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Gout

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Basics of gout

Gout is a disease that causes sudden severe episodes of pain and tenderness, redness, warmth and swelling (inflammation) in some joints.

Gout is a dramatic example of a type of arthritis called crystal arthritis, sometimes called microcrystalline arthritis because the crystals are very small. The crystals form in the joint space. As the body tries to remove the crystals, a painful inflammation occurs.

It usually affects one joint at a time–often the large joint of the big toe. It also can affect other joints such as the knee, ankle, foot, hand, wrist and elbow. In rare cases, it may later affect the shoulders, hips or spine.

Facts and myths

Gout once was mistakenly thought to be a disease of the wealthy because it seemed to be caused by eating rich foods and by drinking too much alcohol. Although diet and excessive drinking do have something to do with gout, they are not the main cause of the disorder.

Prognosis

Gout affects everyone differently. Some people have one episode and never have any other problems with it. Others have several episodes along with lasting joint pain and damage.

There is no cure for gout, but it can be controlled quite well with medication. Proper treatment can help you entirely avoid attacks and long-term joint damage.

Incidence

Gout affects more than one million Americans from all walks of life. It can occur at any age but the first attack often affects men between the ages of 40 and 50.

Gout affects women as well. In fact, the number of postmenopausal women who have gout is increasing. However, it sometimes is difficult to diagnose gout in these women because they also may have osteoarthritis, a disease that causes the breakdown of joint tissue leading to joint pain and stiffness. Among the affected joints are finger joints, the joint at the base of the thumb and the joint at the base of the big toe. The confusion occurs because urate (the salt of uric acid) crystals tend to deposit in areas where osteoarthritis already has caused joint damage such as in the hands and feet.

Symptoms

Attacks of gout usually develop very quickly. The first attack often occurs at night. You may go to bed feeling fine but then wake up in the middle of the night with extreme joint pain.

During an episode you may notice:

  • sudden, severe joint pain
  • joint swelling
  • shiny red or purple skin around the joint
  • extreme tenderness in the joint area–the area may be so tender that even the touch of a bed sheet may cause severe pain.

An episode of gout can be triggered by:

  • drinking too much alcohol
  • eating too much of the wrong foods
  • surgery
  • a sudden severe illness
  • crash diets
  • injury to a joint
  • chemotherapy

Progression

At first episodes usually are few and far between. They last only a week or so and then everything seems to go back to normal with no symptoms between episodes. If the disease is not controlled by medication, attacks may occur more often and may last longer. Repeated episodes can damage the affected joint(s). If your joints have been damaged, you may have joint stiffness and limited motion after an attack.

Gout generally occurs in three phases:

  1. A sudden onset of joint pain and swelling (often in the big toe) that goes away after five to 10 days (or longer in some instances).
  2. A period of time when there are no symptoms at all, followed by other acute severe attacks.
  3. After a number of years, if not treated, the development of persistent swelling, stiffness and mild to moderate pain in one or more joints after numerous acute (generally severe but short-lived) episodes.

Causes

Figure 1 – Joint with gout versus a normal joint. Click to enlarge.

The pain and swelling of gout are caused by uric acid crystals that deposit in the joint. Uric acid is a substance that normally forms when the body breaks down waste products called purines. Uric acid usually is dissolved in the blood and passes through the kidneys into the urine. In people with gout, the uric acid level in the blood is so high that uric acid crystals are deposited in joints and other tissues. This causes the joint lining (the synovium) to become inflamed.

After several years, the uric acid crystals can build up in the joint(s) and surrounding tissues. They form large deposits called tophi that look like lumps just under the skin. Tophi often are found in or near severely affected joints on or near the elbow, over the fingers and toes and in the outer edge of the ear. If the tophi are not prevented or treated, they can damage joints (see figure 1).

Uric acid crystals can form stones in the kidneys, in the ureters (tubes connecting the kidneys and bladder) or in the bladder itself. Several factors may cause the formation of these deposits. For example, the deposits may be caused by not drinking enough liquids. Because of this lack of fluid, the urine is unable to dissolve all the uric acid. Deposits also may form as a result of metabolic abnormalities such as the body’s inability to make urine-less acid. In other instances, diet may be the culprit. With some people, a diet rich in foods that further increases the production of uric acid may increase their chances of developing kidney stones. If your doctor suspects that diet is a contributing factor, you may be asked to collect several urine samples. Tests then will be conducted to determine the amount of uric acid your body produces. These tests are particularly helpful because some people with gout produce and eliminate a large amount of uric acid. These people may be more likely to develop kidney stones. People with gout also may have high blood pressure or kidney infections. Since these problems can cause kidney damage, your doctor will check for signs of these problems and treat them if they occur.

