Thirty eight year old Ram Bahadur awoke with an exquisitely tender right big toe which was red and swollen. It was so painful that  even the weight of a light blanket hurt. He mistakenly thought he must have banged his foot at night. He was a general manager of a hotel in Kathmandu; and as he started out for work that day,he wore his shoes with great difficulty and hobbled around the hotel with the big toe throbbing  away. He was relieved to see the  doctor, who after a careful examination told him that in all likelihood he had gout. Some tests were ordered, and he received effective pain medicines.


This vignette happens all too regularly in Nepal. Although the true burden of disease in Nepal is not known, gouty attacks  are common and seems to start at a younger age group ( less than 40 years) in Nepal than what is usually noted in Western medical  textbooks ( over 60 years). The reason for this predisposition at a younger age is not known.


Gout has been around for many centuries. There are pictures from the seventeen and eighteen hundreds in Europe where rich people are shown to be eating plenty of meat and drinking lots of wine.  Then the next picture shows a devil-like figure attacking the big toe of the indulgent person with a trident causing excruciating pain. Although other joints can be involved it is classically the big toe that gout affects. Importantly unlike another common joint disease, rheumatoid arthritis, gout does not simultaneously affect joints on both sides of the body ( bilateral ). It is usually a single joint that is involved on one side; and for doctors this unilateral involvement helps among other things in characterizing gout. 


Gout ( sometimes non- specifically called “baath” in Nepali) is a very painful type of arthritis ( joint disease) which often starts at night and is caused when uric acid crystals form in joints.Although not always a reliable test, uric acid in the blood is often checked to diagnose gout. Certain foods( red meats, organ meat, fish,alcohol, “gedagudis”, and sugary soft drinks) increase the risk for gout.Eliminating most high protein food will help, but it may not always be practical. Many gout sufferers carry a list ofother food stuff to avoid including tomatoes and spinach, but this may be scientifically baseless. Some medicines like diuretics ( water pill), aspirin, and some diseases like diabetes, obesity and kidney problems may also lead to gout. So avoidance of these medicines and proper control of these diseases will help.


If you get more than 2 or 3 gouty attacks per year, it may be prudent to consider taking medicines  long term to prevent gout and other related complications such as kidney stones. Effective drugs like allopurinol for prevention of gout that have been tried and tested for over many decades are available, but they need to be used under proper supervision of a competent doctor. Often just avoiding certain food stuff may not be enough to avoid the gouty attacks that Ram Bahadur suffers from.


Many doctors think that gout may cause predisposition to coronary artery disease. The existing data is not clear on this. But gout is indeed related to the “metabolic syndrome” which clearly is a harbinger for heart attacks.