Understanding Gout

For centuries Gout has been inaccurately portrayed as the “disease of kings,” because gout has long been associated with the kind of overindulgence in food and wine that only the rich and powerful could afford. But the fact is that anyone can be affected by gout and the risk factors are varied. Fortunately, it is possible to treat gout and reduce its agonizing attacks by avoiding food triggers and taking advantage of the medication options available today.

What is gout?

Gout is a painful, progressive and potentially debilitating form of arthritis that has been recognized since ancient times. Gout attacks cause a sudden onset severe joint pain that is often accompanied by other signs and symptoms of inflammation including redness, swelling, and tenderness of the joint. The initial attack may begin in the middle of the night with extreme pain and inflammation reaching its peak within 12 hours. The initial attack generally resolves over about a week and then disappears completely, even if untreated.

Although an attack typically affects a single joint most often in the cooler regions of the body, like the big toe for example, some people develop a few inflamed joints at the same time. Other joints commonly involved include the ankles, knees, and less commonly the hands and elbows. Gout can affect people differently. Some people have only one attack, and never experience another. Other people however experience gradually progressive attacks, which can lead to joint damage.

People who have repeated attacks of gout over many years can develop tophaceous gout. This causes large numbers of uric acid crystals to collect in joints, bones, and cartilage. This collection of crystals causes a nodule or tophus to form. The tophus causes resorption and erosion of the bone, and can potentially cause deformity. The presence of tophi near the knuckles or small joints of the fingers can be a distressing cosmetic problem. Tophi are usually not painful or tender. However, they can become inflamed and cause symptoms like those of an acute gouty attack. Tophaceous gout was more common in the past, when treatment for hyperuricemia was unavailable.

People with gout are at increased risk of developing kidney stones. Uric acid crystals can collect in the urinary tract and form a stone. Rarely, uric acid crystals collect in the kidney itself causing inflammation and scar tissue, which can reduce kidney function.

Treatments are now available to control most cases of gout, but diagnosing this disorder can be difficult and treatment plans often have to be tailored for each person.

What causes gout?

Gout is caused by elevated uric acid levels in the blood, called hyperuricemia; up to two-thirds of individuals with hyperuricemia never develop symptoms. It remains unclear why some people with hyperuricemia develop gout while others do not.

Gout occurs when excess uric acid, a normal waste product, accumulates in the body as crystals and deposit in the tissues and joints. This happens most frequently because the kidneys are unable to sufficiently remove uric acid from the body through the urine or less commonly because uric acid production increases. Certain foods, such as meat, shellfish and alcohol, may increase uric acid levels and lead to gout attacks.

Some medications also can increase uric acid levels. Examples of such medications include low to moderate-dose aspirin, diuretics, and immunosuppressants used in organ transplantation such as cyclosporine. With time, increased uric acid levels in the blood may lead to deposits of monosodium urate crystals in and around the joints. These crystals can attract white blood cells, leading to severe gout attacks. Uric acid also can deposit in the urinary tract, causing decreased renal function and even kidney stones.

Who gets gout?

Gout affects approximately 2 percent of people in the United States. Although gout can occur at any age, its onset occurs most commonly in men after age 30, and in women after menopause. Gout is strongly associated with obesity, hypertension, hyperlipidemia, diabetes and renal disease. Because of genetic factors, gout tends to run in some families.

How is gout diagnosed?

Several other kinds of arthritis can mimic gout, so proper diagnosis is essential. Gout is strongly suspected if a person has an acute attack of joint pain, followed by a period when there are no symptoms. It is important to confirm the diagnosis of gout to ensure that potentially harmful medications are not taken unnecessarily over a prolonged period of time.

A correct diagnosis may depend on finding the characteristic monosodium urate crystals when performing a synovial fluid analysis from the fluid of an affected joint. Tophi located just beneath the skin can also be sampled with a needle to diagnose tophaceous gout. However, some people do not have uric acid crystals in their synovial fluid when symptoms are present. In this case, the clinical diagnosis is based upon a person’s symptoms and a physical examination.

An important note to keep in mind is that uric acid levels in the blood can be misleading, as these may be temporarily normal or even low during attacks. Uric acid levels also are often elevated in people who do not have gout.

How is gout treated?

The goal of treating flares of gouty arthritis is to reduce pain and inflammation quickly and safely, and then to prevent further attacks and joint damage. It may be necessary to use more than one drug to achieve this goal. Deciding which medication to use is based upon several factors, including the person’s general health and medical history. Anti-inflammatory medications are the best treatment for acute gout attacks, and are best started early in the course of an attack.

Traditional treatment for acute gout has consisted of nonsteroidal anti-inflammatory drugs, or NSAIDs, that work to reduce pain, swelling, and inflammation in the joints and tissues. NSAIDs— such as indomethacin and naproxen— have become the treatment choice for most acute attacks of gout. There is no evidence that any one NSAID is better than others. Although aspirin is an NSAID, it is not usually recommended for the treatment of gout because of it’s potential impact on uric acid levels in the blood. Some people are unable to take NSAIDS because of medical conditions such as ulcer disease, impaired kidney function or the use of blood thinners. These medications are most effective in the treatment of a gout attack when they are started as soon as possible, before the attack is full blown.

