Dana A. Brown, PharmD

Dr. Brown is an assistant professor of pharmacy practice at Palm Beach Atlantic University, Lloyd L. Gregory School of Pharmacy, West Palm Beach, Florida.

	Gout is a condition in which there is too much uric acid in the joints, tissues, and sometimes, even the kidneys. When this acid builds up, crystals are formed, often causing pain in the affected areas.

	Gout occurs much more frequently in men—approximately 10 times as common&mdash;than in women.As you age, the risk for having gout increases. Additionally, having a family history of gout is linked to the development of the condition.

	Other risk factors for gout include being overweight or obese; drinking alcohol; heart failure; history of kidney disease; lead toxicity; high cholesterol; high blood pressure; and medications such as diuretics (fluid pills), niacin, aspirin (>2000 mg/day), levodopa, and cyclosporine. Eating certain foods high in purines, a natural substance found in cells, is also a risk factor. For the most part, high-purine foods are also high in protein, and these foods include organ meats like liver, and some fish, such as herring, salmon, and sardines.

	The most common symptoms associated with gout include pain, redness, warmth, and swelling in the affected joint(s). Patients commonly describe a worsening of pain with touch. Although gout attacks may be slightly different from patient to patient, they typically come on suddenly, occur during the night, and affect the big toe. Other joints and tissues that may have a buildup of these crystals include the insteps, heels, ankles, knees, fingers, wrists, and elbows.

	How is gout treated? Lifestyle changes, such as losing weight, reducing alcohol intake, avoiding foods high in purines, and controlling blood pressure and cholesterol, can help to lower the buildup of these crystals in the body; however, when used alone, these methods are often ineffective in bringing levels back to normal. Thus, medications are often used to help.

	Treating a gout attack early is important to reduce the pain as quickly as possible. Hot pads and/or cold packs may provide additional pain relief. In addition, several medications are available to treat gout attacks.

	This class of drugs works quickly to relieve pain and is a cost-effective option. The data do not suggest, however, that these medications are better than any other treatment option for gout attacks. Indomethacin, a prescription medicine, is commonly used; however, other anti-inflammatory medications may be used, such as ibuprofen and naproxen (available over the counter), and sulindac, by prescription. This class of medications should be used cautiously in patients with a history of peptic ulcers, kidney disease, heart failure, or coronary heart disease. Side effects of anti-inflammatory medications may include increased risk for bleeding, rash, nausea, diarrhea, and heartburn.

	An alternative to anti-inflammatory drugs for the immediate treatment of gout attacks is colchicine. This drug is most effective when given as quickly as possible; within 24 to 48 hours is best. Beginning treatment after 48 hours of symptoms does not tend to be as successful, when compared with starting it earlier. If you are prescribed this drug, instructions commonly include taking it every 2 hours until diarrhea occurs, symptoms have gone away, or a total of 8 mg has been taken. Side effects include nausea, vomiting, and diarrhea.

	Steroids are reserved for patients who cannot tolerate or who do not respond well to anti-inflammatory medications or colchicine. If you are prescribed steroids to relieve the pain of a gout attack, they may be given either by injection into the affected joint or taken by mouth. Steroids generally are used for the shortest period of time possible, due to the risk of side effects, such as osteoporosis, cataracts, diabetes, high blood pressure, and many others.

	Pain from gout attacks usually resolves within a few days of treatment. Patients may never have another attack, or a second attack may occur as late as 5 to 10 years after the first episode.

	Patients who have frequent gout attacks, certain softtissue swellings, or kidney stones from the build up of uric acid are often considered for beginning treatment to prevent gout attacks. This decision should be discussed with your doctor, who should take into consideration how well your kidneys are working, as well as your uric acid level.

	Colchicine is commonly used to prevent recurrent attacks of gout. Taking low doses of this drug once or twice daily has been shown to prevent gout attacks, especially in patients who have normal or slightly increased uric acid levels.

	Another option available by prescription is allopurinol. When given once daily, allopurinol is effective in reducing the production of uric acid. This is the treatment of choice for patients who have kidney stones from gout and for patients who have kidney problems and/or disease.

	It is important to note that allopurinol is not used to treat gout attacks; in fact, an attack may occur when beginning therapy, and the attack can be managed with anti-inflammatory medications or colchicine. Side effects of allopurinol may include nausea and diarrhea. Patients who develop a skin rash, hives, itching, swelling, blood in the urine, or trouble breathing should stop taking the medication and seek immediate medical attention, as this may indicate a potentially fatal allergic reaction.

	Another class of drug is available by prescription to help prevent gout attacks from recurring. These medications, which include probenecid and sulfinpyrazone, work by reducing uric acid levels through urination. They should not be used if you do not have normal kidney function. Patients taking these medications should drink at least 8 to 10 full glasses (8 oz each) of water every day to prevent the development of kidney stones. These drugs may interact with other drugs, such as penicillin, indomethacin and other aspirin-like products, and other antibiotics. The use of low-dose aspirin for the prevention of coronary heart disease is generally acceptable, however.

	Side effects associated with this therapy may include nausea, vomiting, headache, dizziness, sore gums, or flushing. As with allopurinol, the presence of shortness of breath, blood in the urine, rash, hives, and/or swelling may indicate an allergic reaction. Immediate medical attention should be sought.

	You may want to consider stopping preventive medication if you have been symptom-free for about 1 year. Stopping therapy presents a risk for an attack of gout, however. All health care practitioners involved in your care should have a full understanding of any underlying diseases or health conditions you may have as well as all of the medications you are taking, in order to develop the best treatment plan and stop gout from being a big pain in the big toe.

Articles

Gout: A Big Pain in the Big Toe

, is a group of risk factors that increase a person's chance of developing heart disease, stroke, and type 2 diabetes. It is estimated that 47 million American adults have the metabolic syndrome, and it appears that men and women are at equal risk. Although the condition is more common in later life, an estimated 4.2% of adolescents 12 to 19 years of age have the metabolic syndrome.

	The core risk factors that make up the metabolic syndrome have remained consistent. A few changes have been made, however, as experts have learned more and more about heart disease and diabetes. The most recently updated list of risk factors is as follows:

		A lot of fat around the abdomen (called central obesity; a waist circumference of more than 40 inches in men and more than 35 inches in women)

		A high level of triglycerides (150 mg/dL or more) or if you are taking medication to lower your triglycerides

		Reduced high-density lipoprotein (HDL—the good cholesterol; less than 40 mg/dL in men and less than 50 mg/dL in women) or if you are taking medication to raise your HDL

		High blood pressure (130/85 mL of mercury or higher) or if you are taking medication to lower your blood pressure

		High fasting blood sugar level (100 mg/dL or more without having any food for the past 8 hours) or if you are taking medication to lower your blood sugar

	It is important to note that your waist measurement is not necessarily the same as the waist size you use to purchase clothing. Instead, a properly trained health care provider should take the measurement of your waist to determine whether you are classified as having central obesity. As already stated, metabolic syndrome also is known as insulin resistance syndrome. This condition is related to the fact that the body cannot use insulin very well and will make too much insulin. Too much body fat and not enough exercise also contribute to this risk. Also, some people have genes that increase their risk for developing insulin resistance. Patients with insulin resistance commonly go on to develop type 2 diabetes.

	How Is the Metabolic Syndrome Diagnosed?

	There is no absolute way to diagnose this condition. However, having at least 3 of the 5 risk factors listed above generally means that you have the metabolic syndrome. If you have any of these risk factors or are unsure whether you do, you should see your doctor.

	Weight loss and increased physical activity are extremely important in reducing the risk for heart disease and diabetes.

	Diets low in saturated fats, cholesterol, and carbohydrates as well as high in fiber are recommended to help you lose weight. Dietary changes you make should not be looked on as "going on a diet." Instead, they should be lifestyle changes that you maintain throughout your life. Generally, weight loss of about 10% over a 6-month period is recommended. However, your physician can help you determine how much weight you need to lose.

	Moderate exercise (for example, brisk walking) for 30 minutes most days of the week is recommended. The time you spend exercising may be broken up into smaller time periods to fit your daily schedule if needed. It is recommended that you start slow (such as walking for 5 minutes every day) and gradually increase the amount of time you spend exercising. Exercise is good for improving your cholesterol level and burning off calories. Before you begin exercising, it is important that you talk with your doctor to be sure that your body can handle the increased physical activity.

	Some patients with the metabolic syndrome may need medications to reduce their risk factors for heart disease and diabetes. If you have high blood pressure, your primary care physician may ask you to start exercising and/or to reduce the amount of salt in your diet. Losing weight also will lower your blood pressure. If you still have not reached your goal blood pressure with these lifestyle changes, you may need one or more medications. Treating high blood pressure is a very important way to help lower your chances of developing heart disease. If you have a low HDL level or a high triglyceride level, reducing your alcohol intake (no more than 2 drinks per day for men or 1 drink per day for women) can help improve your cholesterol level. Also, diets low in cholesterol and saturated fats but rich in foods from plant sources, as well as physical activity, help to lower cholesterol in your body. Smoking cessation is another way to help you reach your cholesterol and blood pressure goals. Despite these changes, medications may still be needed. Some patients with the metabolic syndrome have a high fasting blood sugar level. Reducing carbohydrates, losing weight, and increasing physical activity are helpful to improve your blood sugar level. Sometimes medications may be required to help lower your chance of developing type 2 diabetes.

	If you have any of the risk factors mentioned above for the metabolic syndrome, you should see your physician. Take control of your life, and help lower your chances of developing heart disease and diabetes!

Dr. Brown is an assistant professor of pharmacy practice at Palm Beach Atlantic University, Lloyd L. Gregory School of Pharmacy,West Palm Beach, Fla.

Understanding the Metabolic Syndrome

	Menopause, often called the "change of life," is a normal part of women?s aging process. During this period, a woman?s body makes fewer hormones. Among other things, hormones regulate the monthly menstrual cycle, which includes the "period" or menstruation. During the menopausal transition, periods are less regular, and eventually they stop. Women are considered to be menopausal once they no longer have a period for at least 1 year. Although menopause typically occurs in women between the ages of 45 and 55 years, it may occur in a woman?s 30s or as late as her 60s.

	During menopause, the ovaries make less estrogen and progesterone. Earlier in life, these hormones control monthly periods and the development of breasts and body hair. They also protect bones, which explains why women may develop thinner bones, called osteoporosis, after menopause.

	Because menopause affects women in different ways, it is important to be aware of the possible signs and symptoms that mean that you are starting to go through menopause. Typically, women report changes in their menstrual periods, which may include heavier or lighter periods, shorter or longer periods, or infrequent periods. As women move further through the menopausal transition, they may no longer have menstrual periods at all.

	Many women experience hot flashes, which is the feeling of heat usually around the head and chest areas. They can last from 30 seconds to several minutes and may be accompanied by sweating. Women who experience hot flashes may also experience night sweats. Night sweats occur while sleeping and can be drenching. Other symptoms may include:

	Your health care provider may suggest a treatment called hormone therapy (HT) to help treat symptoms such as hot flashes and vaginal dryness, as well as to prevent bone loss, associated with menopause. An important study called the Women?s Health Initiative showed that HT should be used carefully, and it should not be used by itself to prevent heart disease. In addition, women with a history of breast or uterine cancer, blood clots, liver disease, or heart disease should not use this therapy. Women who have not had surgery to remove the uterus (called a hysterectomy) who are treated with HT should take a combined estrogen plus progestin regimen to help prevent cancer of the lining of the uterus (called endometrial cancer). Women who no longer have the uterus may be safely treated with estrogen only. These hormone products are available in a variety of formulations to meet patient-specific needs, including:

	A treatment called Angeliq is available. It contains the hormones estradiol (a form of estrogen) and drospirenone (or drsp), which is a unique progestin. Most progestins are related to the male hormone, testosterone; drsp, however, is related to spironolactone, and is a product more similar to the hormones in your body.

	Because Angeliq contains the two types of hormones estrogen and progestin, it should only be used in women who have not had their uterus removed. It is approved to treat moderate to severe hot flashes, and to treat moderate to severe vaginal changes that can produce dryness, itching, and burning, associated with menopause. Angeliq is available as a tablet and should be taken by mouth once daily. Taking the tablet either before or after routine daily activities such as brushing your teeth may help you to remember to take it. In addition, this medication should be stored out of the reach of children.

	Angeliq is not for everyone. It should not be used to prevent heart disease, heart attacks, or stroke. If you have a history of liver disease, breast or uterine cancer, blood clots, heart disease (such as a heart attack or stroke), kidney disease, family history of dementia, or adrenal gland disease, discuss whether you should take Angeliq with your physician, because HT may increase the risk of these problems. The unique progestin, drsp, in Angeliq may raise potassium levels and/or lower sodium levels in the body. If you have kidney, liver, or adrenal gland disease and are treated with Angeliq, the risk for high levels of potassium increases. Common side effects of Angeliq include headache, nausea and vomiting, breast tenderness, bloating, irregular vaginal bleeding or "spotting," and hair loss. Other side effects associated with estrogen may include high blood pressure, liver problems, high blood sugar, bloating, yeast infections, and development of fibroids, or benign tumors on the uterus.

	If you experience unusual vaginal bleeding, slurring of speech, severe headache, chest pain, difficulty breathing, vision changes, or leg pain, you should notify a health care provider immediately. You should always discuss all the medications you are taking, including prescription medicines, over-the-counter and herbal products, and any changes in your medications, with your health care provider to protect your health. Follow up with your health care provider regularly to determine if you still need to keep taking Angeliq, and never stop taking the medication without notifying your health care provider.

	Although your body may be going through changes, you may be able to help treat some of your menopausal symptoms. Ask your health care provider if HT is right for you.

Dr. Brown is an assistant professor of pharmacy practice at Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, Fla.