What is Gout?
Gout is a complex form of arthritis. It leads to sudden, painful attacks of swelling, stiffness and tenderness in a joint or joints (usually in the big toe). If left untreated, gout will recur, and can lead to joint, tissue and tendon damage.
Gout often suddenly shows up as a very painful, swollen, red and tender joint. This is usually the large joint of the big toe, but can also happen elsewhere in the feet, knees, ankles, hands and wrists. Affected joints experience a limited range of motion.
The pain is the worst in the first 4 to 12 hours after an attack. Discomfort in the affected joint can last for days to weeks after the initial pain subsides. Severe attacks can lead to discomfort for up to a month. Skin around the joint can peel and itch as it recovers. For recurring attacks, more joints may be affected, with pain lasting longer.
Gout is caused by the accumulation of urate crystals in a joint, which causes inflammation and pain. Urate crystals form when there are high uric acid levels in the blood. High uric acid levels are usually caused either by the increased production of uric acid by the body’s metabolism, or by the decreased removal of uric acid by the kidneys.
Uric acid is produced by the body’s breakdown of chemicals called purines, which naturally occur in the body, and are also found in foods including meats and seafood. Consumption of beverages including alcohol and fruit juices high in fructose (fruit sugar) also increases levels of uric acid in the blood.
Uric acid is usually cleared from the blood and into urine by the kidneys. If uric acid levels are too high, or the kidneys remove too little uric acid from the blood, uric acid build-up can occur. Urate crystals can then form, which are sharp and needle-like. These crystals cause pain, swelling and inflammation in joints and nearby tissues.
The risk of developing gout depends on the levels of uric acid in the blood. Anything that increases uric acid levels also increases the risk of gout. Some factors include:
- Family history: If immediate family members have had gout, you are at a higher risk to have it yourself
- Sex and age: Men are more likely to develop gout because they tend to have higher uric acid levels. They also develop it earlier than women, often between 30 and 50 years of age. Women tend to develop gout after menopause, when uric acid levels rise to around those of men.
- Medical history: Having conditions and diseases such as high blood pressure, metabolic syndrome, heart disease, diabetes and kidney disease increases the chances of getting gout.
- Medications: Medications such as regular use of low-dose aspirin or niacin (which can increase uric acid levels in the blood), thiazide diuretics (which reduce the amount of water and salt in the body), and anti-rejection drugs for organ transplants (eg. cyclosporine) can increase uric acid levels.
- Diet: High consumption of meat and seafood, drinks high in fruit sugar, and alcohol (especially beer because it is high in purines), increases the risk of getting gout. Alcohol reduces the amount of uric acid removed by the kidneys. Constant dehydration and/or rapid weight loss due to a sudden change to a low-calorie diet can also lead to gout due to increased uric acid.
- Weight: Being obese leads to higher levels of uric acid in the blood, as well as a decreased ability of the kidneys to remove uric acid from the blood.
- Recent surgery or trauma has also been shown to increase the risk of gout.
- Rare conditions where there is a reduction or complete lack of an enzyme that is important for controlling uric acid levels, including Kelley-Seegmiller and Lesch-Nyhan syndromes, cause gout.
Gout can lead to more severe complications, including:
- Kidney stones: If urate crystals collect in the urinary tract, kidney stones can form.
- Recurrent gout: Gout may recur in some people several times a year. Medications can be taken to reduce the number of attacks.
- Advanced gout: If gout is left untreated, urate crystal deposits called tophi can form under the skin in fingers, elbows, hands, feet, and back of the ankles along the Achilles tendon. Tophi are not painful themselves, but during a gout attack, can become tender and/or swollen.
Gout can be diagnosed in several ways, including:
- Joint fluid test – Fluid from the joint can be extracted with a needle to be examined under a microscope for urate crystals. This is the only way to get a certain diagnosis of gout.
- Blood test – A blood test can be used to measure uric acid levels if it is hard to acquire fluid from the joint. Similarly, uric acid in the urine can be measured. It is important to note that high uric acid levels do not necessarily mean that gout will occur or has occurred, and low uric acid levels do not necessarily mean that gout will not occur.
- X-ray imaging – X-rays of the affected joint can determine if inflammation is caused by a different condition.
- Ultrasound – An ultrasound of the joint can detect urate crystals or tophi.
- CT scan – CT imaging can also detect urate crystals.
Home treatments for an acute attack include:
- Resting the affected joints 24 hours after onset
- Keeping affected joints elevated
- Icing affected joints to reduce swelling
There are several medications for the treatment of gout. They can be used to treat acute symptoms (pain and inflammation), prevent attacks in the future, or prevent long-term effects such as the formation of tophi, joint damage and kidney damage.
To treat acute attacks and prevent future ones, medications include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs) lower inflammation. Over-the-counter options include ibuprofen (eg. Advil), and naproxen sodium (eg. Aleve). Prescription options that are more powerful include celecoxib (Celebrex), indomethacin (Indocin), and others. A higher dose of NSAIDs can be used to treat acute attacks while lower daily doses can be used to prevent attacks in the future.
- Colchicine (eg. Colcrys) is prescribed for pain relief. A low daily dose can also be used for prevention of future attacks.
- Corticosteroids (eg. prednisone) helps to reduce pain and inflammation. They are either taken as a pill or injected directly in the joint.
Medications are also available to prevent complications from gout, including having frequent attacks or especially painful attacks. These kinds of medications include
- Xanthine oxidase inhibitors that reduce the production of uric acid by the body, thereby reducing the risk of gout. They include allopurinol (eg. Aloprim) and febuxostat (eg. Uloric). They can also shrink tophi.
- Uricosuric agents are drugs (eg. Probalan) that increase the amount of uric acid that the kidney removes from the bloodstream. However, while uric acid levels in the blood are lowered, uric acid levels in urine are increased, which means that the drugs can cause kidney stones, stomach pain and rash.
- Pegloticase (known as Krystexxa) is used to treat severe and chronic gout. It is an enzyme that is injected and can break down uric acid in the blood.
Changes in lifestyle can also reduce the risk of experiencing a gout attack, including:
- Regular exercise
- Maintaining a healthy weight
- Limiting consumption of meats and seafood that are high in purines
- Limiting consumption of beer, red wine, and other alcohol drinks
- Limiting consumption of drinks with high fruit sugar content
Written By: Anna Zhou