Almost all people with gout have too much uric acid in their blood, a condition called hyperuricemia. However, there are many people who have hyperuricemia but not gout. Hyperuricemia is caused by one or both of the following:

  • The kidneys can’t get rid of uric acid fast enough.
  • The body makes too much uric acid.

Hyperuricemia often is caused by using diuretic medications (“water pills”). Diuretics are used to get rid of excess body fluid and to lower high blood pressure. However, diuretics can hamper the kidneys’ ability to remove uric acid, thus raising uric acid levels in the blood.

Other factors such as inherited traits and environmental factors (such as weight, alcohol use and diet) also can play an important role in causing gout.

Diagnosis

To diagnose gout, your doctor will examine you and ask you to describe your symptoms. Your doctor may take blood tests to measure the amount of uric acid in your blood. Remember: A high level of uric acid in your blood doesn’t necessarily mean you have gout nor does a normal level mean you don’t have gout.

Your doctor may check for other types of arthritis such as CPPD deposition disease and infectious arthritis. These conditions resemble gout but are not caused by uric acid crystals. To determine which type of arthritis you might have, your doctor may have to remove fluid from an affected joint and examine it for crystals.

Treatment

Treatment for gout mainly consists of taking medication(s) and watching your diet.

The goals of treatment are to relieve pain, shorten the duration of inflammation during an acute attack, prevent future attacks and prevent joint damage.

Diet

There are many myths about diet and gout. Here are the facts:

  1. Obesity can be linked to high uric acid levels in the blood. If you are overweight, work with your doctor to develop a weight-loss program. Don’t fast or try to diet too severely because that can raise your uric acid level and make the gout worse. If you are not overweight, watch your diet carefully so you don’t become overweight.
  2. Usually, you can eat what you like within limits. If you have kidney stones due to uric acid, you may need to avoid or limit foods that raise your uric acid level such as those listed below. Talk to your doctor about what foods you may have to avoid.

You may need to completely avoid these foods which may raise uric acid levels:

  • Brains
  • Kidney
  • Broths, gravies
  • Sardines, anchovies
  • Liver
  • Sweetbreads

You can drink coffee and tea. However, talk to your doctor about drinking alcohol. Too much alcohol may raise your uric acid level and bring on a gout episode. Drink at least 10-12 eight-ounce glasses of non-alcoholic fluids daily, especially if you have had kidney stones. This will help flush the uric acid crystals out of your body.

Medications

Using medications for gout can be complicated. The treatment needs to be tailored for each person and may have to be changed from time to time. People who have hyperuricemia, but no other problems, usually do not require medications.

Medications are used to:

  • Relieve the pain and swelling of an acute attack–these medications include nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, corticosteroid drugs and/or adrenocorticotropic hormone (ACTH).
  • Prevent future episodes–these medications include colchicine, probenecid, sulfinpyrazone and allopurinol.
  • Prevent or treat tophi–these medications include probenecid, sulfinpyrazone and allopurinol.
  • Prevent uric acid kidney stones (with allopurinol).

All of these drugs are powerful so you need to understand why you are taking them, what side effects may occur and what to do if you have any problems.

Medications to treat acute attacks

Colchicine has been used to treat gout for over 2,400 years. It relieves the pain and swelling of acute attacks. It usually is taken by mouth in several small doses every day. It works best if taken during the first two days of an attack. When taken by mouth, colchicine can cause diarrhea, nausea and abdominal cramps. If side effects occur, stop taking the drug and notify your doctor. To prevent future episodes, you may have to continue taking a small dose of colchicine after the attack has cleared.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are sometimes used to relieve the pain and swelling of an acute attack. They usually begin working within 24 hours after you start taking them. These medications are as effective as colchicine but may have less frequent side effects. However, side effects from NSAIDs may include stomach upset, headache, skin rashes and sometimes ulcers.

Doctors teach many people with gout how to begin treatment on their own. When a gout episode begins, call your doctor and begin taking your medication. Your doctor may suggest that you keep a supply of medication on hand to take at the first sign of trouble.

Medications that control uric acid levels

The medications listed below are used to treat or prevent tophi and to prevent future gout episodes. (In addition, allopurinol is used to prevent kidney stone formation.) However, these medications do not relieve the pain and inflammation of an acute attack. These medicines start working slowly over many months. They may cause you to have more gout episodes when you first start taking them, so you may have to take colchicine or an NSAID at the same time for the first three to six months to prevent such attacks. Many people with gout do not require these medicines. If you must take them, however, you’ll probably have to do so for the rest of your life in order to prevent future problems.

