Podcast: Play in new window | Download
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 fellow Gout Education Society board member Dr. Brian Mandell. Dr. Mandell, Rheumatologist and Medical Educator at the Cleveland Clinic. The two discuss an overview of gout, its root cause, how it is diagnosed initially, treated over the long-term and the importance of chronic management. Dr. Edwards and Dr. Mandell also touch on the importance of education surrounding gout and its impact on improving management.
Key Takeaways:
- Gout is a chronic disease that requires ongoing management to prevent flares and long-term complications.
- Early and accurate diagnosis is crucial for effective treatment.
- Long-term management focuses on lowering uric acid levels through medication.
- Patients should be proactive in understanding their condition and working with their healthcare providers to achieve and maintain target uric acid levels.
Start your journey with gout today via the Gout Education Society website and sign up for the monthly newsletter.
Follow the Gout Education Society on X and Facebook
Looking for nearby gout specialists? Find rheumatologists, nephrologists and more via the Gout Specialists Network.
Educational Materials:
Listen to episode 2, When Gout Becomes Hard to Manage – What to Expect, now.
Kicking Gout in the Acid is sponsored by Sobi.
Episode 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 is to feel empowered to get gout under control. In this episode, Dr. Edwards will be joined by Dr. Brian Mandel, a rheumatologist from the Cleveland clinic, to provide an overview of the disease, talk more about its management, and the long-term effects on the body over time if it’s not properly treated. Dr. Edwards, take it from here.
Dr. Larry Edwards: Thanks, Ian. Today, I’m joined by a fellow member of the board of the Gout Education Society, Dr. Brian Mandel, from the Cleveland Clinic. Brian, let me have you introduce yourself. Just tell a little bit about your interest in gout and what you do at the Cleveland Clinic.
Dr. Brian Mandell: Thanks, Larry. Of course, it’s nice to be here with you talking about a disease that I have been fascinated with for almost as long as you have been. But my interests do go back quite a ways, which is an interesting tale, in fact, I started doing research on gout as an undergraduate in college, fascinated by the inflammatory response to urate crystals, which was quite dynamic and dramatic in rabbits. And I’ve moved on since to deal not so much with rabbits but much more with people. So, I have a longstanding interest in the mechanism of the disease and treatment of the disease. And I’m currently a rheumatologist and a medical educator at the Cleveland Clinic in Cleveland, Ohio, maintaining my interest in gout with patients and clinical trials as well.
Dr. Larry Edwards: Thanks, Brian. Great to have you here. I think a great place for us to start off would be with a definition of what gout is. I know that the Gout Education Society has done surveys of patients and the lay public about their thoughts on gout. There’s always lots of misconceptions that a lot of people think that when there’s pain going on in a joint that they have gout, but when the pain is gone, then they no longer have gout.
They generally know that there’s something to do with uric acid, but not exactly sure of what that is. And a lot of times, they’ll say that they’ve heard that it’s caused by overindulgence on their part of too much beer, too much fish, too many lobsters, and for that reason, they feel a bit guilty about even having the disease, and I think probably sometimes prevents them from going in and getting medical advice if they think that they’re the cause.
We know these ideas are misconceptions and are outdated now. Can you give us something that’s more of a modern update on what this disease is?
Dr. Brian Mandell: Well, I think you summarized the issues very appropriately here. Certainly, what gets people’s attention if they have gout or if a family member has gout, it’s the flare and the disease, it’s the red hot swollen toe or ankle or knee that gets their attention, and that is gout to them.
And that certainly is the most dramatic part of gout. But the disease itself is not the swollen knee or ankle or toe, it’s really the deposition of uric acid, which is a normal chemical that we all have, but not all of us have so much of it that it deposits in and around joints. And it’s that deposition that is really the disease of gout that then leads to the flares in gout that gets everybody’s attention.
But if we only think about gout as the flare, the red hot swollen joint, we’re really missing the idea of treating the disease. It’s as if someone has the worst headache of their life and they keep getting it, and it’s from a brain tumor. And we can treat the headache, but we’re not treating the brain tumor.
