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Awww ... freak gout!

Once called ‘the disease of kings,’ it can hit anyone — and it’s on the rise

By Kay Lazar
Globe Staff / August 29, 2011

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The sudden pain in Greg Hannoosh’s left big toe was so intense one night he thought his entire foot was going to “blow up.’’

The West Newbury public relations executive hung on until morning, then hobbled in to see his doctor, who took one look at Hannoosh’s swollen, angry foot and concluded that the 41-year-old had gout.

“I didn’t even know what that was,’’ recalled Hannoosh, now 51. “I thought it was an old man’s disease.’’

Gout, long known as “the disease of kings’’ or “rich man’s disease,’’ is a form of arthritis, first identified centuries ago, that is becoming more common as Americans age and pile on the pounds, say researchers and health care providers.

Over the past two decades, the prevalence has risen from an estimated 2.7 percent of the population to 3.9 percent in 2008, and is estimated to affect more than 8 million Americans, according to a study published last month in the journal Arthritis & Rheumatism.

Along with the increase has appeared a crop of new gout medications; federal regulators have approved three new drugs since 2009. They are the first new gout medications after a 40-year drought, and come with a flurry of recent advertisements from pharmaceutical companies touting them.

The promotions have raised questions among health care providers about whether the new therapies, which can be significantly more expensive, are any better than the conventional ones at treating the age-old disease.

“If you convince a lot of people that there is this terrible disease lurking, then it is hard for Americans not to say, ‘Gee, that new medicine sounds good to me,’ ’’ said Dr. Nortin M. Hadler, an arthritis specialist and professor at the University of North Carolina School of Medicine.

Hadler said that in his experience, the new drugs don’t seem to be more effective than those that have been on the market for decades. A self-described skeptic, Hadler has written extensively about aging and what he calls a growing trend in the medical industry to overuse tests and medications to treat patients.

Yet on some basic points about the disease, Hadler and other specialists agree: People who are overweight, have high blood pressure, take diuretics - a common medication for high blood pressure - and have a diet rich in meat and beer are more prone to gout attacks. (Overindulgence in rich food and drink is what earned gout the reputation as a “rich man’s’’ or “king’s’’ disease - King Henry VIII being one of its most prominent representatives.)

Working from that list, Hannoosh was the perfect gout candidate. While he isn’t overweight, Hannoosh has had high blood pressure since his late 20s, had long been on diuretics, and was a big beef-and-beer guy.

“Beer and beef are bad news for me,’’ said Hannoosh, who has struggled to stay away from the stuff.

Gender and age also play a role. Middle-aged men are the typical gout patient, but women start to catch up after menopause, when they gradually lose female hormones that help the body excrete uric acid, a substance produced by the body during digestion.

The disease is caused by a buildup in the blood of uric acid. If the acid levels become too high, crystals may form and trigger an acutely red, hot, and swollen joint - usually starting in a person’s big toe - and excruciating pain.

“Typically it hits you in the middle of the night, and it is so painful, you can’t put the weight of a bed sheet on it,’’ said Dr. Hyon K. Choi, a professor at Boston University School of Medicine and an arthritis specialist who treats patients - including Hannoosh - at Boston Medical Center.

Choi is the lead author of the recent study that analyzed government data to show the increase in gout. It was funded by a company that makes Uloric, a new gout treatment that competes with the generic allopurinol, which has been on the market for decades. Both drugs are designed to lower a patient’s uric acid levels.

Before the new batch of medications hit the market, one of the most common treatments for chronic gout attacks was colchicine, a plant-based therapy that has been used since ancient times and had been available as a generic prescription for more than a century.

When the US Food and Drug Administration in July 2009 approved a new formulation of colchicine, called Colcrys, it gave the manufacturer three years of market exclusivity under rules that encourage compliance with the FDA’s drug-approval process.

The various makers of the older, generic formulation of colchicine were shut out because their products had never been approved by the FDA; they predated agency rules that required such a review but had, until that 2009 action, been allowed to remain on the market.

Dr. Aaron S. Kesselheim, an assistant professor at Harvard Medical School and internist at Brigham and Women’s Hospital, said that since the FDA’s action, some of his patients can’t afford the new drug because their insurance coverage requires them to pay much more for the treatment.

“The same patients didn’t have that issue before, because colchicine was considered a generic drug and was available relatively cheaply,’’ Kesselheim said.

In an article he wrote in the New England Journal of Medicine last year, Kesselheim noted that the price of the new colchicine treatment, compared with the generic, went up by a factor of more than 50, from 9 cents per pill to $4.85.

“It’s really a difficult situation for patients,’’ said Harvard Vanguard family physician Eliza Shulman, who said some patients in her Braintree practice turn to Canada, where the generic medication is still available.

Shulman and other physicians said that despite the new medications, they usually prescribe widely available drugs such as Naproxen or ibuprofen to ease the pain for first-time gout sufferers.

The longer-term strategy, Shulman said, is to help patients lower their uric acid levels to prevent another gout attack.

“We always try to start with nonpharmacologic treatment first, working on the risk factors we can modify,’’ Shulman said. “There are quite a few lifestyle modifications to lower their risk - the big ones are diet and alcohol intake.’’

It’s a hard-learned lesson for Hannoosh, who thought he was a one-and-you’re-done gout sufferer after his first attack in 2001, and had no recurrence for years. He went back to his old beer and beef habits.

“I forgot I ever had gout,’’ he said. “And then all of a sudden, in the fall of 2009, I woke up one night and had the worst attack I ever had. My foot was killing me.’’

That was followed by three more attacks. Today, Hannoosh takes a generic allopurinol medication to keep his uric acid levels in check, eats very little beef, and has sworn off beer.

“I was at a [Red Sox] game at Fenway recently and it killed me not to have beer,’’ he said. “I have a glass or two of wine at the game, but it doesn’t feel right.’’

Kay Lazar can be reached at klazar@globe.com.

WHERE
Most initial gout flares start in lower extremities - ankles, heels, knees - and typically in the big toe.

WHY
A buildup in the blood of uric acid, a substance produced by the body during digestion, forms crystals in some people that trigger attacks.

WHO
People who are overweight, have high blood pressure, take diuretics (a common medication for high blood pressure), and have a diet rich in certain red meats and beer are more prone to gout attacks.

WHAT
Gout is a type of arthritis that is characterized by red, hot, and swollen joints.

WHEN
Middle-aged men are the typical gout patient, but women start to catch up after menopause, when they gradually lose female hormones that helped their bodies excrete uric acid.

Sources: Centers for Disease Control and Prevention; National Institute of Arthritis and Musculoskeletal and Skin Diseases.

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