances and Family

If you have gout, you understand that gout has a definite impact on your quality-of-life during an attack — life sucks.  The pain can be unbearable.  Researchers have looked at this question more quantitatively though and come up with some interesting findings.

As we know, gout is caused by uric acid crystalizing in our joints, which causes an immune response (if you don’t know this, see, Gout Basics).  Even when you are not in the middle of a gout attack, if you have high uric acid levels, crystals are always forming and dissolving and not just in your joints, but all over your body.  These crystals are seen as invaders by your immune system which causes it to respond.  This causes your immune system to alway be in a heightened state of alert and it causes inflammation in your body which can cause many deadly diseases (see, Is Gout Dangerous).  But the problems do not stop there…
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Kidney Stones, a Gout Early Warning?

The “German Professional Association of Internists” released a statement on Monday saying that kidney stones may be an early warning sign for gout.  The statement claimed that as many as 40% developed kidney stones as a first indication of gout.

This makes sense.  It had been known for a long time that high levels of uric acid in the body can cause increased levels of uric acid excreted by the kidneys.  This excess uric acid can form uric acid kidney stones.  Not only that, but uric acid crystals can serve as a catalyst for the formation of kidney stones based on other substances such as calcium.
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Gout in Women

A friend of mine once asked, “Gout?  Isn’t that the old, rich, fat man’s disease?”  Besides being uncharitable, this statement is wrong on pretty much all counts.

  1. People are developing gout at a much younger age now days thanks to the high-fructose corn syrup and other unhealthy dietary habits, but it is still rare for anyone under the age of thirty to get gout – hardly ‘old’.
  2. Now days, you don’t need to be rich to live a sedentary lifestyle and eat the unhealthy foods that helped gout develop its reputation as being a rich person’s disease.
  3. Gout is mostly influenced by genetics, so even those that are not “fat” can get gout.
  4. It’s not just a man’s disease….

Gout: Not Just for Men Anymore

Gout has long been considered male disease because estrogen plays a powerful role in keeping uric acid levels down in women.  However, once women hit menopause, estrogen levels decrease and uric acid levels rise.  In fact, after menopause, women are just as likely to develop gout as men of the same age.
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Alternative Medicine for Gout

Gout is the only disease in all of medicine that has been correctly identified as a unique disease throughout all of recorded medical history. For over four thousand years doctors and healers have recognized pain and swelling of the big toe as most likely being gout. People often ask me what the “scientific name” for gout is.  It’s just ‘gout’ – there has never been any need to rename it.  Things like heart attacks where given more specific names like, myocardial infarction, when our understanding increased, but there has never been any need to rename gout.

In the past, gout was a disease that doctors and healers obsessed over. The disease tended to affected mostly kings and noblemen because they had the means to live a lifestyle that made gout more prevalent - peasants rarely developed gout, even if they where genetically predisposed to gout because their sparse diet and over all fitness (from really hard work) cancelled out this predisposition.

This meant that anyone that came up with an effective treatment, or better yet, a cure for gout would be on the fast track to riches as the wealthy would be willing to pay handsomely for a solution to their gout pain.  This resulted in a myriad of claims about gout treatments and cures, many of which not only still exist today but are widely believed as being helpful for gout. Of course, some of these ancient doctors actually did stumble on substances that have proven to be helpful for gout, but most just do not work.

In this article I will look at some of these treatments and look at which have scientific backing, which do not and which are potentially dangerous.
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The Truth About Homeopathy

I am going to start by saying something that is going to upset a lot of people: homeopathy is a fraud.  Homeopathy started about five hundred years ago under the idea that “what makes a man ill also cures him.”  This idea struggled until it reached it reached a peak in popularity in the 1800s. However, it was criticized heavily by mainstream scientists and was eventually discredited to the point where there where few followers by the 1920s.  However, in the 1970s, sensing a commercial opportunity, homeopathy underwent an worldwide revival.  Unfortunately, homeopathy does not work. This is not an opinion by the way, but a statement that is backed up by two things, 1) the scientific research and 2) common sense.
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Gout and the Sleep Apnea Connection

There is a frequently overlooked factor that can cause an acute increase in the concentration of uric acid in the blood as well as increased likelihood of its precipitation as MSU (monosodium urate or uric acid crystals. See, Gout Basics for background). That factor is the reduction of the concentration of oxygen in the blood, which occurs in an individual suffering from sleep apnea.

Sleep apnea is the repeated cessation of breathing for many seconds at a time during sleep, when the muscles lining the airway relax enough to allow it to close, until the brain jolts them to reopen. The resulting reduction of oxygen in the blood causes the cells in the body to undergo a process of disintegration, which leads to their generation of excess uric acid. Once the uric acid is formed, the process is irreversible, even when breathing restarts. With each apneic period, more and more uric acid is fed into the blood, faster than the kidneys can dispose of it. Furthermore, the increased ratio of carbon dioxide to oxygen in the blood makes the blood more acidic, so that its ability to hold uric acid in solution is reduced and MSU is more likely to precipitate. These processes were described in medical journal literature about twenty years ago, and subsequent literature has confirmed that sleep apnea leads to excess uric acid in the blood and in the urine.
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Why is Gout so Often Mismanaged

I often quote the statistic that 78% of doctors do not properly manage gout. This statistic is true (based on the research study that reported it) but the big question is, why? This article with take a look at this question.

First off, let me start by saying that I am not someone that bashes doctors and the medical community or says things like, “all doctors are arrogant, lazy, over-paid idiots.”  Though, as with any profession, there will always be some that fit this description, most doctors are caring, compassionate, highly competent people that do a fantastic job.  The problem however, is that the medical profession is the victim of technology, its own success and its failures…
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Secondary Gout

For the overwhelming majority of people with gout (90%), gout is a genetic disease.  These cases are called primary gout.  In this article will talk about the other 10% – what is called secondary gout.  There is a very long list of causes of secondary gout.  Here I will talk about the most common and the most serious.

Lifestyle

The single most common cause of secondary gout are lifestyle issues.  Lifestyle covers a lot of different areas.  Unfortunately, one of the most common is obesity.  About 60% of Americans are now considered obese and the number is still growing and is the leading reason why the incidence of gout continues to rise.  Being overweight causes the body to create more uric acid but also reduces the bodies ability to eliminate uric acid.  If you have gout and are overweight, the single best thing you can do for your gout, and for your overall health, is to eat a healthy, well balanced, reduced calorie diet, lose weight and exercise regularly (See “The ‘Skinny’ on Gout Diets”).  Of course everyone that is overweight wants to do this but few people are actually successful, myself included.

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How to Stop a Gout Attack

One of the myths that I wrote about in my Top 10 Gout Myths post is: “Once a gout attacks starts, there is nothing you can do but ride it out”.  In this post I will talk about what to do when you feel a gout attack coming on.

Act Fast!

Gout is caused by an immune response to uric acid crystals forming in the joint (see Gout Basics).  This immune response starts a spiral that quickly causes massive inflammation and pain.  The key to stopping a gout attack is to break the spiral!
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