Gout Part 2

Having the conversation

Susan Reid & Carla White

The challenge

 Beliefs about gout are widespread and based on lived experience. Everything in
our lived experience largely contradicts the scientific discoveries about the
genetic causes of gout for Māori whānau and Pacific people

 How we talk about gout is key to people seeing gout as a serious long-term
condition and understanding the wider reasons to prevent gout attacks,
especially when prevention includes long-term medicine
Case Study
Tahi is 25 year old Māori male who works as a roofer 6 days a week. He had one
gout attack last summer and this summer he’s had two gout attacks. The gout
attacks were painful but went away after a week. Tahi thinks gout’s awful but
also a bit of a joke – and a bit embarrassing. He can’t remember the last time he
visited his GP.
Tahi has been treating his gout attacks by buying Voltaren from a pharmacy near
where he works. He has come to see his GP because the pharmacist told him
she wasn’t comfortable selling him any more Voltaren because he has bought so
much recently – not just for his gout but also because he strained his shoulder
at work and took Voltaren for that pain as well.
Use Ask Build Check

Three steps to meeting health literacy needs; Health Quality & Safety Commission New Zealand, 2022

 Ask questions to find out what Tahi already knows, does and feels about gout e.g who
else in your family gets gout; why do you think you have gout; what seems to cause it;
what have you tried to treat it; how do you feel about having gout; what impact does it
have on your life?
 Why? New information needs to connect to Tahi’s existing knowledge, feelings and
values in order to be believed, retained and used
What you found out Tahi knows and feels
a. My gout is caused by kaimoana – it gives me high uric acid
b. A lot of people in my whānau get gout because we all like kaimoana
c. Gout is painful but goes away after a week
d. Gout’s no big deal – it’s not something I have to worry about most of the time
e. I already use pills to treat my gout
f. I don’t need long-term medicine – I’m too young
g. Apart from the pain, the hardest part is taking time off work – my boss knows
it’s my fault (because of my kai), and the guys give me a hard time
“My gout is caused by kaimoana”
Ideas for discussing this statement
1. Food is a small part of what causes gout attacks. This might not feel like your experience
because there’s an underlying cause of gout that happens long before you get a gout attack.
Right now you only see the end of the story – when it seems like a mussel gives you gout
2. Gout is having high uric acid in your body. A gout attack is when the uric acid in your blood gets
so high that it has to be stored somewhere. It goes to a joint, like the big toe, where it collects
into sharp crystals, tearing your joint apart from the inside – that’s the pain
3. Uric acid comes from purines which are in all foods and drinks. We need purines and uric acid to
live. There are high purine foods and low purine foods
4. When we have too much uric acid in our body, our kidneys usually see it as waste and mimi it
out/ get rid of it in urine. Except this isn’t true for everyone
5. Your genes say to your kidneys ‘hold on to more uric acid’. No matter what you eat and drink,
even if it’s all low in purines, you will still have high uric acid all the time because of this genetic
message
“My gout is caused by kaimoana”
6. When you have high uric acid all the time, you are always at high risk of having a gout
attack. Anything that any sudden increases your uric acid levels means your body starts a
gout attack
7. We connect mussels, red meat, beer to gout because they have high purines – so are the
thing you eat or drink that pushes your body into an attack – but it’s the underlying high
uric acid all the time that you need to worry about. It’s why your body can’t cope with a
couple of mussels
8. This is why other men who are the same age, weight and height as you, and who have a
similar diet will never have a gout attack – because their bodies aren’t programmed to
store a high level of uric acid – they mimi out any extra/ get rid of the extra in their urine
9. The most effective treatment for gout is to help your body stop producing so much uric
acid – and then you can then safely have kaimoana, or red meat and other things you love
without the risk of a gout attack
Gout is not your fault

A New Zealand research study found that what you eat and drink only makes a difference of 10% to your uric acid
(Major et al. Evaluation of the diet wide contribution to serum urate levels: meta-analysis of population based cohorts
BMJ 2018; 363 :k3951 doi:10.1136/bmj.k3951)
“A lot of people in my whānau get gout because
we all like kaimoana”
Ideas for discussing this statement
1. Other people in your whānau will have the same genes, meaning their kidneys store high levels of uric acid
all the time, making them at high risk of gout attacks

