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Gout, the most common form of inflammatory arthritis, can wreak havoc on the body. The good news? It’s easily managed with the right help. Whether you’ve been recently diagnosed, care for someone suffering, or are a medical professional treating the disease, the Kicking Gout in the Acid podcast can help you learn more.
In this episode of Kicking Gout in the Acid, Dr. Larry Edwards is joined by Gout Education Society Board of Directors member Dr. Paul Doghramji, certified family practice physician at Collegeville Family Practice and physician advisor at Pottstown Memorial Medical Center in Pennsylvania. The two discuss the many misconceptions and myths about gout related to such topics as its prevalence, cause, treatment strategies and the role of diet and lifestyle modifications.
Key Takeaways:
- Gout is more common than it’s often perceived – more than 12 million Americans are estimated to have the disease.
- Gout myths are pervasive. Many people incorrectly believe gout is self-inflicted; in truth, gout is largely hereditary and not commonly brought on by poor diet and lifestyle choices.
- Home remedies such as cherry juice are commonly seen as easy treatments for the disease; however, effective management includes anti-inflammatory medications and uric acid-lowering drugs.
- Continual educational opportunities for both patients and medical professionals alike are key to breaking the many myths, misconceptions and stigma surrounding gout.
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Kicking Gout in the Acid is sponsored by Sobi.
Podcast Transcript
Ian Ponitz
Hello, and welcome to Kicking Gout In The Acid, a podcast from the Gout Education Society. My name is Ian Ponitz, and I’m your host for this series. Kicking Gout In The Acid features conversations between Dr. Larry Edwards, chairman and CEO of the Gout Education Society, and experts on the disease.
Each episode will dive into important topics that you, the listener, should know about gout. The goal? To feel empowered to get gout under control.
In this episode, Dr. Edwards will be joined by Dr. Paul Doghramji, certified family practice physician at Collegeville Family Practice and physician advisor at Pottstown Memorial Medical Center in Pennsylvania. The two will discuss common myths, misconceptions, and the stigma surrounding gout. We’ll spend today’s episode breaking down these notions in the hopes of improving education surrounding the disease. Dr. Edwards, take it from here.
Dr. Larry Edwards
Thanks, Ian. We’re joined today by one of the board members of the Gout Education Society, Dr. Paul Doghramji. Paul is a primary care physician in the Philadelphia area and has had a keen interest in gout for a while. Paul, let me have you introduce yourself.
Dr. Paul Doghramji
Yes. Thank you, Larry. It’s great to be here. Paul Doghramji. I am a family physician, board-certified in family practice, and I’ve been that way for a good many years. I got involved in the area of gout, oddly enough, in somewhat of a curved way. About 20-some years ago, my main area of interest was sleep disorders, and one of the things that I wrote about was restless leg syndrome. And then we did this huge national expose on the biology of leg disorders, so I wrote about restless leg syndrome, but at the same time, I also wrote about other things that can happen to legs, like gout.
So, I started writing about gout, and it opened a whole world of things that I got to know about when it came to gout and hyperuricemia. So, I did a lot of writing, and then after that, I still did a lot of education for my primary care providers, as well as the lay public on hyperuricemia and gout. And it’s been wonderful to get all this information that I can share with primary care providers, be they MDs, DOs, nurse practitioners, physician assistants who do primary care, but also laypeople, about, again, the interesting things they need to know about gout, and also, as well, some of the misconceptions. So, it’s been a really good journey, and I’m very pleased to be here to talk more about it.
Dr. Larry Edwards
Well, we’re glad you’re here, too, Paul. I’m glad that you picked up on gout as an area of interest. After all, family practitioners, primary care doctors, and deliverers are the people who see most of the gout. We’re gonna start off today, really talking about myths and misconceptions.
Gout’s a disease that’s been around literally forever. There are inscriptions in the pyramids about gout. There was lots written in the ancient Greek and Roman medical literature about gout. And it’s not surprising that a disease with that kind of history has picked up a lot of misconceptions and myths along the way. Unfortunately, a number of those can really change the way people look at gout as a disease, look at patients that have gout as potentially people who brought this disease on themselves.
I think it’s an important part of education not just to talk about what really causes gout and all, but to dispel some of these misconceptions. What we’re gonna do today is just run through some of the more common ones that we hear about all the time to get your take on them.
