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INSIDE HEALTH – Programme 10.

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TX:Ìý 12.03.19Ìý 2100–2130

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý PAMELA RUTHERFORD

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Porter

Hello. ÌýComing up in the next half hour:Ìý Gout – it may be the butt of many a joke, but, as anyone who has ever had an attack will tell you, it’s no laughing matter. ÌýI will be speaking to a rheumatologist about the best way to treat it.

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And, are you frightened by the prospect of a trip to the dentist? ÌýIf so, you are far from alone – even the toughest people can be affected.

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Clip

The worst one I ever had was a gentleman who was employed in the Special Forces and he said to me, which I’ve never forgotten, I’ve been shot three times but I’d rather be shot again than go to the dentist.

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Porter

I visit a dental psychology clinic to find out how people, like that soldier, are being helped.

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But first, CBD oil – a popular natural remedy based on cannabidiol, one of the many active ingredients found in cannabis, but not the one responsible for getting people stoned.Ìý

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CBD oil is everywhere at the moment, and here at Inside Health we have been bombarded with press releases extolling its virtues as a remedy for a wide range of different ailments, from acne and anxiety, to arthritis and insomnia. ÌýBut is it all too good to be true?

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Dr Margaret McCartney has been looking at the evidence, and she’s in our Glasgow studio.Ìý

Margaret, before we look at what the research can tell us, what’s the legal situation?

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McCartney

So, these are cannabis-based products and these are legal if they’re not regulated under the Misuse of Drugs Act.Ìý And this is different again – these are only allowed to have very low levels of THC, which is the psychoactive component of cannabis or one of the psychoactive components of cannabis and are not authorised as medicines, and they’re not allowed to make any medical claims.

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Porter

Right, well herein lies my issue with CBD oil in that I get bombarded, I’m sure you do, Inside Health does as well, with press releases from marketing and PR companies making all sorts of extravagant claims about this – it’s good for your skin, it’s good for your back, it helps you deal with anxiety.Ìý And yet when you get the actual bottle from the manufacturer there’s no claims at all.

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McCartney

Yeah, and this is so that they remain within the law.Ìý And in fact, I do think there is some sort of quite dirty practice out there with various companies saying well, we can’t make any health claims but all you have to do is look online at what other people are saying about our products.Ìý Which I think is really not very helpful because what we should be referring people to is the evidence base.

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Porter

Well, what does the evidence base tell us?Ìý Are any of these claims supported by evidence?

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McCartney

Well, it’s very interesting, certainly there is a lot of early, very early, research that is saying perhaps there might be some promise for this condition or that condition but when you come to looking for human trials, with real life outcomes, we simply do not have very many of them at all.Ìý Some people are doing really interesting research into whether some cannabis-based products might help people, for example, with schizophrenia but these have just been preliminary trials.Ìý What is clear is when reviewers went to look at all the evidence for things, for example, pain or for the use of these products for things like ulcerative colitis or Crohn’s disease, bowel disorders there simply isn’t enough evidence to make high quality claims about what these products might be useful for.

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Porter

Of course, as we know very well here on Inside Health, a lack of evidence doesn’t mean that these products don’t work.

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McCartney

Of course, but there have been some trials done, reviewers have very clearly said there isn’t enough evidence to say whether this works or not and we should do high quality trials before concluding.Ìý But the problem is if people are making claims that go well beyond that evidence that’s just not fair to consumers and patients.

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Porter

The other issue of course is safety and this is widely promoted as an extremely safe product but if we don’t have evidence to support efficacy presumably, we don’t have evidence to support safety either?

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McCartney

Well absolutely and of course many of the trials looking so far at what the evidence might be have been run over, things like six or weeks, things like that.Ìý What you would really want to have is trials that run over a far longer period.

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Porter

Because, let’s be clear, this is a natural product but it’s potentially quite a potent product in terms that it’s acting on a very important, we think, receptor network in the brain.

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McCartney

Yeah, absolutely, and there’s loads of things that are natural that are not particularly good for us.Ìý Things like heroin, for example, you know you can’t just presume that because something occurs in nature it’s going to be good for you.Ìý What the real test is, is there evidence for it, what are the pros, what are the cons and how do I balance them and what’s the right decision for me.Ìý And at present, we just simply do not have good enough evidence to say that the vast majority of claims that have been made either subtly or fulsomely online for these products actually hold out in practice.