You’ve got to treat the underlying disease. And gout, fortunately, is not a brain tumor, but it certainly is a disease characterized by the buildup of uric acid that can do damage. to various organs in our body. And that, you know, you use the term misconception and I think that that’s spot on. It really is a misconception that it’s not the disease limited to the swollen joint that we need to address.
Dr. Larry Edwards: So in addition to being this acute dramatic flare up of joints. There’s also a very chronic component to it that’s kind of running in the background all the time. So, even when patients are feeling no pain and they’re moving their joints normally, there’s still inflammation back there. And we think that now that background inflammation contributes a lot to the other medical problems that gouts associated with such as cardiovascular disease and strokes, things that we know are associated with chronic inflammation. Gout is a chronic inflammatory disease also. These are important things to think about. Also, the misconceptions about being the patient’s fault. I think that there’s that you know this data very well, Brian, that emphasis on food has been cut way back over the past 10 years as we recognize that modification of diet is good if it’s to lose weight, but there is no specific gout diet that you’re not going to get this disease controlled by diet alone or by giving up something that you’re eating or drinking that you need a good medical approach.
Would you agree with that?
Dr. Brian Mandell: Oh, absolutely. And to carry it even further, it’s not a glass of cherry juice a day keeps your rheumatologist away. It really takes more than that. It took a long time, usually, for patients to build up enough uric acid to start getting gout flares. And it takes a while to really, really lower that uric acid level in the blood and keeping it low, that’ll let those deposits dissolve. And it really is medication that can do that to a great enough degree, that lets us treat, and in fact cure, with a capital C, this disease. But it takes medication, not diet alone. Not the diet is bad, a heart-healthy diet is probably a good thing for all of us. But it’s not going to fix the disease.
Dr. Larry Edwards: That’s absolutely right. Now that we kind of have a definition of the disease in hand, that the patients can consider for us, I think it’s important that we kind of take a look and see how the diagnosis is made, what happens when the patient has their first flare of the disease and who they go to and what’s done to make that diagnosis.
Can you add some light on those topics?
Dr. Brian Mandell: Oh, yeah. I mean, they, you know, again, the dramatic nature of a gout flare, which is what gets people’s attention, often happens early in the morning, first thing in the morning, and invariably on weekends and holidays. And it’s very difficult to suddenly to get into a rheumatologist, or to sometimes even to your family doctor.
So often for that first red hot swollen joint, which you don’t know really what it is if you’ve not experienced it before, in you or your brother or your uncle, it’s a red hot swollen joint that you can’t put weight on if it’s in your foot. So you’re going to wind up at an urgent care center or an emergency room if you’re lucky with your primary care doctor, and they’re going to look at it and say, well, that may be gout, but you don’t know for sure unless you really evaluate whether there’s uric acid in and around that joint.
The most definitive way to make the diagnosis, the gold standard, if you will, is to get a sample of that fluid and you see the uric acid crystals in it. For those of us who do this for a living and are fascinated by gout and can do this, you know, we can clean off the skin and numb it up very well and put a small needle in, take the fluid out, do the evaluation and prove right then and there that this is gout and not something that looks like gout. But in many settings, that’s not really what can happen easily, just the logistics of that. Emergency rooms are not often able to do that. Primary care physicians are not set up to do that. So, initially, it often is made as a, what we say is a clinical diagnosis.
We think the setting is right. It looks like gout, and we’re going to treat it as gout. And that is often the way it’s made, and I emphasize that’s not inappropriate, but you have to always view those scenarios as probable gout until you’ve proven it to be gout. Now, if there’s not fluid to be obtained, we can do advanced imaging techniques, ultrasound, special CT scans are available in some medical centers.
We have it, you have it in your place, Larry, and many medical centers will, but not everywhere. So there are ways to make the diagnosis, but what we know is not the way to make the diagnosis accurately is just by checking the blood urate or blood uric acid level. That’s not adequate to make the diagnosis, nor is likely to be just a standard x-ray. So the gold standard is to get a sample of the fluid. The next best is to do advanced imaging. If we can demonstrate the uric acid deposits.
