Author: Foot Doc
Date: 4/8/2007 8:27 pm PDT
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Although there certainly can be variations in the intensity of the pain, typically, acute gout presents with considerable pain of an intensity which I do not hear in your post. Such episodes are generally also accompanied by swelling, inflammation, redness and local heat, which may often be confused with infection. However, there may be many other diverse reasons why the toe could be stiff and painful, and from your description as given, I would think that gout is not a terribly likely diagnosis. However, it might interest you to know something about gout anyhow . .
Classic gout is what is typically categorized as an inborn error of metabolism, wherein the body cannot properly metabolize purines ( nitrogen-based nucleotides) which are both found in food-stuffs and manufactured by the body. The end result of this error in metabolism is the buildup of excessive levels of uric acid in the blood. The body normally produces a certain amount of uric acid which is generally adequately eliminated by the normal kidney. But when the kidneys are incapable of adequately performing this function, either because they are compromised by disease or because too much uric acid is being manufactured by the body, the uric acid is stored as monosodium uriate crystals in the joint fluids where they often clump into larger deposits know as tophi, and subsequently precipitate the violent and painful inflamatory reaction which you are presently xperiencing.
Two tests are commonly employed in the diagnosis of gout. Blood uric acid level are general obtained, but the results may in both their values and interpretation vary. I've seen classic acute gout in patient who had essentially normal uric acid levels and no indication of gout in folk who had a high uric acid on random routine blood-work. The definitive test for acute gout is the needle aspiration of the inflamed joint and the subsequent finding of the uriate crystals.
Other than the old time standby, cholchicine, which has just about no other proven usefulness in medicine than in gout, anti-inflammatory medications, including strong NSAIDS such as Indocin (indomethacin) or Butazolidin (phenylbutazone)are employed on a short-term basis. Care must be taken to protect the stomach from its sometimes severely irritant side-effects and phenylbutazone, in particular has be indicted in some blood dyscrasias. Colchicine in acute gout is generally taken 1/00 to 1/60 grain every 1/2 to 1 hours until either relief is obtained or nausea, vomiting or diarrhea ensues. Response of the pain and inflamation to colchicine is often seen as a somewhat presumptive diagnosis. Colchicine will produce the adverse GI effects in virtually everyone if enough is taken, and medication for this is often provided perspectively for those placed on the medication. Aspirin and other salicylates are interesting in that the usual dose which is generally used for most pain, headaches etc. can precipitate or make worse an acute attack of gout. Higher doses may conversely be effective, but may also be quite damaging to the stomach.
In any event, in most cases of acute gout, resolution of the initial symptoms is not the end of the story. Without going into what is know as pseudo-gout or gout which may be precipitated by diuretics (Lasix, HCTZ, etc.) The next state in the treatment of gout is in prevention of recurrences, or maintenance phase. I generally recommend that this be done under the supervision of a medical doctor, and not a podiatrist, just I would suggest that a diabetic ulcer of the foot could well be taken care of by a podiatrist, but he/she should not be the primary treator of the underlying diabetes.
There are two main types of medications which are commonly used in maintenance care of gout. First are the urocosurics . . those medication which cause the body to pass the uric acid into the bloodstream where it can be eliminated by excretion through the kidneys. Of course, adequate kidney function is a prerequisite for this medication to be effective. An older, but still useful medication in this class is Benemid (probenecid) used alone or in combination with colchicine. A word of warning though. Since mobilization of the uric acid into the blood is its mode of action, early on in the use of these types of medications, acute attacks may be temporarily elicited. This is most-times transient and generally quickly resolves. Anturane (sulfinpyrazone) is another medication in this class, and is also use alone or in combination with colchicine. Aspirin and other salicylates may interfere with its action.
A different classification of medication for prevention but not treatment of acute gouty episodes is Xyloprim (alopurinal). Its mode of action, unlike that of urocosurics, is the chemical/biologic inhibition of intermediaries in the breakdown of purines to urine. Here again, initial therapy has been know to precipitate an acute attack on a temporary basis, but as with probenecid, this usually passes. Alopurinal is not without it side-effects, some potentially severe and even life-threatening conditions, such as the skin rash seen in Stevens-Johnson syndrome have been occassionally seen. But the vast majority of users of this medication seem to do reasonably well and it is a widely use drug.
The other aspect in the prevention of acute gouty attack, dietary restrictions, has been debated for years. The theory is that if one consumes high quantities foods rich in purine, such as organ meats (liver, kidneys, etc.) or beer or certain types of seafood, or many other foot-stuffs which have varying amounts of purines, then one is more likely to have recurrent gouty attacks. For this reason, gout, long ago, was know as the "rich-man's disease." There is some disagreement among medical people as to whether such dietary restriction are effective or indeed routinely needed, but it probably couldn't "hoit" to stay away from such foods.
Finally, long-standing gout can produce a form of arthritis . . . curiously know as, "gouty arthritis," which has many of the clinical symptoms as osteo-arthritis and is often treated similarly.
One needs to become his/her own expert on the condition and one will likely have far less problem with a problem which can't be cured, but can control.
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