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Porter

Thank you very much Margaret.Ìý And there are some useful links on the Inside Health page of the Radio 4 website.

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Dentist noises

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The sounds of the dentist. ÌýWe spared you the drill, but even the noise of that sucker will have been enough to send shivers down many of your spines. ÌýDental phobia is surprisingly common, as I discovered when I visited the Dental Psychology Service at Guy’s Hospital in London, a leading NHS clinic helping people who struggle with even the thought of a trip to the dentist. ÌýIt was set up a decade ago by Professor Tim Newton.

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Newton

We would basically say everybody has some degree of relationship with anxiety around going to the dentist.Ìý So, that might from someone like me, who’s obviously very mildly anxious but if I was asked to have a tooth extracted, I might get more anxious, to the extreme of phobia.Ìý In the hospital we primarily see people with a dental phobia and that is defined by the phobia having an impact upon their life in some way.Ìý The most common of that would be that they’ve delayed treatment and have very significant dental treatment needs, recurrent pain, infection, often with years and years of avoiding going to the dentist.

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Porter

So, how common is this?

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Newton

Dentistry’s the most common of what we call the simple phobias, so being scared of one thing.Ìý Dentistry is the most common in the UK, it’s about 10-11% of adults and a similar proportion in children.Ìý And a further 38% are moderately anxious.

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Porter

So, that’s nearly half the population.

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Newton

Yeah.

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Porter

So, these people that would never go to the dentist, I mean is it so bad that they wouldn’t contemplate, they might have terrible pain from their teeth but they wouldn’t contemplate going to a dentist?

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Newton

Yes, and often that kind of carries out to other settings – so they might not watch television programmes that involve dentistry.Ìý I had a patient once is used to cross the road when he went to the pub, so he didn’t have to walk past the dental surgery that was on the same side of the road.Ìý The worst one I ever had was a gentleman who was employed in the Special Forces and he said to me, which I’ve never forgotten:Ìý I’ve been shot three times but I’d rather be shot again than go to the dentist.

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Porter

But coming from somebody like that, who can handle most things, that’s amazing.

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Newton

And what was really interesting is that when talked about it there was two things about it:Ìý One is, when he want to the chair he still responded as if he was the child that had been pinned down and he’d never realised that he’d changed.Ìý And the second thing was, it was very much about control, he was very used to being in control of his life and his destiny and dentistry, somehow, stripped that away from him.

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Porter

And is there a common story behind why these people are afraid of dentists?Ìý Why do people develop phobias?

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Newton

So, the most common story we hear would be a traumatic experience at some point during childhood.Ìý Although that’s not everybody.Ìý Some people just report having been anxious all their lives or that their parents were very anxious about going to the dentist and they kind of picked it up from them.

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Michael

So, my phobia was a thing that began before I can really remember, to be honest.Ìý So, it was actually my mother that explained to me what happened.Ìý So, apparently when I was a baby, around 18 months, two years old, there were some issues with my teeth coming through my gums and I had to have a small piece of dental work done.Ìý That involved some anaesthetic and apparently, she remembers vividly that the anaesthologist [sic] could not get the needle to go in, basically.Ìý And I obviously, being quite young, got more and more distressed, etc. etc.Ìý And it’s something that just stayed with me actually in kind of its side effects.

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Porter

That bit you don’t remember, but when do you remember first having issues with the dentist?

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Michael

So, I probably had an over fondness for fizzy drinks when I was a child, which meant one too many trips to the dentist and I can even remember at the age of say, five, six, seven years old – going to the dentist, for me, was an incredibly distressing experience.Ìý I’d become quite hysterical, quite difficult to control, my mother would more or less have to physically drag me along to the dentist basically.Ìý And once I was there, I would cry etc. etc.

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Porter

And presumably that sort of thing was self-fuelling as well, I mean if you’re being dragged there and held down in the chair and all of that, makes the whole thing much more traumatic for a young child.

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Michael

Absolutely, and I probably didn’t have the most sympathetic dentist, at the time, as well.Ìý I understand he had a job to do but he probably didn’t quite appreciate that he was reinforcing that phobia me in some of the things he did.

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Porter

You say the dentist wasn’t that sympathetic, I mean what were they doing that was wrong in your mind?