One is that gout is a relatively uncommon disease of minor consequence compared to the other kinda higher-priority diseases that follow gout around, such as high blood pressure and diabetes, kidney disease, heart disease. And so, the physicians might not have the time to address gout just because they’re worried about these other things that are the close relatives of gout. What do you think about that, Paul?
Dr. Paul Doghramji
Well, first of all, interestingly, the last patient that I saw right before this recording was a gentleman who came in with knee pain, with a diffusion that most likely is from gout. I see gout quite often, and a lot of primary care providers do see it. I think the problem is that they don’t actually identify it as being gout because gout eventually goes away. Like, within a couple of weeks, it goes away. And they attribute it to maybe a strain, a sprain, overuse, that sort of stuff.
So, it’s a lot more than what you think, and a lot of gout actually goes unrecognized and undiagnosed. In regular practice, because we see men and women in their middle age and in their later years, especially those who have hereditary problems with gout, there’s a lot of it there. You just have to have a high index of suspicion with patients presenting with acute joint pain, whether it’s traumatic or not, that occurs predominantly in the peripheral joints, like the feet, the toes, the fingers, and the wrists, and occurs in a generally monoarticular way. So, it’s a lot more than what we think it is.
Dr. Larry Edwards
Yeah. Absolutely. And it is actually one of the most common forms of arthritis. We see a lot of advertisements on TV about psoriatic arthritis and rheumatoid arthritis, and various other things, but gout is much more common. In fact, it’s as common as a lot of those other medical conditions you talked about, almost as common as diabetes. So, it’s out there. This idea that it’s just a minor concern, how would you address that?
Dr. Paul Doghramji
Well, it’s not a minor concern. The first thing I think we should know is that statistics show that about 20% of adults have hyperuricemia, high uric acid levels. That’s a lot of people. Only about maybe 10%, 20% of those people might get a gout attack, so we don’t really understand in some ways the, you know, why some people get it and why some people don’t. But it’s a lot out there, and hyperuricemia is a bad thing. In many ways, we should think about it as too much blood pressure, too much sugar, too much cholesterol, where not only can it affect your joints, but it can also affect other areas.
You know, Larry, we’re understanding that high uric acid can also be a risk factor for cardiovascular disease and renal disease. So, uric acid, in high amounts, can crystallize and cause damage and inflammation in many other organs of the body, not just joints.
Dr. Larry Edwards
Absolutely. It’s certainly not a minor condition, and it should be up at the top of the list of concerns, I think, when physicians see patients.
Dr. Paul Doghramji
As far as the joint parts are concerned, in a lot of people who get gout attacks maybe once or twice a year or so, there’s this misconception, if I just treat the gout attack, that’s enough, because the rest of the time, they’re fine. And what a lot of people don’t understand is that in between these episodes, in these intercritical periods, uric acid is still damaging the joints, and as the months and years go by, it can increase the probability of developing degeneration of those joints and causing premature osteoarthritis.
So, not only is it damaging joints when they have a gout attack, but also in the intercritical periods, there are things going on. So, it’s necessary not only to treat the gout attack, but also to do something about the uric acid so it doesn’t damage the joints and possibly other parts of the body.
Dr. Larry Edwards
I think that’s a good segue to one of our other common misconceptions about the disease, and that is that people think that when their joint is swollen and painful that they have gout, and when it’s calmed down and there aren’t any symptoms in the joint, they no longer have gout, not appreciating that this is a chronic disease that you will always have with you if you’ve had a gout flare in the past.
I think that leads to other problems, and I want to know if you see this: that patients come in and feel like if they don’t have gout, they don’t need to take their allopurinol or their febuxostat or whatever other gout drugs they’re on. Is that a problem that you see, Paul?
Dr. Paul Doghramji
That’s almost as bad as saying, “What, you know what? My heart feels fine, so I don’t need to take heart medicine.” No, that’s not how we work it. Everybody pretty much knows that a lot of medications that we take are preventative. And with hyperuricemia in gout, high uric acid in gout, we need to lower the uric acid so you don’t get gout attacks, and also possibly prevent some of the other deleterious effects of high uric acid, like I said, like damaging the cardiovascular system, as well as the kidneys. So no, it’s not enough just to treat the attack. It is very important to get the uric acid down to a safe level.
