Q: I have pain in my big toe joint, which is excruciating at times. Sometimes in the middle of the night, I have a sudden onset of severe pain at the base of my big toe. The joint becomes swollen, red, hot and tender. These episodes keep recurring.
I drink a lot of beer, probably too much. These episodes seem to happen when I drink excessively. The pain and swelling used to go away in a few days if I took over-the-counter ibuprofen, but I’ve been having mild pain there almost continuously since my last episode. What should I do?
A: Your symptoms are typical of gout, which is a common inflammatory form of arthritis. Gout is caused by the accumulation of uric acid (urate) crystals in your joints and tissues.
Gouty arthritis occurs most commonly in the joint at the base of the big toe, but can also flare up in other joints including the smaller toes, the ankle, or the knee. You should see your doctor for evaluation, blood tests (including a uric acid level), and X-rays to determine if you are suffering from gout or another kind of arthritis. Untreated gout can cause joint damage, decreased mobility, kidneys stones, and gouty tophi (painless lumps under the skin near joints, on feet, hands, elbows, Achilles tendons, or even on your ears).
Your body may be producing too much uric acid, or not excreting it fast enough. Your body produces uric acid when it metabolizes purines. Purines are naturally occurring in your body, but are also found in foods like meat, mollusks, and oily fish, so reduce or eliminate them from your diet.
Blood tests for uric acid levels are most accurate during flares of acute gout, although a normal uric acid level doesn’t eliminate the diagnosis of gout. An aspiration of your joint demonstrating the presence of uric acid crystals in the gold standard test for diagnosis. X-rays may demonstrate deterioration of the involved joint.
Ask your doctor if you’re having attacks of acute gout, with a history of asymptomatic gout in between episodes. Have you now developed recurrent, interval, or chronic gout? The treatment recommendations are different.
Do your part by modifying your lifestyle and reducing risk factors. Excessive alcohol intake is the most common risk factor for developing an attack of acute gout. Imbibing more than two drinks/day for men (or one drink/day for women) is considered excessive from a health perspective. Stop, or dramatically reduce, your intake of alcohol.
Does your father have gout? Are you overweight? Other risk factors include: medications like aspirin, diuretics, and immunosuppressive drugs; dehydration; diseases (hypertension, heart disease, high cholesterol, diabetes); an unhealthy diet, trauma to the joint, or severe injury or illness.
Acute treatment includes pain management with non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, or steroids, and/or medications like colchicine. For recurrent or chronic gout, your doctor may prescribe a drug like allopurinol or probenecid to lower your uric acid level, aiming to keep it less than 6. These drugs should always be taken as prescribed with plenty of water as they may have side effects.
Stay well hydrated. Avoid sugary drinks, high fructose corn syrup and alcohol. Limit your intake of animal products (other than low fat dairy). Eat lots of vegetables and herbs, whole grains, and low glycemic fruits (especially cherries). Use plant oils like olive or canola.
Get plenty of omega-3 fatty acids (high quality supplements are fine since you’re reducing animal protein consumption). Try taking MSM, Vitamin C, and folate. It may be beneficial to drink coffee. Exercise 30 minutes daily and lose weight if your BMI is more than 25.