Gout

What is Gout?

Gout is a form of inflammatory arthritis that develops in some people who have high levels of uric acid in the blood. The acid can form needle-like crystals in a joint and cause sudden, severe episodes of pain, tenderness, redness, warmth and swelling.

What Are The Stages of Gout?

There are several stages of gout:

Asymptomatic hyperuricemia is the period prior to the first gout attack. There are no symptoms, but blood uric acid levels are high and crystals are forming in the joint.

Acute gout, or a gout attack, happens when something (such as a night of drinking) causes uric acid levels to spike or jostles the crystals that have formed in a joint, triggering the attack. The resulting inflammation and pain usually strike at night and intensify over the next eight to 12 hours. The symptoms ease after a few days and likely go away in a week to 10 days. Some people never experience a second attack, but an estimated 60% of people who have a gout attack will have a second one within a year. Overall, 84% may have another attack within three years.

Interval gout is the time between attacks. Although there’s no pain, the gout isn’t gone. Low-level inflammation may be damaging joints. This is the time to begin managing gout – via lifestyle changes and medication – to prevent future attacks or chronic gout.  

Chronic gout develops in people with gout whose uric acid levels remain high over a number of years. Attacks become more frequent and the pain may not go away as it used to. Joint damage may occur, which can lead to a loss of mobility. With proper management and treatment, this stage is preventable.

Who Is Affected?

Gout occurs in about 4% of American adults – about 6 million men and 2 million women.

Gout Risk Factors

Genes: If family members have gout, you’re more likely to develop it.

Other health conditions: High cholesterol, high blood pressure, diabetes and heart disease may raise your risk.

Medications: Diuretic medications or “water pills” taken for high blood pressure can raise uric acid levels; so can some drugs that suppress the immune system taken by rheumatoid arthritis and psoriasis patients, as well as transplant recipients.

Gender and age: Gout is more common in men than women until around age 60. Experts believe natural estrogen protects women up to that point.

Diet: Eating red meat and shellfish increases your risk.

Alcohol: For most people, more than two liquor drinks or two beers a day can increase the risk of gout.

Sodas: The fructose in sweet sodas has recently been shown to increase gout risk.

Obesity: Obese people are at a higher risk for gout, and they tend to develop it at a younger age than people of normal weight.

Bypass surgery: Those who have undergone gastric bypass surgery have an increased risk.

Gout Symptoms

For many people, the first symptom of gout is excruciating pain and swelling in the big toe – often following a trauma, such as an illness or injury. Gout may also appear in another lower-body joint, such as the ankle or knee. Subsequent attacks may occur off and on in other joints, primarily those of the foot and knee, before becoming chronic. 

Gout usually affects one joint at a time, but if left untreated it can affect many joints. Joint pain that used to resolve in a week to 10 days could become a milder, but constant pain. Eventually, untreated gout can cause other problems. Tophi – painless but disfiguring lumps of crystals formed from uric acid may develop under the skin around joints. The crystals can also form kidney stones.

Gout is associated with other serious health risks such as high blood pressure, diabetes, chronic kidney disease and cardiovascular disease.

Gout Causes

Gout appears to come on suddenly, often in the form of a painfully swollen big toe or lower body joint. In reality, it’s the end result of a process that’s been taking place in the body for a while.

The underlying cause of gout is different from those things that trigger a gout attack. Gout is the result of excess uric acid in the body, a condition called hyperuricemia.

Uric acid is a substance that normally forms when the body breaks down purines, which are found in human cells and in many foods.  Uric acid is transported by the blood to the kidneys and eliminated in the urine. However, some people either overproduce uric acid or they produce a normal amount, but their kidneys can’t process it efficiently and an excess of uric acid builds up. Some, but not all, of those people may develop gout. 

Lifestyle factors, such as a diet high in certain high-purine foods, obesity and excessive alcohol use – especially heavy beer consumption – also can contribute to development of hyperuricemia and gout. 

Gout Triggers

Medical or health triggers of gout:

• Joint injury
• Surgery or sudden, severe illness
• Infection
• Taking certain diuretic medications for high blood pressure, leg swelling (edema) or heart failure
• Taking the drug cyclosporine
• Starting a uric acid-lowering treatment
• Chemotherapy

Lifestyle triggers of gout:

• Crash diets and fasting
• Drinking too much alcohol
• Eating large portions of certain foods high in purines (red meats or shellfish)
• Dehydration (not getting enough fluids)
• Sweet sodas

Gout Diagnosis

To diagnose gout, the doctor will take a patient's medical history, examine the affected joint and do a blood test. He or she will also ask about:

• Other symptoms
• What medications the patient is taking
• The patient's diet
• How quickly and intensely the gout attack came on

Details of the attack the doctor is looking for: severity of pain, length of attack and joints affected.

The doctor will need to rule out other potential causes of joint pain and inflammation such as infection, injury or another type of arthritis. He will take a blood test to measure the level of uric acid in your blood. A high level of uric acid in your blood doesn’t necessarily mean you have gout, just as a normal level doesn’t mean you don’t have it. He may take an X-ray, ultrasound, CT or MRI to examine soft tissue and bone. The doctor might also remove fluid from the affected joint and examine it under a microscope for uric acid crystals. Finding uric acid crystals in the joint fluid is the surest way to make a gout diagnosis.  