Now, as far as numbers go, we want the uric acid to be below six milligrams per deciliter, and in really bad gout situations, like patients having tophi, you know, those are the big nodules that occur on the fingers and toes and in the knees, in those people, we want to get their uric acid levels below five milligrams per deciliter.
So, no, just treating a gout attack isn’t enough. It’s important to lower the uric acid so that you don’t get the damaging effects of hyperuricemia in the intercritical periods.
Dr. Larry Edwards
Yeah. This intercritical period, I think, has been under a microscope, if you will, for the past five, ten years, trying to figure out exactly what is going on during this period of apparent calm of the disease. And it ends up that most of the destruction that we worry about, the destruction of the joints, the effect on cerebrovascular, blood vessels causing either heart attacks or strokes, all of that is a part of the inflammation that doesn’t disappear after the normal five to seven days that a gout flare lasts, but goes on for many, many months afterwards. So, I think taking that seriously, even if symptoms aren’t there, is a very important process.
Another common myth that I hear about all the time is that patients is that they’ve been viewed by their friends and family members as bringing the disease on themselves, and for that reason, they’re embarrassed by it. They are told that because they are eating too much of the wrong kind of food or drinking too much alcohol that this is the reason that they have gout. We now know that isn’t true. Can you expound on that, Paul?
Dr. Paul Doghramji
Yeah, absolutely. That’s almost like saying a diabetic is diabetic because they eat too much sugar. Most people know that’s not the case. There’s a hereditary background to almost everybody who has gout. If you look at their genetic tree, they can identify somebody who’s had gout. It’s a hereditary problem that predominantly occurs as a result of the kidneys’ not being able to get uric acid out of the system.
Now, dietary changes, or let’s say a diet that’s not very conducive for gout, yes, that can elevate uric acid a little bit. But just going on a low-purine diet or a gout diet will only lower your uric acid just a tiny bit. So, there’s a big misconception among people that if they have a gout attack, it was because they ate the wrong things, or they have gout because they just need to change their diet. Dietary changes can only make a very minor difference in preventing gout and making the uric acid go down to normal. It always helps a little bit, but when you have gout and hyperuricemia, high uric acid levels, in almost all cases, you have to do something more, typically take medication to lower the uric acid down to a safe level.
Dr. Larry Edwards
Yeah, I think all of that is true. It’s important to recognize the distinction between a food causing the disease. You’re absolutely right that I don’t think you could eat your way into having gout or drink your way into having gout if you didn’t have these genetic predilections to develop the disease.
Flares, a little different thing. Probably almost half of patients with gout recognize something that kind of triggers them, and there are a lot of things other than food that do that. Getting severely dehydrated is certainly one. Going and having an operation in the hospital is something that, a lot of times, can trigger this. And for some people, certain foods will trigger them too, but that’s much different than saying that it’s the cause of gout.
Dr. Paul Doghramji
Let me add also one other thing. Another myth, as far as lifestyle is that weight has nothing to do with it, and we now know that patients who have obesity, who have a weight problem, are much more likely to have more gout problems. So interestingly, one of the things that we ask our patients to do who have gout is to lower their weight. So that can have a good effect on lowering uric acid. Most people actually don’t know that. It’s another good reason for us to help our patients who have a weight problem to lose their weight, other than, of course, you know, their sugar, their blood pressure, arthritis of the knees, et cetera. There are many advantages to lowering your weight. But now here’s another reason, which is to bring the uric acid level down.
Dr. Larry Edwards
Yeah, and weight loss is a recommendation of the American College of Rheumatology for treating this. The important thing is not to allow your patient to believe that they’re gonna lose all of this weight in lieu of taking medications for gout. It’s a lot of wishful thinking. The idea is to go ahead and treat the uric acid level and get it down, as you mentioned before, with medicines like allopurinol or febuxostat. And then if, in the process, the patient was able to lose significant amount of weight, and here we’re talking about, 15 to 20% of their body weight was what’s required to make some difference, then maybe they could cut back on these gout drugs rather than trying to achieve the weight loss first and not be on a treatment therapy.
People are always asking, “What is a gout diet?” There isn’t really a gout diet. In the old days, we used to say things that were low in purines, which are the precursors for the formation of uric acid, but those are very difficult diets to stay on. Just as an experimental researcher back 50 years ago, I would put myself on a purine-free diet occasionally, and I don’t think I ever made it out to the full seven days. It was just too terrible.