Allopurinol (Lopurin, Zurinol, Zyloprim) reduces the amount of uric acid in your blood and urine by slowing the rate at which the body makes uric acid. It is the best medicine for people who have kidney problems or kidney stones caused by uric acid.

Occasional side effects include skin rash and stomach upset. Stomach problems usually go away as your body adjusts to the drug. In rare cases, this drug can cause a severe allergic reaction. If you have a skin rash along with hives, itching, fever, nausea or muscle pain, contact your doctor right away. This drug also may make some people drowsy or less alert. Make sure you know how you react to this medicine before you drive or operate machinery.

Some drugs lower the uric acid level in your blood by increasing the amount of uric acid passed in your urine. They help dissolve tophi and prevent uric acid deposits in joints. The drugs commonly used to lower uric acid levels in gout are probenecid (Benemid, Parbenem, Probalan) and sulfinpyrazone (Anturane). They usually are taken by mouth on a daily basis. Your doctor will adjust the amount of medication you take based on your blood uric acid level. When a normal level of uric acid is reached, no more crystals will be deposited in your joint(s). Those already present will start dissolving.

Common side effects include nausea, skin rash, stomach upset or headaches.

While the skin rash sometimes can be serious, other side effects usually are not serious and may go away as your body gets used to the medicine. If any side effects continue to bother you, contact your doctor.

Take these medications with plenty of liquids. Do not take aspirin with these drugs because it blocks their effects on the kidneys. Read the labels of any prescription or over-the-counter medicines you take to be sure they don’t contain aspirin.

Tips for taking Probenecid, Sulfinpyrazone or Allopurinol

At first, probenecid or sulfinpyrazone may increase your risk for kidney stones by increasing the uric acid content of the urine. To prevent this problem, keep your urine diluted by drinking 10-12 eight ounce glasses of fluid every day.

Probenecid, sulfinpyrazone and allopurinol also may cause you to have more frequent gout episodes at first. During this time, you may have to take colchicine or an NSAID for the first three to six months to prevent an episode.

Take your medicine exactly as your doctor instructs. In order to be effective, these medicines must be taken continuously. This will help your body get rid of excess uric acid and will keep the uric acid level from rising again.

Do not take double doses of your medicine. If you forget to take a dose, take it as soon as possible. However, if it is almost time for your next dose, skip the dose you missed.

Talk with your doctor about all the drugs you’re taking. This includes over-the-counter drugs such as aspirin or diuretics. Some of the gout medications will not work properly if you are taking other drugs at the same time. Don’t start any new drugs without being sure they will work properly with the ones you’re already taking. The amount of medications you take will depend upon your symptoms and laboratory test results. You may only need to take one drug. On the other hand, it may be necessary to take a combination of the drugs listed here. Not all people with gout require these drugs. Whether you take these drugs depends on your doctor’s judgment and your willingness to make a lifelong commitment to taking daily medications.

Surgery

Surgery is rarely used to treat gout. If you have large tophi that are draining, infected or are interfering with the movement of your joints, you and your doctor may decide to have them surgically removed. There are several kinds of operations that can be done to relieve pain and improve the function of the affected joints.

Credits

Some of this material may also be available in an Arthritis Foundation brochure.

Adapted from the pamphlet originally prepared for the Arthritis Foundation by Louis A. Healey, Jr., M.D. and Herbert S. Diamond, M.D. This material is protected by copyright.

Gout

  • Overview
  • Overview of gout
    • What is gout?
    • Causes of gout
  • Discovery and diagnosis
    • First symptoms and attacks of gout
    • Tests and diagnosis of gout
    • Feelings about the diagnosis of gout
  • Treatment & Self-management
    • Treating the pain and inflammation of attacks
    • Long-term treatment to lower uric acid and prevent gout attacks and long-term problems
    • Practical tips for gout
    • Diet and self-management for gout
    • Monitoring gout
    • Decisions and feelings about gout treatments
    • Side effects of gout medication
    • Living with gout and other conditions
  • Living with gout
    • Everyday life with gout
    • Gout: age and experience
    • Gender and gout
    • Pain and ongoing symptoms from gout
    • Gout: mobility and footwear
    • Gout: leisure and social activities
    • Impact of gout on family, friends and relationships
    • Gout: work and finances
    • Thoughts about the future and long-term effects of gout
  • Support and information
    • Finding information on gout
    • Gout: experiences with health professionals
    • Sources of support for gout
    • Historical perceptions and myths about gout
  • Messages to others
    • Messages for other people with gout
    • Messages about gout for health professionals
  • People’s Profiles
    • Men aged 50 or under at first attack
    • Men aged 51 or over at first attack
    • Women aged 50 or under at first attack
    • Women aged 51 or over at first attack
    • A doctor speaks – gout

  • Resources and Information
  • Credits
  • 10 Questions About Managing Gout

    Gout is a disease that can flare without warning. Asking your doctor these 10 questions can help you better manage the condition.