Gout Treatment

Treating gout requires a two-pronged approach that combines medications and lifestyle changes.

Treating an Acute Gout Attack

Here are the steps for getting the pain and swelling of a gout attack under control:

• Take an anti-inflammatory medication as soon as possible
• Ice and elevate the joint
• Drink plenty of fluids (no alcohol or sweet sodas)
• Call your doctor and make an appointment
• Relax; stress can aggravate gout.
• Ask friends and family to help you with daily tasks.

Despite the sudden onset and intense pain, gout attacks usually peak and resolve within a week or 10 days and then disappear completely. The first 36 hours are typically the worst. However, it’s important that once you have an attack, you begin working with your doctor to control uric acid levels and prevent future gout attacks.

Medications for Treating An Acute Gout Attack

Here are the medications used to treat an acute gout attack.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are frequently used to quickly relieve the pain and swelling of an acute gout episode and can shorten the attack, especially if taken in the first 24 hours.

Corticosteroids

Corticosteroids (such as prednisone) can be taken by mouth or injected into an inflamed joint to relieve the pain and swelling of an acute gout attack. They can also be injected systemically if the attack doesn’t respond to other medications or if many joints are affected. Injection of adrenocorticotropic hormone (ACTH), a synthetic drug that stimulates the body to produce corticosteroids naturally, can help treat a gout attack. Corticosteroids and ACTH usually start working within 24 hours after you begin taking them. 

Cochicine

Colchicine is derived from a plant that has been used to treat gout for more than 2,000 years. It helps to relieve the pain and swelling of acute attacks. Colchicine’s most common side effects are diarrhea, nausea and abdominal cramp, but more severe side attacks can occur. Like all gout medications, it has been shown to be most effective if taken at the first signs of a gout attack.

Reducing Uric Acid Levels

Medications that lower uric acid are intended to prevent gout attacks and keep the condition from becoming chronic. Your doctor will wait until your most recent gout attack is over before starting these medications, because taking them during an attack can worsen or prolong it. Taking these medications can be challenging – as uric acid levels drop, crystals in your joints may shift, triggering another attack. However, sticking with your treatment plan is the best way to prevent future attacks. Your doctor may prescribe an anti-inflammatory medication such as a low, but regular dose of colchicine or an NSAID, along with one of the medications below for the first six weeks to 12 months to prevent attacks.

Allopurinol reduces the production of uric acid. It is often prescribed at a low daily dose at first, with the dose gradually increasing over time. Occasional side effects include skin rash and stomach upset. Stomach problems usually go away as your body adjusts to the drug. In rare cases, allopurinol can cause a severe allergic reaction.

Febuxostat may be an option if you develop side effects from allopurinol or have kidney disease. Like allopurinol, febuxostat decreases the amount of uric acid made in the body. It’s also started at a lower dose, which may be increased if uric acid levels remain high. Side effects can include nausea and joint or muscle pain.

Probenecid acts on the kidneys to help the body eliminate uric acid. The medication is taken daily and may be combined with antibiotics to boost effectiveness. Common side effects include kidney stones, nausea, skin rash, stomach upset and headaches.

Pegloticase is used when standard medications are unable to lower the uric acid level, a condition known as refractory chronic gout. Pegloticase reduces uric acid quickly and to lower levels than other medications. The drug is administered every two weeks by intravenous (IV) infusion. Side effects can include infusion reactions, gout flares, nausea, bruising, sore throat, constipation, chest pain and vomiting.

One of the best ways to take care of your health if you have gout is to take a proactive role in your own treatment – a process called self-management.

Here are some lifestyles changes you can make to help you manage gout.

Gout Self Care

Adopting healthy lifestyle habits is a key part of an effective gout treatment plan. Eating a healthy diet, engaging in regular physical activity and losing weight if needed can lower your risk of repeated gout attacks, as well as the chances of developing heart disease, which is common in people with gout.

Diet

Developing a lifelong eating strategy that focuses on following a heart-healthy diet should be the goal for people with gout. This diet includes all the food groups, especially vegetables, whole grains, plant proteins such as nuts and legumes, and low-fait dairy. Refined carbohydrates and processed foods should be kept to a minimum.

The following foods either lower uric acid levels or are good for the heart:

• Skim milk and other low fat dairy products
• Whole grain foods
• Plant oils (olive, canola, sunflower)
• All vegetables
• Some fruits (those that are less sweet)
• Vitamin C supplements (500 to 1,000 milligrams daily)
• Coffee – if you already drink it
• Water

The following foods are high in purines, or are known to trigger gout attacks:

• Red meat and organ means (liver, tongue and sweetbreads)
• Shellfish such as shrimp and lobster
• Sugary beverages
• Excessive alcohol (more than one alcoholic drink for women and two for men within 24 hours)

Physical Activity and Weight Management

Reaching and maintaining a proper weight is an important part of managing gout. Not only does losing weight help reduce the uric acid in the blood, it can lessen the risk of heart disease or stroke, both common in people who have gout. Being physically active is an important part of managing weight. But getting started on losing weight or being active isn’t always easy. A doctor can help patients set realistic goals and choose appropriate exercise.