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Michael

Yeah, so definitely at a low level being sort of – trying to be quite firm with me, as a seven, eight-year-old boy I can understand that…

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Porter

Get in the chair, keep quiet.

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Michael

Exactly, but there were a couple of things which I’d say probably went a little bit further than that.Ìý Telling me that they weren’t putting a syringe in my mouth and then switching dental instruments for syringes and things like that.Ìý

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Porter

Trying to catch you by surprise.

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Michael

³Û±ð²¹³ó…

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Porter

Which just accentuates your anxiety.

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Michael

I mean, absolutely, because then, in my mind, that meant that I couldn’t try dentists.Ìý And I think when you’re in a dental chair, even a normal person, would concede that’s a slightly vulnerable position to be in.

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Porter

At the worst, how bad was it for you?

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Michael

I didn’t go to a dentist for 10 years.Ìý So, from the age of about 18 or 19 until my late 20s until I was about 30.Ìý And the only thing that eventually did make me go to the dentist was when I broke a tooth.Ìý Ended up with quite a large hole, which was why the tooth had broke because underneath the tooth was rotten.

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Porter

And that’s when you decided, look, enough’s enough, I need to do something about this?

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Michael

Yeah, initially I kind of went down my old strategy of going to the dentist and saying – okay, can you do this without anaesthetic, what can you do.Ìý And she just pretty bluntly put it to me that there’s not much you can do with a giant hole in your mouth without anaesthetic, she described it as torture effectively.

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Porter

So, you had a problem with a broken tooth, you finally decided you needed to do something about it, what happened then?

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Michael

I basically googled to see whether there were any dentists that were particularly sympathetic, let me say, in this area and I came across a dentist based in the City of London, she sort of suggested that perhaps being referred to the unit here would be a better long term strategy for me.Ìý She could address the immediate problem but she couldn’t deal with my needle phobia but she new some people that could.

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Newton

There are two broad elements to the programme.Ìý The first is based around something called graded exposure which is very gradually coming to face the thing that you fear.Ìý And it’s a process that can take quite a prolonged time but it’s breaking down the feared stimulus or the feared behaviour into bits.

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Porter

And in most cases that feared stimulus is what?

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Newton

So, we break it into four broad modules.Ìý So, there is the room – so the sights, the sounds and the smells of the dental surgery.Ìý There’s a sort of module about injections and about 25% of the people that we see as dentally phobic are only scared of injections.Ìý Then there is the bit about sort of having an examination – someone looking in your mouth and perhaps feeling judged.Ìý And the fourth bit is sort of what I call the sharp pointy drilly bits.Ìý And we tend to address them in that order.Ìý So, we would do the room, and then injections and then examination.Ìý Then the final bit of treatment.

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Porter

And just give me an example then, I mean you talk about graded exposure, but give me an example of practically what that might mean.

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Newton

So, injections are a good example.Ìý So, we would start with something very simple that the patient could perhaps manage which might be as easy as looking at a photograph of the injection equipment or actually touching and handling the injection equipment.Ìý And then once the patient feels comfortable with that, we might move on to having the needle with the cap on it placed in their mouth for increasing periods of time.Ìý So, we estimate that an injection takes about 30 seconds, so we might start with one second, five seconds, 10 seconds, working with the patient so they set their own target.Ìý And then take the cap off, leave the injection equipment in the mouth but not penetrating.Ìý And again, build up the time.Ìý And then the final step will be having the injection.

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Porter

And each time you’re teaching them how to control the anxiety that whatever stage you’re at generates, so, they become more comfortable with the idea.

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Newton

Yes.Ìý So, we would start with teaching some very simple skills about breathing, thinking about being more relaxed, relaxing your muscles.Ìý But also, importantly, we teach them that they can stop us at any time, so if their anxiety becomes too much they can stop, take a break, and we’ll go back a step.

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Michael

So, the way it was sort of explained to me, from the outset, was that we’d go through like a gradual process of first picking apart the mental side of it, so to understand what the mental triggers were for me, which scenarios were okay, which scenarios weren’t.Ìý And then within that start to pull those apart and perhaps start to simulate some of them.Ìý So, starting with basic things like being in the same room as a needle, for example, as a syringe.Ìý And then progressing, step by step, to do more and more.

