Pain is one of the most common complaints we encounter in general practice, and it can come from all sorts of places – the back, the abdomen, even from teeth (for people who misread the sign on the way in). But the pain that patients frequently describe as the most excruciating they’ve ever felt? The one that comes from their big toe.
The culprit? Gout. A condition associated with King Henry VIII and Queen Anne – which has been dubbed “the King’s disease”, the “unwalkable disease”, or rather poetically, the “bitter fruit of luxury” – over the centuries.
We tend to associate gout with images of rotund Georgian lords and ladies, swigging wine around some Bacchanalian feast. But we now know that gout is not always a result of indulgence.
In fact, gout is surprisingly common. I see a couple of new cases each year, plus some patients returning with another painful flare up. That’s the nature of gout: it can come and go – episodes sometimes separated by months or years – or become a more persistent, chronic problem. It more commonly affects men, who are three to four times more likely to develop it than women. And it’s now become a condition of younger patients too, as obesity and metabolic disease become more widespread; in fact, there are estimates that by 2050 that 96 million people across the globe could be affected – that’s compared to the estimated 56 million sufferers in 2020.
Gout is caused by increased bloodstream levels of a compound called uric acid. This is a natural waste product, made when cells turnover and renew themselves.
Uric acid is also generated from diet, particularly from certain foods high in compounds called purines. Examples of purine-rich foods include oily fish and seafood, game, and offal like liver and kidneys – hence the association with those extravagant Georgian feasts.
When uric acid levels rise too high, it starts to precipitate out into needle-like crystals, particularly in and around the joints. These crystals are an irritant and can trigger inflammation within the joints, making them red, hot, swollen and particularly painful – the cardinal signs of inflammation.
Overindulgence is not the only reason
There are a considerable number of risk factors for gout. Excess alcohol and obesity are two definite examples, which – alongside a high purine diet – give some credence to portly aristocrats being struck down after one banquet too many. But people today are still getting gout so it’s clearly not all about port and a haunch of venison.
Other foods can contain purines too, including wholegrains and some vegetables such as beans, cauliflower and asparagus, which if eaten in abundance might have similar effects. One colleague once reported gout in a patient who ate vast amounts of broccoli each day.
Family history is also a risk factor – if you have a parent or sibling who has gout, you’re at increased risk yourself. It’s also associated with several other medical conditions, including chronic kidney disease, psoriasis and certain cancers, like leukaemia. Some medications can increase uric acid levels too, particularly diuretics which are used to treat blood pressure and heart failure.
But risk is just that – risk, not guarantee. Having one or more of these risk factors, or even having raised uric acid doesn’t mean you’re destined to develop gout. It is, however, worthwhile seeking medical advice if you do develop any symptoms – and for a multitude of very good reasons.
Gout is not a trivial illness
I recently watched a brilliantly funny film called Savage House, in which Richard E. Grant plays Sir Chauncey Savage, a social-climbing aristo who is desperate to save his impoverished country home by hosting the Duke and Duchess of Devonshire. Upon developing gout a few days before this lavish occasion, he threatens his misbehaving big toe, saying it will be “severed and fed to the mice” while hobbling round Savage House with a slice of raw steak strapped to it.
It’s a comical but incredibly accurate way to describe gout – it’s often so intensely painful that it usually makes walking extremely difficult. Since the lightest touch to the affected joint can be agony, some people find it impossible to bear the weight of a bedsheet touching their feet at night. In fact, it’s possible to purchase a foot cage that lifts the bedclothes clear of the feet. It might sound ludicrous, but for someone in the midst of an acute gout flare, it can prove invaluable.
And gout can affect more than just the big toe, inflaming many other joints – including those in the feet, ankles, knees, wrists, and elbows. If left untreated, the uric acid crystals can erode the joints and cause permanent or severe damage.
High uric acid can also impact more than just the joints – it can cause damage to internal organs too. There is an increased risk of both cardiovascular and chronic kidney disease if gout is left untreated. It can even cause kidney stones.
Gout really does warrant attention. Happily, there are readily available options to treat gout in the acute phase as well as reduce the chance of it coming back.
Treatment requires more than lifestyle changes
Given the association with diet and obesity, it makes sense that eating less purine-rich food and losing excess weight could potentially help. But only about a third of the uric acid our bodies produce comes from dietary sources – the rest comes from normal body metabolism. Amending lifestyle is unlikely to make a significant difference to uric acid levels by itself.
To tackle gout, the plan of attack is twofold: first, treat the inflammation, and when that’s gone, reduce the amount of uric acid in the bloodstream to prevent gout returning.
In an acute episode, GPs use ibuprofen, corticosteroids or another medicine called colchicine, for their anti-inflammatory effects. Getting treatment started as soon as possible really helps here – as does resting and elevating your feet to take the weight off the joint.
Once that’s sorted, the focus shifts to reducing uric acid. This can be measured with a simple blood test, which is also required to make the diagnosis. One important medication here is allopurinol, which helps reduce the amount of uric acid the body makes. Following up with a GP is important as the dose usually needs to be increased to reduce uric acid to manageable levels. Other options are available if allopurinol doesn’t work, or isn’t tolerated.
Lifestyle steps shouldn’t be pooh-poohed though – reducing weight, limiting alcohol, increasing exercise and reducing sugar intake can also have an impact – with benefits that are wider reaching than just preventing further attacks. Remember that gout is associated with heart disease, so these changes can also benefit cardiovascular health too.
The face of gout has really shifted over the centuries. And it doesn’t always follow the rulebook – I’ve diagnosed gout in patients with no family history, no other chronic conditions, and no obvious risk factors.
Perhaps the biggest misconception of all is that we’ve brought gout upon ourselves and therefore have to tolerate it. But beyond the colourful history is a condition that can cause pain, disability, and lasting damage. And is associated with some serious health problems.
A new or significant pain in your big toe or another joint deserves more than hoping for the best. Don’t allow it to become anything more, and get it checked out.