Dr. Larry Edwards: The other diseases they can present like this are frequently listed as either an infected joint or a severe strain. Usually, as you mentioned, these symptoms come on late at night. So it would be pretty unusual to develop a muscle or tendon strain, uh, while you’re in bed asleep. And an infected joint, they’re fairly rare and usually require that there’s a source of infection someplace. So, a presumed diagnosis is legitimately worked on, as you say, in lieu of drawing the fluids off.
I think the nature of the pain with gout sets it apart from most other things to the Hippocrates called this the unwalkable disease. And that’s truly that I think that this is very abrupt onset pain from no pain as you go to bed at night, as you said, to some of the worst pain you’ve had in your life. And not just as a pain when you move the joint, but just the lightest touch on it. Something that we physicians call L adenia. is fairly unique to this disease. So I think that there’s ways clinically of suggesting that this is gout and not one of these other conditions that have abrupt onset of pain.
Dr. Brian Mandell: Although there are, you know, will be patients who have different types of pain that will ultimately wind up being diagnosed as gout, that are different, but those cannot be characterized with the same degree of suspicion. So we often, in retrospect, will say, you know, those twinges of pain that you had were not so severe that lasted hours or maybe a day or so that then went away.
Once we know that and have proven that it’s gout, we may wind up saying, boy, those other things were gout. But it’s very dangerous to make the diagnosis of gout for those atypical circumstances without proving it first.
Dr. Larry Edwards: So the patient presents to the ER, as you say, or the urgent care clinic, or if the primary care doctor’s office is open to that person, and he’s having an acute flare, what generally do these physicians, these care providers, do to help the patient?
Dr. Brian Mandell: Well, the first thing that’s on every physician’s mind when a patient comes in with obvious pain is to try to relieve the pain. I mean that’s what we’re trained to do and you know we go back to Hippocrates for that too. That’s our mission. So what usually winds up if gout is suspected is that some form of non-steroidal anti-inflammatory drug may be given, medicines that could be over the counter but given in higher doses or prescription strength. That may be tried. Some form of steroid may be tried. If patients come in and the doctor’s not so convinced or not comfortable enough with that, they may wind up giving narcotics for the acute pain in an effort to do the right thing.
For those of us who treat a lot of gout, we’re not fond of that approach particularly, mainly because it doesn’t work as well as the anti-inflammatory. And, of course, there’s all the concerns with getting on narcotics now without getting a real answer to what’s causing the pain or treating the pain. But those are the ways I think that most commonly we’ll see it treated.
A physician who is maybe a little bit more savvy about the diagnosis and comfortable with treating it, but yet is not in a position to be able to aspirate and prove that it’s gout, might use Colchicine, which has been around since the Egyptian writings, uh, on Papyrus from the pharaohs. It’s been around for so long.
And it is effective in many, not all patients, but very effective in some. And now it might be another way that this could be treated initially. I always harp on the idea, you know, when I’m talking to emergency room physicians or general internists that, you know, the goal is yes, to make people feel better as quickly as we can, but don’t forget that we really need to get a diagnosis here.
And when you’re talking about making a diagnosis of gout, you’re talking about a disease that is lifelong until it’s treated and cured.
Dr. Larry Edwards: And I think another thing about those treatments for the inflammatory component of gout is that the sooner you start them, the more effective they are. That a lot of times patients will kind of tough it out at home and just sit around and keeping their leg elevated and try not to do anything, but it’s a painful process that lasts for, I don’t know, 5, 7, 8, 10 days. And a lot of times they’re not even putting weight on it for the first several days.
Dr. Brian Mandell: And there’s some that think that maybe ice will help a little bit. I must say I’ve not been as impressed with that from patient stories as other people have, but people will try that as well. But, you know, the first time it happens when your foot, you know, the, the, the mind is a terrible thing to waste.
So the explanation that we give to ourselves is, Oh, I stepped off the curb wrong. And then you talk to the patient. Well, when did you do that? Well, I’m not really sure. I think I did it a week ago. Well, You know, come on, let’s think about this, but you know, it’s, it’s natural to think that you injured it in some way and maybe hope that that happens, but I think you’re exactly right. You’ve got to get it ideally as early as possible.