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Porter

And did you find it alarming to be in the room, even with just the syringe sitting on the side with a needle in it?

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Michael

Yeah, I mean my heart rate would go up noticeably, even if I just walked into a GP surgery, let alone physically being able to see a syringe.Ìý What I really like about the treatment was that whilst I was pushed a little bit further every week, it was always within agreement with me in terms of what the next step.Ìý And that sort of allowed me to balance off against what was uncomfortable.

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Porter

It was at your pace?

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Michael

Yes, but with a gentle nudge to go a little bit further every time.Ìý

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Newton

So, we offer people 10 one-hour appointments.Ìý It varies from patient to patient a great deal and we tend to be driven by the pace that they feel comfortable at going at.Ìý So, we kind of want them to be challenged but not too challenged.Ìý So, I can tell you that my personal average is usually five one-hour appointments before someone’s receiving some form of dental treatment.

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Porter

And in terms of effectiveness, what does the evidence tell us about how good this intervention is?

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Newton

So, we know that for our service 93% of those who attend the service for the initial assessment will end up having dental treatment without any intervention, other than local anaesthetic.

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Porter

That’s an incredible success rate.

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Newton

Yeah, well, we’re very proud of it.Ìý Also, another very important aspect for us is that those are maintained so that people going to primary dental care – and we know that about 80% of our patients will be doing that at two years.

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Michael

So, I now go to the dentist on a regular basis, my six monthly check up, I’ve had a couple of pieces of dental work done.Ìý I’ve had blood samples taken since, for the first time in pretty much my entire life I’ve had a blood sample taken.Ìý So, yeah, I’ve got to the point now where I now have those copying strategies and those mechanics and actually just the confidence that I can go in, I’m not going to enjoy the experience but I can get it done, which is the important thing.

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Porter

What’s changed?Ìý Is it that you’re less anxious about the needles or that you still get the anxiety but you’re in a position to control it?

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Michael

Definitely the latter for me.Ìý It’s still something that I find uncomfortable, I still very much have a reaction, I still get anxious but it doesn’t really hold a fear for me anymore in that sense.

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Porter

This sort of anxiety’s very common, what would you say to people who might be listening who’ve never really done anything about it, I mean their only course of action is avoidance, so they just don’t go to the dentist?

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Michael

The hardest bit is actually making the decision to do something about it.Ìý Once you enter a process like this, everyone’s path, I’m sure, will look a little bit different but the hardest decision is actually deciding to come here in the first place.Ìý Once you’ve done that, the rest of it – it’s hard but if you’re persistent it’s doable.

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Newton

Essentially, I have two top tips.Ìý The first is, try not to avoid because, if you think about it, if you go to the dentist when you’re not in a pain there’s a greater likelihood that they won’t have to do much.Ìý So, that will be reassuring and that will be an easier visit than going when you’re in pain.Ìý But that’s not always possible.Ìý Not always true but largely true is that part of the anxiety is that you build up a fear that your teeth must be really, really bad and so we often, more times than not, we can have a very reassuring message that actually it’s not as bad as you thought.Ìý And there are things we can do and we can give you that beautiful smile, which is really what dentistry’s about.

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And the second thing, would be to take some time to think about what would be important to you in a dentist.Ìý And when we ask patients this it’s often quite revealing, so it’s often that feelings of trust or feeling that they’ve been listened to or taking their time.Ìý And then you can have that conversation – are these things that you would be able to give me?Ìý And if they can’t then okay, they can’t.Ìý But if they can then you might have found the right dentist for you.

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Porter

Professor Tim Newton and one of his grateful patients, Michael.

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And while access to NHS clinics like his can be difficult there are at least eight others across the UK but you will need a referral from your dentist or GP. ÌýThere is a list of the clinics on our website – where you can also subscribe to our weekly podcast – please do – and find out how to get in touch.

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Susan emailed with a query about gout:

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Susan (read)

“I would like you to look into gout, still widely perceived as a self-induced condition caused by a poor lifestyle. ÌýWhy is it still not taken seriously? ÌýOften the response is just to laugh about too much drink and fine living, with the sufferer just having themselves to blame.Ìý

And is there any new research on how best to manage it?