2. Māori whānau and Pacific people tend to have genes which stop their kidneys getting rid of extra uric acid

3. 90% of high uric acid in your body is caused by genes, kidneys and weight. Only 10% of high uric acid is
caused by food and drink
“Gout’s painful but goes away”
“Gout’s no big deal – not something to worry about ”
Ideas for discussing these statements
1. A gout attack is temporary but
• Each attack is damaging the affected joints and this can lead to permanent joint problems and disability
• Regular use of high doses of pain medicines like Voltaren, Ibuprofen or Prednisone to manage the pain of attacks are
bad for your stomach and can lead to other health problems
• You tend to get more frequent attacks as you get older
2. The underlying problem of high uric acid is ongoing. Between your gout attacks, high uric acid levels in your
body will create lumps, called tophi, around your joints and these will damage your joints in the long term if
not treated
3. High uric acid is related to other health problems such as heart disease, diabetes and kidney problems
4. There are long term medicines for gout that help your body reduce the amount of uric acid in your body to
safe levels – this prevents attacks, tophi and other problems
Green uric acid crystals (can grow into
Tophi)

Image from Professor Nicola Dalbeth ADHB and University of Auckland

Tophi

Image from Professor Nicola Dalbeth ADHB and University of Auckland

“I already use pills to treat my gout”
Ideas for discussing this statement
1. Yes the pills you use treat the pain of an attack by reducing the inflammation in the joint. Pain pills like
Voltaren, and Ibuprofen treat pain from inflammation. They are known as NSAIDS (non-steroidal anti-
inflammatory drugs). These pills treat the symptoms of the attack (pain and inflammation) but don’t treat
the cause of the gout attacks (high uric acid)
2. Unfortunately, regular or ongoing use of high doses of NSAIDs and other pain medicines such as Prednisone
are bad for your stomach and can lead to other health problems
3. Ongoing high levels of uric acid in your body, every gout attack, and ongoing NSAID use, is doing long-term
damage to your joints and body
4. There are long term medicines that treat the cause of gout by helping your body reduce the amount of uric
acid to safe levels – this prevents attacks, tophi and other problems
5. The most common long-term medicine is allopurinol. Allopurinol stops the body making so much uric acid
in your mimi/pee/ urine
“I don’t need long-term medicine - I’m too
young for that”
Ideas for discussing these statements
1. Daily prevention medicine is normal & keeps you well (same approach as
preventing asthma)
2. Avoiding attacks and the risks of permanent damage, is awesome
3. Stops gout getting in the way of normal life e.g. work
4. Allows you to do all the things you enjoy e.g. family time, activity, kaimoana

5. Managing gout attacks by diet alone leaves you at high risk of attacks, and
every attack does damage; plus you still have other problems from underlying
high uric acid
Considering long-term medicine –
uncertainty is natural
A person may be reluctant to start long-term medicine. It may help to make a list of the good and not so good
things about taking uric acid medicine and discussing this with someone they trust.

What is good about taking What is not so good about

uric acid medicine taking uric acid medicine
No more pain Remembering to take it
every day
Uric acid medicine – PREVENTION is
AWESOME
 Preventing the build up of uric acid in your body, and preventing attacks protects your joints,
stomach, kidneys and heart from long-term damage
 Allopurinol has been around for 60 years and is very safe
 Allopurinol is taken once a day, every day and this will keep your uric acid levels low
 The treatment goal for uric acid is 0.36 mmols/L (or lower 0.30 mmols/L if you have tophi)
 Taking it will mean you have no more attacks (this might not be true in every case) – and can
safely eat foods that used to cause gout attacks
 You take it forever. If you stop, uric acid will build up quickly again.
Starting allopurinol
 People start on a low dose of allopurinol and this will be slowly increased until you reach your
treatment goal for uric acid
 This is called titration (starting low and increasing dose slowly)
 Starting allopurinol will cause the uric acid crystals in the joints and tophi to start dissolving and
this can cause some attacks. So when allopurinol is started, a person will also be given pain
medicine to use daily for a few months and maybe another pain medicine to be used short term if
they get an attack
 A person’s dose of allopurinol will keep increasing monthly until they reach the treatment goals
for uric acid of under 0.36 mmol/L or 0.30 mmol/L if you have tophi
Focus on the 90 per cent
Using the Change your life booklet
 What is gout – pages 2 and 3
 How is your gout affecting you and picture of crystals – page 4
 Unpacking uncertainty – page 7
 Information about uric acid medicines – page 6
 Information about gout attack medicines – page 8
 Matt’s story and Luka’s story – two young men on allopurinol
pages 10 & 11
 Recording your gout medicines – page 9
 Recording your uric acid test results – back page
Other resources
• Order Change your life booklet – currently available in English,
Samoan and Tongan. Te Reo Māori version available soon.
Order here Gout Booklet (google.com)
• Let’s talk gout video demonstrates how Ask, Build, Check can be incorporated
into discussions about the long-term management of gout Let's talk gout | He Ako Hiringa
• Audio only of the same video Episode Four: Let's talk gout (part 2) | He Ako Hiringa
• Podcast with Professor Nicola Dalbeth, Carla White and Meihana Douglas (Health
Psychologist and Health Improvement Practitioner) on how to better
communicate with people with gout to improve health outcomes
• Episode Three: Let's talk gout (part 1) | He Ako Hiringa