Diseases

Gout

Gout is the most common type of inflammatory arthritis. It is caused by a buildup of uric acid in the body and the formation of uric acid crystals in the joints.

When buildups of uric acid crystals are attacked by the body’s immune system, the affected joints become red, hot, swollen, and sore.

People with gout can have flares of extremely painful, warm, red and swollen joints. The big toe is the most common joint affected but other joints can be affected as well.

Managing Gout

The best way to manage gout is to keep levels of uric acid in a healthy range. Foods including meats, fish, seafood, alcohol, and sugary drinks increase uric acid levels in the body.

Who Gets Gout

Everybody makes uric acid but when the levels are too high it can lead to gout.

Gout is most likely to start in men in their 40s or 50s. Gout almost never occurs in women until they reach the menopause or if they have a kidney problem.

Gout often runs in families so it is likely that genetics play a role in the development of gout. Men who have family members affected by gout have a higher chance of having gout themselves. This usually involves a genetic problem with the kidneys and how they handle uric acid.

Gout is more common in people with kidney problems or those taking certain medications such as diuretics (water pills).

Understanding Gout

Symptoms

Sudden and Severe Pain in a Joint

Gout presents itself in the form of an attack (or flare) that usually happens very suddenly and often in the early hours of the morning.

It’s not uncommon for a person with gout to go to bed feeling fine, and then wake up with a joint that feels like it’s on fire.

In most cases only one joint is affected at first. The big toe is the most common joint to be affected in people with gout. Other likely targets are the ankle and knee.

Multiple Joint Involvement

Over time, more than one joint can become affected. Other joints commonly affected by gout include the ankle or foot and the knees. An attack on these joints can make it hard to walk or sleep.

When gout becomes severe, the wrists, elbows and fingers can be involved.

Tophi (Deposits of Hardened Uric Acid)

When uric acid levels remain too high for a long time, it can start to crystallize in other tissues and form deposits of hardened uric acid. These are called tophi (pronounced Toe-Fie).

Most often tophi develop over the elbows, on the backs of the hands, and in the finger pads. They can also be found on the tendons behind your ankles or on the outer edges of the ears. Tophi can be painful. If left untreated, tophi can rupture or cause damage to nearby tendons and bone.

Chronic Gout

Gout can be a serious, long-term (chronic) condition. Some people can still have mini-attacks where the joint stays swollen all of the time.

These “mini-attacks” aren’t as painful as full ones but affected joints can still feel very sore.

When uric acid levels stay high crystals continue to form causing the gout to “grumble” along. In the long run, this can cause damage to the joints and even destroy them.

Duration and Frequency of Flares

Gout flares usually go away after about 7 to 10 days of treatment. It might be several months or years before another flare happens.

If a person has had one attack of gout, chances are that they will eventually have others.

Diagnosis

Gout is often diagnosed by a primary care physician (family doctor). If there are questions a rheumatologist, a type of doctor that specializes in arthritis and autoimmune disease can be consulted.

To diagnose Gout, doctors will take a careful and complete history and perform a thorough physical examination. They will note if their patient has risk factors for gout, such as high blood pressure or diabetes, and which joints are affected. Gout often attacks only one joint in the toe, ankle, or knee.

Based on this information, the doctor will likely order tests like blood tests and might draw a sample of fluid from an affected joint to inspect.

It’s important for doctors to rule out other diseases that can sometimes look like gout.

Common Tests to Diagnose Gout

Joint Fluid Test

To look for crystals of uric acid: a needle is used to draw a sample ofthe fluid in an affected joint (the fluid in between joints is called synovial fluid). The fluid can be inspected under a microscope to look for uric acid crystals.

To rule out an infection: Sometimes gout can look like an infected joint. The fluid extracted from an affected joint can be cultured on a laboratory dish to see whether or not bacteria grow. It will only grow if the joint has an infection.

Blood Tests

Looking for high levels of uric acid in the blood: Patients with gout have high levels of uric acid in their blood. Uric acid levels can fall during an acute attack of gout which can make the diagnosis confusing. Some patients with high levels of uric acid don’t develop gout. The results of this test must be taken into context with a patient’s symptoms and the results of other tests.

Looking at kidney function: A blood test for creatinine test helps doctors assess kidney function. The results of this test is important to consider because the kidneys clear uric acid from the body.

Scans

Ultrasound: Musculoskeletal (MSK) ultrasound can show crystals of uric acid in a joint or identify tophi (hardened deposits of uric acid).

X-Rays: Can help rule out other types of arthritis and can sometimes see classic changes of chronic gout.

Causes

In gout, the body’s immune system attacks crystals of uric acid that have formed inside the joints, causing the affected joints to become red, hot, swollen and sore. These crystals form when the level of uric acid is too high.

How Uric Acid Builds Up

The body is constantly making uric acid and is also getting it from many types of food. In healthy people who don’t suffer from gout, their kidneys keep a steady level of uric acid in the blood by filtering excess amounts out and getting rid of it in urine.

If the kidneys can’t keep up, uric acid will start building up in the blood. If the level gets high enough, it will cross a point where it starts to form crystals. The crystals collect in the fluid inside joints.

The body’s immune system thinks the uric crystals are foreign invaders and attacks them, causing the pain and inflammation that gout is known for.

There are several reasons why the kidneys might not be able to get rid of excess uric acid fast enough. It can happen naturally as we get older. Other times people with healthy kidneys simply have a hard time getting rid of uric acid. This is likely genetic and can run in families. Other people have kidney diseases that reduce the function of the kidneys.