But there are diets we recommend just for general health in people with metabolic syndrome. There’s the DASH diet that was developed specifically for hypertension, and then a general Mediterranean diet, which I think would be good for all of us to stick fairly close to as far as its benefits on cardiovascular disease and kidneys. I think the important thing from this discussion, Paul, is that diet in and of itself isn’t gonna cure somebody of their gout. It certainly can help if they lose a bit of weight and stick to a diet, like we mentioned, as far as the DASH diet or the Mediterranean diet.
What I’d like to turn to now is just some of the home remedies that are frequently discussed with patients. I think that they pick them up from family members who have had gout or people just sitting around the office discussing their gout. We’ll talk about whether or not there’s any utility in these at all. I don’t know, Paul, if you’ve ever heard this, but wrapping your joint with cabbage has been mentioned any number of times and is on the internet, and the use of cherry juice extracts and concentrates is frequently commented on. Ice setting of the acute flares of gout has been discussed. Have you had any, uh, feelings about these, um, these particular home remedies, Paul?
Dr. Paul Doghramji
You know, people these days are very savvy. The internet has a lot of information, so they’ll go on there. Plus, also, their friends and relatives will tell them a lot of things to do. None of them is really that useful. That’s what I tell my patients. I’ve seen patients come and say to me, “I’m wrapping it in cabbage. I’m wrapping it in this copper thing. I’ve drank cherry juice. I’m taking vitamin C, coffee.” Coffee does lower uric acid a little bit, which is pretty good, but nonetheless, I mean, none of these are really going to do anything to make a gout attack go away or stay away.
“You know, eventually my gout attack went away.” The answer is it’s gonna go away anyway. You know, within a week or so, all gout attacks eventually go away. So what I tell people is, “Let’s stick to the important thing, which is that uric acid in your system is bad for you. It’s going to damage your joints and other parts of your body as well. We need to get the uric acid level down to a point where not only is it no longer damaging, and not only is it now neutralized, but you’re not going to get gout attacks.” That’s the point to remember.
Dr. Larry Edwards
Exactly. The Gout Education Society has conducted a number of surveys in the past, both with the lay population to get a feel for how gout is perceived by the general population, and by surveys of patients as well with gout. Some interesting findings from our 2019 survey showed that two-thirds of patients think that it’s embarrassing to have gout. 50% of the general population thinks that gout should be an embarrassing disease. So those who are watching somebody suffer, again, they’re kind of thinking that this is a disease that’s been caused by the sufferer.
Another one of our findings is that about 75% of patients with gout think that they could avoid taking any gout medicines if they just followed a gout diet. We mentioned before that that’s not a real thing, that you can stick to a good diet like the Mediterranean diet and potentially lower your uric acid by a milligram per deciliter, but never enough really to get to the target that we think about.
Interestingly, two-thirds of patients thought that drinking cherry juice was as effective as taking the prescribed gout medications. But on the other hand, only about a third of gout patients have ever reported taking cherry juice. So, there are these various things that have a big footprint as far as myths and misconceptions. There is some data on cherry juice. I might add that it has some anti-inflammatory activities, probably roughly comparable to taking the ibuprofens or the naproxens, but nothing really that’s gonna cure the gout.
These kinds of misconceptions, I think, are pretty rampant, and you see those as well, Paul?
Dr. Paul Doghramji
Absolutely. And I think the reason for that is because the overwhelming misconception is that gout is self-induced because of poor discipline, you know? And when something like that happens, then all of a sudden embarrassment kicks in. What we need to do is to allay some of those the misconceptions and fears and suggest to the public that, again, this is a hereditary problem where, you know, your dietary changes and your lifestyle aren’t gonna make that much of a difference.
The main thing to do is to get your uric acid down to a level, in most cases, with medication. If there’s gonna be any lifestyle change, yeah, as you said earlier, try a DASH diet, a Mediterranean diet, but also weight loss, where in most cases patients with gout do carry an extra amount of weight. Those are the things that they need to do, and hopefully, that will take away their misconceptions and also their embarrassments, and also their self-contempt that they are the cause of the problem. That’s not the case. It’s a hereditary problem, and there are plenty of things that can be done to make the condition neutralized.