Colchicine may be prescribed instead of a nonsteroidal antiinflammatory drug. Colchicine unlike the nonsteroidal antiinflammatory drugs, does not increase the risk of ulcers, has no known interaction with anticoagulants, and in proper doses does not affect kidney function. However, colchicine can have significant gastrointestinal side effects, including abdominal cramps, nausea, vomiting, and diarrhea. If side effects occur, stop taking the medicine and call your doctor promptly. For this reason, colchicine is generally reserved for patients who cannot tolerate nonsteroidal antiinflammatory drugs, or it is used at low doses as prophylactic therapy.

Corticosteroids are the most effective anti-inflammatory agents. The most commonly used oral steroids include prednisone, and methylprednisolone. Steroids may be used if nonsteroidal antiinflammatory drugs and colchicine cannot be used. They may be given orally, by intramuscular injection or directly injected into the affected joint.

Prophylactic therapy aims to prevent or reduce the occurrence of acute flares of gouty arthritis. Colchicine is usually recommended as prophylactic therapy. Colchicine, which is taken daily at low doses to avoid gastrointestinal side effects, reduces the frequency of acute gout attacks, particularly while starting other medications that lower uric acid levels.

Prophylactic colchicine is a helpful bridge as a person progresses from an acute flare to preventive therapy.

Preventive therapy includes medications and dietary changes that can be used long-term to lower uric acid levels and prevents the progression of gout. These medications do not relieve the pain and inflammation of an acute attack. Not everyone with gout will require preventive therapy; those who have rare or mild attacks are often able to manage their gout by treating the acute attacks alone. On the other hand, people with sporadic gout flares that are unusually prolonged, painful, and/or disabling are often encouraged to take preventive therapy.

Uric acid-lowering medications lower uric acid levels by improving excretion or decreasing production of uric acid. This therapy is usually started after a gout attack has resolved. People who take their medication regularly experience fewer attacks. At present, preventive therapy is continued indefinitely because there is no benefit to taking a break from medication.

Lowering uric acid levels is a process that can take weeks or months because rapidly lowering uric acid levels in the blood can cause acute flares of gout. Medications to lower uric acid should be started at a low dose and increased slowly until the blood uric acid level is reduced and maintained at a level where uric acid crystal formation is unlikely. Blood levels of uric acid are monitored periodically to ensure that the goal uric acid level is maintained. Once a commitment is made to use any agents to lower uric acid levels, therapy should be increased gradually until levels are less than 6 mg/dl at which point crystals can be dissolved.

Allopurinol works by preventing the formation of uric acid. It is the most commonly used drug for lowering uric acid levels in gout. It is the best medication for most people who have gout and need to have uric acid controlled by medication. Allopurinol can cause side effects including skin rash, fatigue and stomach upset, although these problems occur in a relatively small percentage of patients. In rare cases, allopurinol can cause a severe allergic reaction. If you have itching or a skin rash along with hives, fever, nausea or muscle pain, call your doctor promptly.

Probenecid is used to lower uric acid levels in the blood by increasing the amount of uric acid excreted into the urine by the kidneys. Probenecid is much less effective in people with kidney disease. Probenecid can cause side effects, including rash, stomach upset, headaches and kidney stone formation.

Lifestyle changes and dietary modifications

Lifestyle changes and dietary modifications may make it easier to manage this lifetime disease. In some patients, dietary modifications are helpful in reducing the frequency of gout attacks. Because obesity is a risk factor for gout, as well as for many other health conditions (heart disease, diabetes, and high blood pressure), losing weight is an important goal. However, “crash” or fad diets and fasting are not recommended.

Dietary guidelines for patients with gout have changed over the years. The current recommendations include reducing the intake of red meat and seafood, and reducing or eliminating the intake of beer and distilled spirits (“hard liquor”). High-fructose corn syrup products, (such as some types of non-diet soda) increase blood uric acid levels and are not recommended. Coffee may decrease the risk of gout. Vitamin C (500 mg/day) has a mild uric acid-lowering effect and may be recommended.

Changes in diet are often recommended along with medications, but the reduction in blood uric acid levels due to diet change alone is modest (15 to 20 percent), even with very strict diets.

In Conclusion

Gout can be controlled and even prevented if it is diagnosed correctly, appropriate medication is taken, and diet and lifestyle changes are followed. Co-existing medical conditions and other medications can complicate the treatment of gout. No two patients are exactly alike and recommendations can vary from one person to another. As experts in the treatment of arthritis, rheumatologists evaluate patients to determine whether gout is the cause of their arthritis, educate them about the role and proper use of medications as well as other treatment measures, and act as a resource to primary care physicians.

Thank you for taking the time to learn more about gout. Our team of Mayo Clinic trained and Board Certified Rheumatologists at the Arthritis Center of Nebraska are ready to serve you in your healthcare needs. We invite you to call 402-420-1212 for more information or to schedule an appointment.

Fast Facts

Intense painful swelling in the feet (and especially the big toe) may indicate gout.
Treatment options exist, but therapy should be individualized for each person.
Avoiding alcohol and certain fish and meats helps prevent further gout attacks.
Points to remember

Gout can be diagnosed accurately by identifying the characteristic crystals in the fluid in joints.
There are two types of treatment for gout: medications to control the attacks of joint pain such as NSAIDs, colchicine and corticosteroids, and medications that can lower the level of uric acid in the body over time so the attacks occur less frequently or not at all.
People with chronic gout often require lifetime treatment with drugs to lower uric acid levels.
Life style changes such as weight control, limiting alcohol consumption, and limiting meals with meats and fish rich in purines can also be helpful in controlling gout.

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About the Author

A Texan by birth, Dr. Rick Chatwell was born and raised in San Antonio. He graduated with Honors from what is now the University of the... Read more.