Posted 9 Feb
Words by Sarah Keenihan.
Imagine you’ve got a medical condition that causes swelling and intense pain in your left big toe and sometimes a knee. It comes on quite randomly: you wake up, and damn! There it is again. When it does hit, it stops you standing and walking normally. You can’t shop, work or do exercise. Can’t even bare the weight of a bed sheet on your leg. These episodes leave you feeling miserable and frustrated.
This is gout. Around 1 million Australians are affected – typically older individuals, more frequently men – and often they’re struggling to find a treatment that works.
Dorsa Maher is aiming to develop a solution.
“Treating gout effectively can be really difficult, because there’s not a one-size-fits-all approach,” said Dorsa.
“In my research I’m looking at the medications used to manage gout, and mapping their benefits and safety. I hope to create new knowledge that allows doctors to prescribe personalised therapy,” she explained.
Dorsa studied pharmacy as an undergraduate, and is doing a PhD in Clinical and Health Sciences at UniSA.
Our bodies can seem like a closed book for scientists studying gout. Some of disease’s contributing factors are clear, but it gets messy unpacking exactly how these create patient experiences.
Gout causes and symptoms do not appear to be connected in a linear relationship – at least from the outside. And that’s why treatment is tricky.
It is known that gouty troubles start when levels of urate – a breakdown product from the body’s metabolism and food digestion – rise in the blood. Urate builds up in joints as monosodium urate crystals, creating a trigger for inflammation, swelling and pain. This is called a “gout flare”.
Taking medication – typically the drug allopurinol – to lower blood urate levels is effective in treating gout over the long term. The trouble is, initially allopurinol can lead to a rise in the number of painful flares, for 6 or even 12 months. Imagine what this is like for a patient – you go to a doctor to get help for your gout, and they give you a drug that seems to make your gout worse.
“From the patients perspective, they may think this initial rise in flares means their medication is not working and so they might stop taking it,” Dorsa explains.
“And so they’re left with a dilemma. Take the medication and risk an increase in pain short–term, or don’t take the medication and risk permanent joint damage long–term.”
The key to effective gout management then is to manage inflammation and pain well enough to allow the urate-lowering drug time to work.
“It can take up to two years for the urate-lowering drugs to dissolve all the crystals in your body,” Dorsa said.
“My work aims to create a guide on the best anti-inflammatory drugs to use for each patient so they can comfortably and safely get to that point.”
Common anti-inflammatory drugs include non-steroidal anti-inflammatories (things like aspirin or ibuprofen), corticosteroids and colchicine. These drugs have some serious side effects, and aren’t suitable for all patients – especially those in older age brackets who often have other conditions to manage.
“Gout often occurs in people who have other health issues such as diabetes, heart disease, high cholesterol and kidney disease,” Dorsa said.
“Anti-inflammatory drugs can become toxic for people with these medical conditions, and so we can’t use these drugs in all gout patients – they can be truly dangerous for some.”
Removing this risk of harm requires better evidence about patients and medicines – which is where Dorsa’s research comes in.
Right now, Dorsa is analysing published studies relating to gout management, looking in particular at the benefits and safety of drugs to treat gout flares.
She’s also collecting data from consenting patients at a gout clinic in Adelaide.
“We ask them about their cultural and geographical background, whether other family members have gout, general medical information, diet and lifestyle factors, and how they usually manage gout flares,” Dorsa said.
“I’m also collecting responses on what they think of the medicines they use, and if they’re happy with the information they get from doctors.”
Patient blood samples are taken and used to measure levels of urate and treatment drugs. Molecules that reflect overall health are also monitored, plus a gene called ABCG2, which is thought to play a role in gout.
“All up, what I’m hoping to be able to do is create a big picture; a data-based model of gout, that allows a doctor to enter all the features of a particular patient, and work out what the risk of gout flare is for that person,” explained Dorsa.
“Then doctors can help their patients understand what they might experience, prescribe safe drugs to manage flares and manage gout properly in the long term.”
Gout has been described in written human history since the ancient Egyptians in 2640 BC. Maybe soon we’ll have a more effective way to treat it for good.