Dr. Larry Edwards
To make matters worse, we’ve just conducted a study that looked at biases by physicians towards gout. This was really put together by some social psychologists and people who know how to measure these things better than I do. They showed that physicians do hold a bit of a grudge, certainly an implicit bias against people who have gout that even extends beyond the obesity part, that it’s not just that the physicians don’t like taking care of people who are obese, but gout specifically. So, I think there’s some education that needs to take place within our own profession.
Dr. Paul Doghramji
That’s absolutely the case, and, you know, I’ve done hundreds of lectures on gout across the country over the last 20 years or so. And I continue to get raised eyebrows from these clinicians because they’ve had very little information given to them, whether it’s been through their medical training or in their residency or even post-residency. So, the amount of education about gout is very, very lacking. And I can understand how, you know, clinicians can also have a negative bias against patients because they simply just don’t have the right information to be able to make the right conclusions about what gout is and what needs to be done by them to help their patients.
Dr. Larry Edwards
Right. So, in addition to the pain of gout, the physical pain of gout, there’s also this heavy social pressure and bias against the disease these people have. I think that makes it a doubly tough disease to have. And I think you’re absolutely right, it’s the lack of education that’s being filled in by misconceptions and myths.
Well, you’re a person who takes a lot of time educating your patients about the various diseases they have and gout in particular. Can you tell us a little bit about just what you tell patients when you’re first making the diagnosis and how you might follow that up in subsequent visits?
Dr. Paul Doghramji
Yeah, absolutely. One of the beauties of being in primary care, which I absolutely love, is that I get to see my patients often. They come back to me and for follow-up visits, et cetera, so it gives me many opportunities to discuss their problems and to reiterate them, review them, so that it kind of sticks better, and you have a better idea about what’s going on. Because, you know, a lot of times when you talk to patients, some of the information you give them doesn’t stick, or you don’t say it right, so having many opportunities is very good in primary care.
But the first thing that I do try to tell patients is what we already talked about, and that is allaying their fears and also reassuring them that this isn’t something that they’re doing to themselves. It is a hereditary problem predominantly occurring as a result of some defective kidney workings, so their kidneys are not able to get uric acid out of their system, and that uric acid is a potentially toxic substance because when it crystallizes, it can cause inflammation, and that inflammation can occur in joints and in other parts of the body.
So, the idea is to lower uric acid. In lowering uric acid, you have your role, and I have my role. Your role may be as far as some dietary changes and weight loss. My role is to give you the right medication and make sure that you don’t have any problems taking the medicine, monitoring your uric acid, and making sure that I get you to that safe level. Also, my job is to treat your inflammation when it occurs, so you don’t have so many days where you have a very painful joint. So, I generally say this kind of information to patients. When they come in, I continue to reinforce what I’ve said to them so that it does stick, so they do understand that this is a condition that occurs as a result of uric acid buildup that has a genetic basis to it, where their kidneys are just not excreting uric acid too well, and we just gotta get rid of the uric acid predominantly by using medications. And these medications, for the most part, are very safe and very effective.
Dr. Larry Edwards
Yeah, I think you brought up some important points there, that it’s the reiteration on multiple visits of just exactly what you’re trying to do with these uric acid-lowering drugs and why it’s important to maintain these drugs over a lifetime. This is not a disease that you can stop treating at some time and not expect it to come back.
Dr. Paul Doghramji
The only exception to that, if I can say so, Larry, is that, you know, I do have patients that have morbid obesity where they have BMIs of 40, 45, 50. And if they have a weight-loss situation like in gastric bypass and they lose an awful lot of weight, like losing 25, 30% of their weight, their uric acid levels may go down to a level which is safe. But those are the exception rather than the rule.
Suffice it to say that it’s exactly what you said, which is that with hyperuricemia and gout, too much uric acid causing gout is a lifelong condition, so the medication that patients take is lifelong. Very similar to taking diabetes medicine lifelong, taking blood pressure medicine lifelong, and taking cholesterol medicine lifelong.
Dr. Larry Edwards
Exactly right. I think all of these are very important parts of monitoring patients. I think that it’s incumbent on the patient to know what their serum uric acid level is themselves and to really be quizzing their physician if they’re not at target. And here, I’m not saying just getting close. The minimum target that we shoot for a uric acid is less than six. I think all of us would like it to be even lower than that because it can help dissolve the crystals that are already formed and prevent new ones from forming.
Is there anything else about this topic of myths and misconceptions in gout that you think we should cover, Paul?