A person’s diet can influence if they get gout. Gout has been historically described as the “disease of kings” because it seemed to target wealthy nobility. That’s because a long time ago, it was correctly thought that gout was the result of eating a diet that was rich in meats and alcohol.

Animal foods and alcoholic beverages are a rich source of uric acid. Sweetened drinks (soft drinks, sodas, and fruit juices) containing high-fructose corn syrup can also play a role.

Certain medications can interfere with the kidneys’ ability to get rid of uric acid and can lead to gout. The most common example are “water pills” (diuretics), a type of medication that is often used to treat high blood pressure or lower leg swelling.

Risk Factors

Common risk factors that can increase a person’s chances of developing gout include: kidney problems, age, gender (male), high alcohol intake, excessive intake of sweetened drinks, diuretics (water pills), and a family history of gout.

Other associated diseases include high blood pressure, high cholesterol, diabetes or insulin resistance, thyroid disease, and obesity are also seen with gout.

Treatments

Gout should be treated in two ways. The first way is to treat any immediate painful attack (flare). The second way is to treat the big picture problem of too much uric acid in the body.

Addressing the problem off too much uric acid can help reduce the number of future attacks and their severity, and can minimize long-term damage to the joints and other tissues that can be caused by uric acid crystals.

Immediate Treatments for Attacks

Rest, Ice, Compression, and Elevation

A good way to start treating gout is using Rest, Ice, Compression, and Elevation. This is the same way athletes treat acute injuries like a sprained ankle. For example, if a foot is affected by a flare of gout, a patient should put it up on a chair with a pillow, apply a cold pack (if it’s not too cold or uncomfortable), and rest it.

Non-Steroidal Anti-Inflammatory Drugs

The most common medicines used to treat attacks of gout are Non-Steroidal Anti-Inflammatory Drugs. They tend to work really well as long as a person is taking enough of the right NSAID for the job.

The most used anti-inflammatory drug indomethacin. Other common anti-inflammatory drugs used for gout are Celebrex (celecoxib), Aleve (naproxen), ibuprofen (sold over-the-counter with the brand names Advil or Motrin), and Voltaren (diclofenac).

Non-Steroidal Anti-Inflammatory Drugs can increase blood pressure, affect the kidneys, and irritate the stomach, potentially causing ulcers, so it is always best to check with a doctor before taking them.

Colcrys (Colchicine)

An older but very effective therapy for gout is Colcrys (colchicine). This is a natural remedy that comes from a toxic flower called the meadow saffron (also known as the autumn crocus or naked lady).

Colcrys interferes with the body’s inflammatory response in a way that is beneficial to people suffering from a gout attack.

In older times, small amounts of this toxic plant was used to cleanse the bowels because it causes diarrhea. The same thing happens today to patients who take too much colchicine!

At most, people with gout typically tolerate 0.6 mg taken two to three times a day.

Prednisone (Oral)

The synthetic corticosteroid prednisone is a very effective treatment for gout.

High doses of prednisone taken for a week or two will often clear up gout attacks. One issue with this medication is it will raise blood sugar levels in people with diabetes.

Cortisone Injection

Joints can be injected with the natural steroid cortisone to quickly reduce inflammation.

This is a very effective remedy and is relatively low risk because it is a local therapy that is precisely focused on the affected joints.

Anakinra (Kineret)

A newer treatment for acute attacks of gout is Anakinra (Kineret). Anakinra is a biologic medication that blocks a molecule called Interleukin-1 and reduces the inflammations with gout.

It is typically given as a daily subcutaneous injection of 100 mg for three days.

Big-Picture Treatments to Reduce Attacks

Medications that Lower Uric Acid Levels

Zyloprim (allopurinol) and Uloric (febuxostat) are two good and very similar medications that treat gout by lowering the level of uric acid in the body. They work the same way on uric acid. The difference between them is that the body gets rid of allopurinol through the kidneys and febuxostat through the liver.

Starting or stopping one of these medicines can trigger an attack of gout. Patients who start taking one of these medications should never stop because of an attack – this will make things even worse. In such cases, patients should see their doctor to treat the new attack with different medications.

Over time, Allopurinol and Uloric will help prevent attacks of gout.

Maintaining Overall Health

Gout tends to happen in people who have other health problems. For example, gout is more common in people who have high blood pressure, high cholesterol, heart disease, diabetes and in those who are overweight or obese. Improving health is very likely to improve gout.

People with gout should strive to improve their overall health, and do everything they can to keep blood pressure and cholesterol at healthy levels. For people that also have diabetes, it is important to keep blood sugar under control. Smokers are urged to quit.

Diet Changes

People with gout can improve their condition by changing their diet to avoid or minimize foods and beverages that are known to significantly increase uric acid in the body.

Meats and animal products, fish, seafood, and alcoholic beverages (especially beer) are all known to increase uric acid levels, which make an attack of gout more likely to occur.

Sweetened drinks like soft drinks, sodas, and fruit juices can also play a role in gout, especially when they contain high-fructose corn syrup. These drinks make it harder for the kidneys to clear out excess uric acid.

Recent research has shown that all vegetables are absolutely fine and do not contribute to gout symptoms. In the old days, scientists used to think that vegetables high in a type of chemical called purines were harmful. We now know that plant purines won’t affect gout.

Attacks can also sometimes be triggered by dehydration and trauma. It’s important to stay well hydrated so the body has enough water to clear excess uric acid through urine.

Video

Watch Canadian rheumatologist Dr. Andy Thompson discuss Gout in this short video: