Is It Rheumatoid Arthritis or Gout?

Q: I am a 50-year-old man recently diagnosed with rheumatoid arthritis (RA). But I have had joint symptoms
for some time, beginning two years ago with a bout of excruciating pain and swelling in my left toe and
progressing to episodes of pain and swelling in my feet, knees and wrists. While these incidents may have
been early signs of rheumatoid arthritis, gout is also a concern of mine. Do you think I have arthritis or gout?

A: It sounds to me like you have gouty arthritis, or gout, an inflammatory disease that occurs when excess uric acid (a
bodily waste product) circulating in the bloodstream is deposited as sodium urate crystals in certain joints.

The excess uric acid may be caused by genetic factors or kidney disease. The condition may be aggravated by certain
drugs such as diuretics and low doses of aspirin or by consuming too much alcohol or foods rich in purines, which are
broken down into uric acid.

If your physician didn't know about your previous problems, it's not surprising he diagnosed your condition as rheumatoid
arthritis; gout was probably not even on the radar. In its later stages gout can look a lot like RA, causing pain and
inflammation in multiple joints.

In some cases, untreated gout can be associated with a positive rheumatoid factor, an antibody often detected in the blood
of people with rheumatoid arthritis. Even buildups of sodium urate can form lumps under the skin that resemble the
nodules fairly common in RA.

But that's where the similarity ends. The causes and treatments are entirely different. Unlike gouty arthritis, RA occurs
when the body’s immune system – which normally protects us from infection – mistakenly attacks the thin membrane that
lines the joints. RA may begin acutely in many joints or start gradually in several joints causing damage and pain. Initially,
the involved joints are the knuckles, middle joints of the fingers, wrists, and joints that attach the toes to the feet.

Gout, on the other hand, often starts as your problem did – with excruciating pain and swelling in the big toe – and often
follows a trauma such as an illness or injury. Subsequent attacks may occur off and on in other joints – primarily those of
the foot and knee – before becoming chronic. In its chronic stage, gout can affect many joints, including those of the
hands. But this can take a few years to happen.

Unlike rheumatoid arthritis, gout is a well-understood and highly treatable disease. Medications are available to stabilize
uric acid levels and relieve acute pain and inflammation. With appropriate treatment gout can be controlled and future
attacks prevented. The biggest obstacles in controlling gout are improper diagnosis and noncompliance. If a doctor doesn't
diagnose it properly, he cannot treat it properly.

Like some other forms of arthritis, gout requires a medical regimen all its own. Taking the proper medications and taking
them faithfully – even during periods when you feel absolutely fine – is essential to controlling gout. Maintaining a
reasonable weight and limiting alcohol consumption can help control gout as well.

If you haven't already had a joint fluid sample examined for urate crystals, I would recommend you speak to your doctor
about having one at your next visit. Or if the medication he has prescribed for your RA (and I assume he has prescribed
one or more) doesn't seem to be helping, schedule a visit sooner. It is important to determine whether you have arthritis
or gout – the sooner you know and begin proper treatment, the sooner you will experience relief.
Fight Gout with Your Gut
By Amy Long Carrera

Coffee or tea? Wine or beer? Mushrooms or anchovies? Regular or diet?

If you’re one of the estimated six million Americans who have gout, you share a common confusion about how your diet
can bring on or stave off a gout attack. The latest research may provide some answers.

Most people with gout believe they should avoid all purines, the nitrogen-containing compounds that are metabolized into
uric acid in the body. But the reality is, the over-consumption of purine-rich foods and the under consumption of water are
often what lead to gout attacks, and research has shown that not all purines are bad – and they aren’t the only part of
your diet to watch.

A gout attack can occur when uric acid builds up in the bloodstream. High levels of uric acid in the blood lead to the
formation of crystals that often accumulate in the joints at the base of the big toe, but also can form in the elbows, ankles,
wrists and other joints. Painful gout flares are characterized by severe pain and inflammation.

The good news is there are many ways to alter your diet to help keep a gout flare at bay. Based on recent research, here
are some of the best preventative measures you can take.

Go with good dairy

Investigators also found that low-fat dairy products may improve excretion of uric acid in the urine. Those who consumed
a serving or more of low-fat milk or yogurt a day had less uric acid in their blood than those who abstained. High protein
and low purine content of milk may explain dairy’s protective effect.

Get your java perks

Once thought to contribute to gout attacks because of its caffeine content, coffee may now be in the clear. Two separate
studies reveal that drinking coffee reduces the risk of gout for men and women. Results of the larger study, which included
45,869 men older than age 40 with no history of gout, showed the risk of gout was 40 percent lower for men who drank
four to five cups a day – and 59 percent lower for men who drank six or more cups a day when compared to men who
never drank coffee. In the other study researchers reviewed food questionnaires from 14,000 men and women age 20 or
older, and found that the more coffee (regular or decaf) the participants drank, the lower their uric acid levels were. Tea
seemed to have no effect.

Switch to diet soda

Recently, fructose (a component of sugar) has come under fire for bringing on bouts of gout inflammation. Over 12 years,
data was collected on soft drink intake from 46,000 men without gout. The more regular soda (a concentrated source of
fructose) the men drank, the higher their risk of gout. Diet soda however, had no effect.

Fill up on water
Recent research shows drinking more water means fewer gout flares. One study done at Boston University School of
Medicine revealed that with each glass of water consumed in 24 hours before an attack, the risk for recurrent gout attacks
decreased. For example, those who drank five to eight glasses of water had a 40 percent reduced risk of a gout attack
compared with those who drank only one glass of water or less in the prior 24 hours. The study’s authors could not make
specific recommendations about the amount of water people should drink because it depends on their underlying medical
conditions and physical activity levels. Talk to your doctor about how much water you should drink each day.

Enjoy your vegetables

Vegetables with purines, like mushrooms, asparagus and spinach, may have gotten a bad rap. Scientists found no
correlation between the intake of these vegetables and gout risk. It’s possible that beneficial compounds in these foods
may offset the moderate purine content.

Avoid alcohol
Beer is strongly correlated with gout flares, with hard liquor coming in a close second. Moderate wine consumption,
however, (think a glass a day for women and two for men) had little or no effect on uric acid levels or risk of gout.

Check your antioxidant-C intake

Vitamin C intake of at least 500 milligrams (mg) a day from food and supplements decreased incidence of gout in 46,000
men with no history of the disease. The powerful antioxidant may compete with uric acid for reabsorption into the body.
Those at risk for kidney stones, which includes those with gout, should avoid intakes of more than 1,000 mg daily.

Eat a balanced diet

A well-balanced diet, using the U.S.D.A. dietary guidelines for Americans, can help prevent attacks, as well as maintaining
a healthy weight and avoid fasting or high protein diets.

All of these measure can help prevent gout attacks, however, the majority of people with gout require maintenance
medications to keep uric acid levels in check. The target level of uric acid in your blood is less than 6 mg/dl. Altering your
diet may lower this number by 1 to 2 mg/dl, and achieving and maintaining your target uric acid level means reduced risk
of gout flares over time.
Safe Foods for Gout
Q: I have gout and have heard that alcohol and some foods can aggravate the condition. Can you tell me
which fruits, vegetables, meats or seafoods I should eat – or avoid? Is there any type of alcohol – wine, beer,
spirits – that is better or worse for me than others?

A: Because dietary management of gout is so restrictive and of limited benefit, medication is the best way to treat gout.
In addition to medications that treat the inflammation and other symptoms that occur during a gout attack, medications
exist that can treat the underlying metabolic condition of hyperuricemia – too much uric acid in the blood. Hyperuricemia
can occur either when the body produces too much uric acid or when the body does not excrete enough uric acid. Drugs
exist to treat both causes.

Purine compounds produce uric acid crystals, which then build up in soft tissues and joints, causing the painful symptoms
of gout. Dietary management focuses on reducing the amount of gout uric acid in the system and on managing the
disorders that occur frequently among patients with gout, including diabetes mellitus, obesity, hyperlipidemia (high blood
levels of fats), hypertension and atherosclerosis (hardening of the arteries).

The primary dietary modification traditionally recommended is a low-purine diet. Avoiding purines completely is impossible,
but strive to limit them. People with gout should learn by trial and error what their personal limit is and which foods cause
problems.

Laura Rall, PhD, nutrition researcher at Tufts University in Boston, says, "Begin by eliminating foods in the 'high-purine'
category while reducing your intake of foods in the 'moderate-purine' category. If you don't have gout attacks after trying
this, you may add more foods from the 'moderate' category or occasionally try a food from the 'high' category. Using these
guidelines, you may be able to determine a safe level of purine consumption and enjoy some of your favorite foods without
experiencing attacks."

Foods considered high in purine content include:

* Alcoholic beverages (all types)
* Some fish, seafood and shellfish, including anchovies, sardines, herring, mussels, codfish, scallops, trout and haddock
* Some meats, such as bacon, turkey, veal, venison and organ meats like liver

Foods considered moderate in purine content include:

* Meats such as beef, chicken, duck, pork and ham
* Crab, lobster, oysters and shrimp
* Vegetables and beans such as asparagus, kidney beans, lentils, lima beans, mushrooms and spinach
Safety of Fish Oil Supplements with Gout
Q: A doctor advised me to take fish oil supplements to improve my cholesterol level. But the source of fish oil
in many preparations includes sardines, trout and herring – fish that are high in purines and on the list of
foods I should avoid because I have gout. How much purine is in fish oil supplements? Should I take them or
not?

A: Purines are found in the meat of the fish but not in highly purified, molecularly distilled fish oil, so it should not affect
your gout. I recommend everyone consume at least 2,000 milligrams (mg) per day of EPA and DHA (two fatty acids in fish
oil crucial to human health). Those with autoimmune disorders and arthritis should consume 3,000 to 6,000 mg in divided
doses with meals.

Buy only pharmaceutical-grade, molecularly distilled fish oil supplements. And go to the supplement company’s Web site
and make sure you research what you’re getting. Also, know that using fish oil supplements to bring down your cholesterol
level may thin your blood. If you have any bleeding disorders or already are taking medications to thin your blood, such as
clopidogrel (Plavix) or warfarin (Coumadin), please talk to your doctor.