Dr. Paul Doghramji
There are a couple of things I think that we kind of haven’t touched on that I think are very important and worth mentioning. When patients come in with a painful, hot joint, it should be considered that they have gout, and there are certain tests that can be done. One of them, of course, is to get a serum uric acid level, but if you get this serum uric acid level during an attack, it may be spuriously low. So try to get a uric acid level two or three weeks after an attack is gone, so that the uric acid level can be a true reflection of what’s going on. That’s one thing.
The second thing is doing other kinds of testing, like X-rays. X-rays are, for the most part, useless as far as gout goes. Ultrasounds may be of some benefit. CAT, DECT scans these can be somewhat useful, but for most situations, they’re impractical to get. So this is a clinical diagnosis that a clinician has to make.
One other thing, though, is joint aspiration. I’m a big fan of doing a joint aspiration, getting fluid out of a joint. Knees are very easy to get fluid out of. Sometimes, gout in the big toe, podagra as it’s called, is a little bit more difficult. But I still try to extract some fluid because if you can send that fluid to the lab for analysis, and they can look at the fluid under a microscope, a negatively birefringent polarized light, and it can show the crystals, and you can make a diagnosis outright.
So some of the things that we haven’t touched on are making the diagnosis with either radiologic methods, which in most cases are useless, but also aspirating a joint to make a diagnosis.
But one other thing is treatment. As far as treatment goes, we kind of haven’t touched on that. A lot of clinicians don’t know this, but any kind of anti-inflammatory medication can be used so long as you use it early in the course and you use a high enough dose. So ibuprofen, 800 milligrams three times a day; naproxen, 500 milligrams twice a day; indomethacin, 500 milligrams twice a day. Any one of these can be used. Just take it until the gout flare is gone. But also we can use colchicine at .6 milligrams to be taken, two right away, then one one hour later, and that’s it. And in some cases where you can’t use those two medications, you can actually even use corticosteroids.
But you can’t use the pack that’s for six days or so in the methylprednisolone. That’s only six days. That’s not gonna be good enough. You’re going to have to use prednisone in 10 or 20 milligrams, getting up to 60 milligrams a day for between five to seven days, then gradually taper it.
But one of my favorites is to actually inject the joint with corticosteroids. That can give them immediate relief because we also put xylocaine in there, and it can give them good relief and very quick relief in certain joints if you can get to them. So these are some of the other things that I think are important for our medical providers to know, as well as the laypeople.
Dr. Larry Edwards
Yeah, I think that is very important. Again, the new recommendations in the American College of Rheumatology are, as far as treating the acute flares, having a pill in the pocket, as they say. So that whatever you’re gonna use to treat that particular patient with, for their flares, whether it’s the ibuprofen or naproxen or the steroids or the colchicine, they have ready access to it because these gout flares occur at the most inopportune times, frequently in the middle of the night. It seems like always on a Friday night, too, just when the doctor’s office won’t be open the next day. But they should actually have those medications available to them because if you can start them within the first eight to ten hours of the onset of pain, you can shorten that painful flare down substantially from the seven or eight days to just one or two days. So I think those are good things to think about, Paul.
What I hope we’ve done today is talk about a disease that is just covered with misconceptions and things that people hear around from other gout sufferers, and what they see on the internet that isn’t helpful. They might increase this feeling of responsibility for having their own disease. Hopefully, we’ve dispelled a lot of that. I think your emphatic statements, Paul, that this is a genetic disease primarily and not one of being gluttonous or overimbibition of alcohol. You need to understand that most patients with gout don’t even drink alcohol. They aren’t massively obese; they’re just like everybody else walking around, only they have a genetic problem with their kidneys getting rid of uric acid. So hopefully that’ll help them pay attention to this disease and get it treated the same way they would their blood pressure and their diabetes. and their heart disease.
I want to thank you for joining us today, Paul, and let us hand this back to Ian.
Ian Ponitz
Thanks both for having this fruitful discussion today that can help those with gout, their caregivers, and medical professionals alike kick gout in the acid. If you have gout or treat gout, you can learn more through the website: gouteducation.org
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We’ll be back next month with another episode of Kicking Gout In The Acid. Until then, make sure to like, subscribe, and follow our shows on Apple Podcasts, Spotify, and other major platforms.
Thanks for listening in.
