Dr. Roach: Woman new to gout learns pain is excruciating

Keith Roach
To Your Health

Dear Dr. Roach: I am a 50-year-old female in fair health who was recently diagnosed with gout. I experienced excruciating pain in my left big toe only that came in bursts, then would subside to a dull pain, followed by another burst of pain. This pain was as bad as kidney stones, which were worse than childbirth. Why is gout so painful, and what can be done to minimize recurrences in the future?

— C.C.

Dear C.C.: Gout is caused by crystals deposited in the joints and occasionally in other soft tissues. The crystal is uric acid — strictly speaking, it’s monosodium urate — and they look like needles under the microscope. They cause an intense inflammatory reaction with redness, swelling, pain, warmth and loss of function.

Dr. Keith Roach

Most people with acute gout agree with you that the pain is exquisite, among the most painful they have experienced. Any movement may cause extreme pain, and I have had many patients use a shoebox (or similar) to protect their feet from gout pain being exacerbated by even a sheet on the big toe, which is the most common place to get an acute gouty attack. There are lots and lots of nerve endings in the big toe and in and around other joints where gout occurs.

Diet and medications together form the basis of treatment. Uric acid is a product of purine metabolism. Purines are components of DNA and are found in high amounts in meat and seafood. Recent studies have shown that dietary restrictions are most useful in those people with gout who are overweight, and most with well-controlled gout can tolerate meat and seafood without significant risk of a flare. However, legumes such as beans, peas or lentils decrease risk of gout flares. Weight loss is effective in reducing gout attacks in those who are overweight.

Medication treatment of gout is appropriate for people with recurrent (two or more per year) or disabling flares; those with uric acid deposits in soft tissue, called tophi; and those with kidney disease due to gout. Medications such as allopurinol, which lower uric acid levels, are good to prevent gout attacks, but paradoxically can cause or worsen an acute attack. Anti-inflammatory drugs or colchicine are more commonly used for acute attacks and sometimes when starting preventive treatment such as allopurinol.

Dear Dr. Roach: There’s lots of info out there regarding systolic blood pressure, but what about diastolic blood pressure? My top number is always fine, but the bottom goes between 82-88 regularly. I’ve been diagnosed with diastolic dysfunction and would like more info regarding this bottom number that’s not mentioned as much as the top number.

— M.P.A.

Dear M.P.A.: The left ventricle, which pumps blood to the body, has two phases: systole, when the chamber squeezes the blood out and the aortic valve is open, and diastole, when the aortic valve is closed and the ventricle refills. The peak blood pressure, represented by the top number, is systolic, while the bottom number (diastolic) is the blood pressure when the left ventricle is filling up. Both systolic and diastolic numbers are important, as elevations in either of them increases risk of heart disease and stroke.

However, if the systolic number is not elevated and the diastolic number averages around 85, the magnitude of your risk is small.

Diastolic blood pressure elevations mostly represent an issue with the blood vessels in the body, while diastolic dysfunction refers to a decreased ability of the heart to relax, sometimes called a “stiff ventricle.” Longstanding high blood pressure is a major risk for diastolic dysfunction. Diastolic dysfunction and high diastolic blood pressure do not have to be linked, but often are.

Readers may email questions to ToYourGoodHealth@med.cornell.edu.