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Porter

Around a million people in the UK have gout. It’s caused by a build-up of uric acid in the body, a natural waste product produced by the metabolism of dietary purines found in lots of things – ranging from beer and seafood, to offal like kidneys and liver.

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The accumulation of uric acid is something that typically occurs over many years. ÌýEventually tissues become saturated and crystals start to form, in joints and under the skin.Ìý Factors that can trigger an attack of gout include binge drinking, heavy physical exercise, trauma such as stubbing your toe, illness, dehydration, surgery, dieting and some medicines like diuretics.Ìý

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Dr Tim Tait is Consultant Rheumatologist at United Lincolnshire Hospitals.

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Tait

Well a typical acute attack will, quite commonly, start in the middle of the night.Ìý The patient will feel as though they’ve got a searing, really acute, pain, often starting in the big toe, although it can affect any joint.Ìý The toe will become hot, red, painful, it may affect the whole foot, they’ll have a struggle to put their foot to the ground, they’ll have a struggle to bear even the weight of the bedclothes or a sheet on their foot.Ìý And many people, for the first attack, wonder if they’ve actually broken something.Ìý The pain is supposedly as about as intense as it’s possible to feel.

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Porter

An all too familiar scenario for listener, Steve.

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Steve

It all started last summer.Ìý We had a BBQ the night before, beers were quaffed and whisky was drunk and I most probably did have that extra sausage.Ìý Didn’t think much of it, of course, at the time, I had a great time.Ìý The morning after, though, I was driving my son to a hockey match and I noticed my left foot was kind of a little bit painful.Ìý And I had thought I might have, in my drunken stupor, maybe caught my foot somewhere and I thought this doesn’t feel right.Ìý Anyway, after I’d dropped my son off for the hockey match, driving back to the house, the pain was definitely getting worse and it was so bad that I could barely put the clutch in, in the car, as I was changing gear.Ìý So, I arrived home and got out the car and quite frankly I could barely walk, I was hobbling up the stairs and the pain was – you know my foot felt like it was on fire.Ìý Said to my wife – I think I’ve hurt my foot, feels like it’s broken, it really is that painful.Ìý So, I looked at my foot and it was bright red, I mean it really was scarlet.Ìý The pain just got worse, absolute agony, it was so bad, that night, I just couldn’t sleep and I was really worried actually and really quite concerned because it was so acute.Ìý So, went to the GP, with help I have to say, I still couldn’t walk, it was a good 24 hours after I felt the pain initially and I couldn’t walk, went to the GP, I was diagnosed with gout.

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Porter

So why do people like Steve get gout? ÌýTim Tait.

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Tait

There’s quite a number of different factors.Ìý The first one can be genetic, around 6% of people who get gout have genetic causes where they lack one of the transporter proteins in the kidney that gets rid of uric acid.Ìý So, they genetically are prone to hanging on to large amount of uric acid within their body and they develop gout at a relatively young age.Ìý The second group are patients where for a number of different reasons, to do with occasionally obesity, occasionally other drugs, occasionally a combination of factors, called the metabolic syndrome, they have more uric acid in their body and they then are much more likely to get gout for a number of reasons.Ìý The third group, who tend to get gout, are older people whose kidneys may not be as effective as they were when they were younger and they simply have a struggle to get rid of sufficient uric acid because their kidneys are not working as well as they did when they were younger.

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Porter

Is there any truth in the sort of Falstaffian image of a middle-aged gentleman with red face, portly, having gout, is it something to do with over-indulgence – drinking too much red wine, too much rich food?

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Tait

It’s quite complex in that it’s wrapped up within the metabolic syndrome concept.Ìý There was a very large study from North America which looked at this.Ìý And they showed that people who have high intake of red meat and seafood, who have a high intake of sugary soft drinks and a high intake of alcohol, particularly beer and lager, have a significantly increased risk of developing gout.Ìý There’s a slightly lower risk for people who eat white fish and also drink spirits.Ìý And actually, wine appears to have a relatively lower risk.Ìý I think the gentleman you’re thinking of was probably more likely to be drinking port, which is a fortified wine and therefore comes under the spirits thing, and possibly had a diet that was relatively rich in meat and purines.Ìý So, I think your stereotypical portly gout patient nowadays is more likely to be overweight, possibly have early diabetes, possibly early hypertension and be wrapped up in sort of the metabolic syndrome.