Dr. Larry Edwards: And again, I think that the treatment, the earlier it started, the more effective it is that you can head off a lot of these flares. If you start the anti-inflammatory treatment right at the very first signs of the symptoms and not wait. You can shorten the time that the joint’s painful at all from a week or so down to a day or maybe a day and a half by jumping on it quickly.
So I think that there’s a reason for having those kind of medications available to you. Your doctors, as Brian just mentioned, aren’t going to be around at 2 or 3 in the morning to write you a prescription for anything. So, whatever it is that you and your doctor have decided are going to be a good treatment for gout, that you should always have it with you, and that includes if you’re going away on a trip somewhere to take it with you and have it with you at work even. So we call that a pill-in-the-pocket approach, that it’s an effective way to do it.
Dr. Brian Mandell: All the more reason, you know, to have made that diagnosis as accurately as you can, so you’re comfortable in taking that approach, not worried about some other reason why that might be happening. And, and I always emphasize to patients that, you know, when, whatever medicine we wind up using, once we’ve proven it’s gout, that it’s going to be treated flare if it’s going to happen, that you should always have some, and you adopt it if you travel, always have it at work. These gout flares happen at the most inopportune times.
Dr. Larry Edwards: And that kind of leads us to our next topic in this podcast, and that’s how do we handle the long term consequences of gout? Though we’ve said that a lot of patients believe that gout is the painful flares, but we know that this is an ongoing chronic disease that needs suppression of the uric acid. So can you tell us a little bit about what appropriate long-term treatment of gout looks like?
Dr. Brian Mandell: So the issue, of course, is always to be available with some approach to treatment of flare when it happens. But to really treat the disease, as we’ve talked about, you’ve got to get to the root cause, which is the deposits of uric acid.
So, number one, always be able to treat the flare. But once we’re at that point, we know the disease is there, we know the disease comes from deposits of uric acid, our goal long term is to get rid of those deposits. And once the deposits are gone, flares are not going to happen anymore. So how do we get rid of those flares?
So, It’s not so easy just to go in surgically and just kind of scoop them out. That doesn’t work. For one reason, the deposits are in many, many places. But fortunately, we can dissolve those flares by lowering the amount of urate or uric acid in the blood. And as that level in the blood goes down, the deposits will kind of melt away with the uric acid in those deposits going into the blood. And ultimately, We’ll get rid of it through our kidney or actually through the intestines to some degree as well.
So we have several options with medication to lower the level of urate in the blood, which will ultimately lead to the dissolution, the dissolving of those deposits, and thus really truly cure the disease.
And it’s not many rheumatic diseases that we can talk about that we can actually cure. But gout is one.
And I think by cure you mean that they can become symptom-free over time, as long as they stay on the medication.
As long as they stay on the medication, because what we say is, you know, however you got there to begin with, if you let your blood urate level go back up, the whole thing is going to start again.
The metaphor that I use is, you know, why this happens is pouring, you know, sugar into your iced tea. And you pour too much sugar in, it’s gonna settle on the bottom of that glass. You can dissolve it by adding a whole lot more iced tea, and then stirring it up, and it’ll go away. But if you keep pouring sugar into that, it’s gonna come back.
And if you open a joint, you’re gonna see a lot of white stuff in the bottom of that joint. It’s not sugar, it’s uric acid. So we need to keep the uric acid level low, and once you’ve stopped getting flares, and you think everything is gone, It may be gone, but if you stop your medicine, it’s going to come back.
So that’s really just a true message that I always re-emphasize to the patient. So we can cure it, but we cure it with ongoing medication.
Dr. Larry Edwards: So this leads to the concept of a treat to target. What you’re referring to is that the ceramuric acid level can precipitate out and form these uric acid crystals around the body and that usually does that at a concentration of uric acid of about seven or slightly less than that.
When we treat with these uric acid-lowering therapies, we’d like to pick a target and across the world, the various rheumatology groups have settled on six milligrams per deciliter as the target. The British like a little bit lower at five milligrams, and I personally like the lower the better because that means that you’re going to resolve these deposits of uric acid even quicker.
