Got Gout?

More and more people do. Why?

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Gout is a strange, medieval type of medical condition that manifests without warning, often in a person’s big toe, of all places, and causes almost unbearable pain and suffering without being fatal. Gout disappears just as mysteriously, and always threatens to reappear at any time, like some sort of invisible, unreasonable, otherworldly punishment.

If ever there was a medical condition perfectly suited to myth and literature, gout is it. Not surprisingly, it has shown up among famous literary characters throughout the centuries, including Sir Leicester Dedlock of Dickens’ Bleak House and Casaubon in Eliot’s Middlemarch. It has also occurred throughout the ages among many literary writers themselves, as well among legendary leaders and intellectual giants, including John Milton, Alfred Lord Tennyson, Joseph Conrad, King Henry VIII of England, Martin Luther, Voltaire, Charles Darwin, Sir Isaac Newton, and Benjamin Franklin. (For Dr. Thomas Sydenham’s 17th-century description of a gout attack, click here.)

Gout is hardly a romantic condition, but over the years it gained a reputation as quite patrician. It was called the “disease of kings,” and its appearance signified high living. Indeed, for a time doctors only diagnosed the wealthy with gout; members of the working class with the very same condition had the far less respectable “rheumatism.”

Doctors didn’t get it all wrong. Cases of gout have doubled in recent decades, and new research has confirmed that over-consumption of such luxury foods as red meat and shellfish and hard liquor and beer (but not wine) can trigger the ailment. These foods are rich in purines, which are metabolized into needle-shaped crystals of uric acid that can, in excess quantities, inflame the joints. (That gout can also result from consumption of other foods high in purine, such as lowly dried beans and peas, was likely unrecognized, or at least overlooked, in the old days.)

Another recent study found a new trigger for gout — sugary soft drinks. A study published earlier this year in the British Medical Journal followed 46,000 men with no history of gout for 12 years and documented 755 new cases. The researchers discovered that those men who consumed at least two soft drinks per day had an 85 percent greater likelihood of developing gout than those who drank less than one per month; even at lower levels, increasing soft drink consumption increased the risk for gout, regardless of other risk factors for gout.

Perhaps more surprisingly, the researchers also found that drinking lots of fruit juice and eating lots of fructose-rich fruits like apples and oranges also increased risk for gout, but not as significantly. Excess of fructose may inhibit the excretion of uric acid. They concluded that the current dietary recommendations for gout should focus not only on restriction of purine intake but also on restriction of fructose-rich foods.

But it’s not all about diet for some people who suffer from gout. For them, genetics plays a significant role in hyperuricemia, and one in four people with gout have a family history of it. A recent study of the genes of more than 12,000 people identified the specific gene variant that may increase or lower the risk of a person developing gout. The gene variant, called SLC2A9, was already known as a transporter of fructose, but in this new study, researchers found the variant also plays a key role in transporting uric acid. Presence of SLC2A9 appeared to hinder the ability of the kidneys to filter uric acid from the bloodstream and was linked to low levels of uric acid excretion and gout.

This genetic component may explain why some people whose lifestyle consists of habitual overeating and overeating don’t develop gout while others do. Still, researchers have suggested that what Americans are eating may have a lot to do with a resurgence of the ailment.

In fact, gout is alive and well as the most common form of inflammatory arthritis among men over 40; in 2005, roughly three million Americans had gout in the prior year,
up from an estimate of 2.1 million in 1990, according to the National
Arthritis Data Workgroup. It surely comes as no surprise, in this era of overindulgence and obesity, that gout is not relegated to old novels and to dead poets, revolutionaries and kings. It is today just as ridiculously painful as it was in centuries past, but luckily doctors know a bit more about how to treat it. Making it go away for good, however, remains a mystery for the ages. • 28 July 2008

REFERENCES: “Soft drinks, fructose consumption, and the risk of gout in men:prospective cohort study.” Choi HK & Curhan G. BMJ. 2008;336:309-12. “SLC2A9 is a newly identified urate transporter influencing serum urate concentration, urate excretion and gout.” Vitart V, Rudan I, Hayward C, et al. Nat Genet. 2008;40:437-42. “Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II.” National Arthritis Data Workgroup. Arthritis Rheum. 2008;58:26-35. “The Key to Dedlock’s Gait: Gout as Resistance.” Gordon, JB. Included in Literature and Sickness. Edited by David Bevan. Amsterdam: Rodopi Press. 1993. Gout:
The Patrician Malady. By Roy Porter and G. S. Rousseau. 
New Haven: 
Yale University Press. 1998.

 

Jennifer Fisher Wilson is the science reporter for Annals of Internal Medicine. Her stories are available at www.annals.org.

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