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Porter

What’s the most effective treatment for treating an acute attack that we have at the moment?

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Tait

If you have an attack at home, the first thing to do is to elevate the joint, put some ice on it.Ìý There are three major categories of drugs that we would use.Ìý The first and probably the commonest, particularly in primary care, would be non-steroidal anti-inflammatory drugs – drugs such as ibuprofen, naproxen, something similar to that.Ìý Given with something to protect the stomach, so a proton pump inhibitor or something similar.Ìý They will be usually fairly effective in settling the acute attack.Ìý The second drug to settle it would be Colchicine, again usually given twice a day, increased to three or four times a day, it’s limited a little bit by side effects, particularly diarrhoea and stomach upset.Ìý And the third category of patients are given steroids in one form or another, either as tablets, occasionally as intramuscular injection and equally occasionally as an injection directly into the joint that’s affected by the gout itself.

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Porter

Since I’ve been a GP, we’re much more aggressive in terms of diagnosing it and managing it, can you explain what’s changed recently and why?

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Tait

So, the original guideline was to look after a first attack, to change people’s dietary habits, to change their lifestyle things but perhaps to wait for the second or even the third attack to treat gout.Ìý The updated guideline looks to treat gout much more aggressively, possibly after the first attack.Ìý And this really goes back to work that’s been done which shows that in patients after their first attack there’s evidence of crystal deposition in and around the joint.Ìý And therefore, to try and prevent further joint damage it’s worthwhile treating, as early as possible, and probably after the first attack.Ìý

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There’s also evidence that gout, per se, increases your risk of cardiovascular disease, of all cause mortality, of renal disease and therefore trying to address and reverse those problems and to reduce the risk of those seems to be very worthwhile, particularly as gout itself is actually a potentially completely treatable condition where you can provide an effective, almost a cure, if you lower the uric acid and reduce the amount of gout in the tissues and hopefully clear the gout crystals from the tissues and then you have a patient who potentially on treatment is essentially free of gout.

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Porter

Tim, in terms of the regular preventive therapy that we use to reduce uric acid levels, how it’s actually working?

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Tait

The commonest drug that we use is a drug called Allopurinol, which has been around for quite a few years now.Ìý It blocks the conversion of the precursor of uric acid, purines, into uric itself.Ìý The idea is basically if you think of your bloodstream as like the bath in your house, if your kidney, which is your plughole, isn’t working terribly well your bath is filling up because you’re still making uric acid.Ìý It eventually spills over and Allopurinol, essentially, turns the tap down, so that the amount you can get rid of through your kidneys is faster than the amount you’re making, which then lowers the level in your bloodstream or in your bath, in the analogy, and then the stuff in your tissues can dissolve back into your bloodstream and go away out through your kidneys.Ìý Now that’s a fairly slow process, it can take about six to nine months for the attacks to settle, although they may still get the occasional one.Ìý The uptake of uric lowering drugs is fairly poor and only 40% of patients with gout ever receive uric lowering therapy in one of the more recent studies.Ìý And the perseverance with them is also poor, so that after a year only 50% who’ve been started are actually still taking it.

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Porter

What’s happening to all of those people who don’t then continue with their medication, what are the implications for their joints?

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Tait

Well gout itself is the most common inflammatory arthritis in this country, affecting about 2.49, 2.5% of the population.Ìý Of itself it damages joints, so the risk is if you’re having recurrent gout attacks that you will be doing damage to your joints.Ìý The risk with the uric acid crystal deposition is that even when you’re not getting attacks, if you’re forming lumps of uric acid crystals under your skin or around your joints, called tophi, they can themselves cause damage to the bones and on x-ray we can see that just occasionally in some patients they get damage to the bones called erosions.Ìý And that tends to occur where these lumps of gouty tissue are forming.Ìý So, untreated you run the risk of, firstly, damaging your joints and secondly, you run the risk of the other conditions that gout can predispose to, such as high blood pressure, kidney disease, heart disease, things like that.

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Porter

Dr Tim Tait. ÌýÌýAnd there are more details on gout, including its role as a marker for other health issues, on our website.

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Just time to tell you about our next programme. ÌýE-Cigs and vaping may be all the rage but they’ve polarised opinion among public health experts. ÌýJoin me next week to find out why.

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ENDS