The lower the uric acid from your sugar analogy, the quicker the response and the elimination of not just the deposition of uric acid around the body, but also all the symptoms that patients are trying to get rid of, like their flares in their chronic arthritis.
Dr. Brian Mandell: Yeah, like you, I agree that I aim generally for lower than 6, I mean 6 is picked almost as a magic number, it’s picked because it clearly is below 7, and we want it definitely below 7.
I generally aim for lower than that, and if people have an awful lot of deposition that we can actually even see, You know, some patients will get these deposits under the skin, in the ears, in places, in addition to the joints that we can see, suggesting that they really have a lot of urate burden. I’ll go even for significantly lower, at least for a while.
I’m a firm believer that the goal is to keep this really down to the point where those deposits are not forming. And that estimate of 7 is probably different than different people. I mean, it may be that number may be 7 in me and it may be 6.5 in you. And if I aim for 5.5 or 5, I know I’m well enough below for anybody, most likely, and I’m gonna get rid of those deposits.
Dr. Larry Edwards: I think another important thing about the treat to target is that the patient should know the target and they should know what their uric acid is at its most recent drawing and be able to tell you very much like a patient with diabetes can tell you what their blood sugar is running or a patient with hypertension can tell you what their blood pressure was.
Everybody that has gout should know whether or not they’re at target and if they’re not at target they should be raising a row in their doctor’s office wanting to know why they’re not being adequately treated and I would support you in going and creating that row.
Dr. Brian Mandell: Yeah, well, we like, we’re rowy people, but I totally agree.
And the numbers when this has been looked at as to how physicians are practicing, it’s, It’s a little bit embarrassing when you look at the statistics. And people say, well, what’s the dose of a medicine that you would be using? You know, alipuradol, different types of medicines that lower the urate.
They’ll say, what’s the dose? And I get that question from physicians too. And I say, there’s no one dose. The dose is what it takes in a given patient to get to that target, to get the urate low enough. I’m not going to give you, if you have high blood pressure, you know, pill X and say, this is a great pill, just take this and I’ll see you in two years, assuming that pill X is going to work great for you.
I’m going to make sure that you’re monitoring your blood pressure at home, you’re coming in and I’m going to check your blood pressure again. And the way to do this when we’re starting people to treat their lowerin urate levels with medication is to check the blood test. And you’re going to check it periodically until it gets to where you want it to be, and then less frequently, but still check it occasionally to make sure it’s staying there.
Because if you haven’t checked it, you don’t know what it is.
Dr. Larry Edwards: There is good information on our gout education website that can, uh, tell you exactly how your gout has been or should be treated.
Brian, can you talk a little bit about the benefits of having good chronic control of your uric acid, what kind of things are you avoiding? You mentioned before that you can cure it as far as the flares numbers going down and over time disappearing. And over time usually means a couple few years of being on therapy before they can really disappear. What other kind of things will having uric acid under control do for you?
Dr. Brian Mandell: Yeah, I think, you know, the strongest data that we have and, and honestly what means the most to the patients sitting across the room from me is this absence of flares, that we’ve stopped the flares. That’s first and foremost. But it is quite clear that gout is a metabolic disease. It’s a lot of genes that go into this too, but this is a genetic metabolic disease that can affect many other organs.
You know, in 2024, we’re not positive about what is associated with high levels of urate and what is caused by elevations of urate, but there’s a lot of smoke, if not absolute fire in saying that there is associations with high levels of urate, with progression of kidney disease. If you have kidney disease, it’s more likely to progress if your urate levels are higher.
There is some evidence that suggests that higher levels of urate are associated with higher blood pressure. There’s associations with coronary events, heart attacks, angina, some heart failure. All of these things are associated with elevated levels of uric acid. So there is this sense that if we keep the urate level, we will be helping those other comorbidities if you will, other problems that go along with having the gout. Some of this has not been proven as I say, it’s more, right now, a lot of smoke and good thought that goes into this. But so far, there’s no downside in maintaining that. So I, I think that we probably are helping the other comorbid conditions of kidney disease, high blood pressure, heart disease by keeping the urate level down lower.
