GOUT - the oldies are better

Nov 5, 2019

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

Tomatoes are the devil's fruit." Eric is not a fan of the delicious companion to bacon on a toasted sandwich. Hate is not too strong a word to describe Eric's feelings towards Roma and her cousins. He claims at least half his friends in Grade 9 hate tomatoes as well. I hate all the Halloween Candy he still has in the house. Okay hate is the wrong word. I'm jealous of his Halloween Candy. And bitter. I'm bitter that in Grade 9 his parents still let him go Trick or Treating. My parent stopped me from Trick or Treating in Grade 6. They said I was way too tall to be running around with little kids. They thought people might start offering me a beer instead of candy.

Am I a better parent since I still let Eric go Trick or Treating? Probably not. But there is a little controversy brewing between an older and newer gout prevention pill. There is a newer medication to prevent gout called Uloric or febuxastat. When it was released in 2010, it was the first new drug to treat gout that Health Canada had approved in 40 years. It seemed to work better than the old standby allopurinol. But now, there are some people who want it pulled from the market.

First let's go back to gout and beer. Gout is a type of arthritis that has a long history of being blamed on poor eating habits. Gout was written about by the Egyptians in 2640 BC. In the last 4600 years it is still the only type of arthritis that is curable. Beside diet risk factors for gout include being male, being overweight and being over 40 years old. And a love of beer. Mmmmmmm. Beeeeerrrrrrr.

A gout attack or acute gouty arthritis happens when uric acid comes out of solution and crystals form in the joints or tissue. Uric acid is a normal ingredient in your blood that is formed by the normal break down of cells. Uric acid is also formed when you eat proteins with purine in them. Foods high in purine include anchovies, asparagus, consommé, herring, meat gravies, mushrooms, mussels, organ meats, sardines and sweetbreads. Sometimes in gout there is an imbalance in how much uric acid is formed from your diet and how fast your kidneys can eliminate it. So, if you eat a lot of purine rich foods and drink a lot of alcohol (alcohol causes your body to make more uric acid and your kidneys to eliminate less) you could get gout. And unfortunately, beer seems to be the worst of the alcohols for gout. But diet isn't the only cause of gout. If your kidneys don't eliminate uric acid very well, you could get gout. Or if you inherited a gene that causes your body to make way too much uric acid you could get gout as well.

Often the first time someone knows they have gout is when their big toe hurts. The pain can be very severe, and the joint pain can appear very suddenly and often at night. The pain becomes worse and worse especially when touched or moved. The joint can get inflamed, swollen and warm and the joint can look red or purplish. What do we try to do if someone complains of gout? First send them to the doctor to get a diagnosis. If it is gout, the doctor will probably give them a prescription for a non-steroidal anti-inflammatory drug (NSAID). The most commonly used one in gout is called indomethacin. This will reduce the pain and inflammation and hopefully make the current gout attack go away.

An older treatment for gout is called colchicine. Colchicine has been used to treat gout for centuries. In pharmacy school we were told colchicine works on gout, but that we didn't really know why. Now scientists are working out that the colchicine actual changes the structure of the microtubules inside the white bloods cells that move uric acid crystals around. Colchicine can be very effective for gout, but it has some rare but nasty side effects including bone marrow suppression. Because of these rare but serious side effects, colchicine is used as a second line treatment behind indomethacin.

Surprisingly to me, steroids are being recommended more often for gout attacks. Medications like prednisone are probably safer then NSAIDS for people with kidney disease, cirrhosis of the liver and heart failure. Prednisone can be safer than NSAIDS for patients prone to stomach bleeds. Usually the dose will be prednisone 30 to 40 mg once a day for 5 days with no taper off period.

If a patient has several gout attacks per year, the doctor will then consider giving them something to reduce the number of attacks. That will usually be a drug called allopurinol. Allopurinol reduces the amount of uric acid your body produces. If you take it every day you will reduce the chance of your next attack. Allopurinol will not help reduce the pain in your current attack. And let's get back to Uloric or febuxastat. It may reduce uric acid levels even better than allopurinol. One downside to febuxastat is that as a newer drug, it is more expensive than allopurinol.

The new controversy is an advocacy group pushing for withdrawal of febuxostat (Uloric) due to concerns it increases risk of death. To start with patients with gout are already at elevated risk of heart attacks and strokes. Some early studies seemed to say that
patients on febuxostat were even more likely to have a heart attack or stroke as compared to people on allopurinol. Because of this the FDA in the US asked for a safety trial. The results of that safety trial are now in. For every 91 gout patients with cardiovascular disease treated with febuxostat instead of allopurinol for about 3 years, one will die from CV-related causes. But this is still not a definite febuxostat kills people and allopurinol doesn't result. However, since allopurinol is cheaper and possibly safer, it should probably remain the first choice for preventing gout.

Nonpharmacological measures should always be the first line of defense to prevent and treat gout. Yes, please listen even though you've heard them before. If you are overweight, try to lose some weight. Make sure you exercise, drink lots of water and quit smoking. Avoid high fructose corn syrup sweetened food and drink. Limit sugar of all types and limit the amount of salt you put on your foods. Reduce beer consumption to 2 or less per day for men and 1 or less per day for women. Wine and spirits should be consumed in moderation as well.

Tomatoes, candy and beer. Did my parents stopping me from Trick or Treating early drive me to like beer more than candy? Maybe. Do I like beer too much? I didn't think so, but recently on a What's App chat with a bunch of friends from high school, someone compared me to Barney Gumble. He is a Simpsons character who, after winning a year's supply of beer, famously said, "Just hook it straight to my veins!" Hyperbole? Perhaps. But maybe I should just let Eric Trick or Treat as long as he wants.

As always if you have any questions or concerns about these or other products, ask your pharmacist.

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.


Read more Health Articles

Unite Interactive