Dr. Larry Edwards: And then throw a stroke in there as another potential side effect of chronic elevation.
Dr. Brian Mandell: Yeah, right. And association with diabetes may probably not cause an effect of stroke, at least in that direction. But all of these things travel together. It’s the metabolic syndrome that people were, uh, have been discussing for several decades.
These things travel together, and I don’t think it’s just a coincidence.
Dr. Larry Edwards: Good discussion, Brian. To round out this section, I think it’s important for me to summarize what we’ve been talking about, and that is the necessity and need for timeliness and initiating chronic therapy for people with gout so that they don’t sit around and wait for years as their symptoms get worse before they decide that they’ll go ahead and take the one pill a day, that it’s, you’re losing ground all the time, that you’re not treating uric acid.
And I think that we have good information now that using appropriate doses of these uric acid lowering therapies that Brian mentioned, that over time, over usually a couple years, you can reduce the number of flares to zero. And as long as you stay on that therapy, and we recommended lifelong therapy, that these issues that we’ve been discussing as potential side effects of having gout disappear.
I think all of that is how patients with gout should look at their disease and be willing to accept the therapy from the get go.
Brian, is there any other issues on this topic that we haven’t covered that you’d like to continue to discuss?
Dr. Brian Mandell: I was thinking to points that you started with early on, this kind of urban legend that if you just follow the right diet, you’re not going to get gout. And yet, there are patients who, you know, have the experience that if they have a, you know, surf and turf and a couple of beers, they’re going to have a flare the next day or so. And that seems to go against what you said. But I think a moment of thought about this is worthwhile, that it is clearly true, and I totally agree with you, you can’t treat the disease just with diet.
But there are some dietary indiscretions, if you will, or just normal habits of eating that may trigger flares. And it may be not just by changing the uric acid, like changing your diet is not going to get rid of that extra uric acid. But certain diets may influence the way that your body reacts to the uric crystals that are there, to the deposits that are there, and may in fact trigger flares for that reason.
Not just by changing the levels of the uric acid in your blood. But may actually prime your immune system to attack those deposits and causing a flare. So if you think that a certain diet indiscretion, if you will, triggers a flare and it’s done it twice, it’s probably true. And you should avoid those dietary habits, at least until the deposits are gone completely.
And then it probably is okay to have a surf and turf and a beer. But not while the deposits are still hanging around.
Dr. Larry Edwards: Exactly. And it’s a fine distinction between saying what triggers a flare versus what causes the disease.
Dr. Brian Mandell: And keeps the disease going, absolutely.
Dr. Larry Edwards: Yeah. The disease itself is primarily a genetic metabolic inflammatory process that’s caused by the kidneys under excreting uric acid, that you can induce flares or probably half the people with gout recognize that there are some trigger foods or trigger drinks that, that kind of set them off and then avoiding them will lessen the frequency, but won’t eliminate the flares.
Dr. Brian Mandell: Or getting admitted to the hospital with pneumonia or a heart attack that can trigger a flare too. The stress to the system and, for reasons that are a little bit mysterious to me, why then some of your gout medicines are stopped when you get admitted to the hospital. That’s one thing that, you know, it drives us crazy, it is a cause of flares when people get admitted to the hospital for something else, and all their gout medicines suddenly are stopped for some reason. Don’t let them do that.
Dr. Larry Edwards: Well, I think that discussions like this should be empowering to patients with gout. They should understand as much about this disease as they can. They should, again, recognize that lowering uric acid and keeping it low for a lifetime with medication is the right approach to it, that the disease can be cured, and the potential side effects of causing other diseases can be hopefully eliminated by that way. I think patients knowing these things can go in and have a real conversation with their health care providers about what they want and what they need. And we are all for that.
I want to thank you for your comments today, Brian. You’ve been terrific. Ian, back to you.
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 our website. gouteducation. org. And stay up to date with our organization by signing up for our monthly newsletter or by following us on X or Facebook at Gout Education.
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.