    Why do I have gout?

    Gout is caused by deposits of sharp, needle-like crystals of uric acid in the joints that create inflammation, redness, and heat around the joint, along with extreme pain. Uric acid comes from two main sources: internally from the destruction of old or damaged body cells and externally from foods, such as red meat and seafood, that contain a lot of a substance called purines.

    A number of factors can increase your chances of getting gout, including genetics, gender, age, weight, and medical conditions, including hypertension. Some medications, like diuretics, can also cause gouts.

    Your doctor may feel that some combination of these factors has put you at high risk, or that your diet has contributed to the problem.

    What other medical conditions are linked to gout?

    High uric acid levels are linked to hypertension, diabetes, high cholesterol levels, and obesity. Treating these conditions may improve gout.

    How long will a gout attack last and how often will I get one?

    An acute gout attack may last from three to 10 days, with or without medication. Some people have only one attack in their lifetime, but without treatment or a drastic change in your diet and risk factors, attacks may eventually happen several times a year.

    What are my gout medication options?

    For an acute gout attack, medications are given simply to reduce pain and inflammation; they do not affect uric acid levels. The options include non-steroidal anti-inflammatory drugs (NSAIDs), oral corticosteroids, and colchicine, depending on what is tolerated best. If only one joint is affected, a corticosteroid may be directly injected into the joint to reduce inflammation and pain.

    After the attack subsides, many (but not all) people will need ongoing treatment designed to keep uric acid levels in a normal range to prevent further attacks.

    “The guide to treating someone,” says Chaim Putterman, MD, chief of rheumatology at Albert Einstein College of Medicine, New York City, “is the number and severity of attacks.” This means you may not need long-term medication if you’ve only had one attack. Long-term treatment either lowers the body’s production of uric acid or speeds up its excretion. Either approach can level out uric acid concentrations in the body.

    Why do I have to continue to take my medication if my gout is better?

    There can be low-lying inflammation between attacks, and crystal deposits can increase in size and eventually become hard and damage the joint. The medications help prevent this. “It’s important to know that gout is a disease of uric acid, so you need to maintain low levels by taking medication every day,” says Dr. Putterman.

    Are there side effects to my gout medications?

    Medications for both acute gout attacks and long-term control of uric acid control can have side effects. Medications that abruptly change uric acid levels can actually bring on a gout attack (or make a current attack worse) while uric acid levels are fluctuating. For this reason, attempts to lower uric acid levels are often postponed until the painful, acute attack has subsided.

    NSAIDs can cause stomach irritation, and corticosteroids, when used short-term for a gout attack, can cause insomnia, stomach irritation, and difficulty controlling blood sugars in the person with diabetes. Colchicine (Colcrys), used primarily for acute attacks, tends to cause gastrointestinal side effects, particularly diarrhea. Because of possible side effects you should record all problems and work with your doctor to find the best medication regimen.

    I took medication a long time ago and it did nothing — does this mean nothing will work for me?

    “Some patients may have been taking medications years ago and had side effects, so they don’t go to their doctor because they think they have nothing to offer,” Putterman says. “This has changed because there are new gout medications.”

    Which medications can interfere with the ones I have to take for gout?

    Taking allopurinol (Zyloprim), which decreases uric acid levels, with certain other medications is dangerous, says Putterman. So you need to tell your doctor about everything you are taking, including supplements and over-the-counter drugs.

    Some diuretics can worsen gout and should be replaced with another medication. Some medications needed after an organ transplant or for cancer treatment can react adversely with gout-controlling therapy. Low-dose aspirin may lead to uric acid retention and high uric acid levels. However, high-dose aspirin may actually lower uric acid levels, but should never be taken without your doctor’s approval because of potential side effects.

    How should I change my diet?

    “Most of the uric acid we generate is endogenous — it doesn’t come from outside sources,” explains Putterman. This means that one of the main causes of gout (and flare-ups) is being overweight, as there are more cells to be broken down. Weight loss will decrease uric acid levels.

    Eating large amounts of certain foods containing high levels of purines, substances that are broken down to uric acid, can increase the chance of a gout attack. They include meat such as bacon, veal, and organ meats (often found in gravy, meat bouillon, and meat broth) and seafood such as haddock, trout, herring, and scallops.

    People who consume reasonably high levels of low-fat dairy products have been shown to have a lower number of gout attacks. Coffee consumption, both caffeinated and decaf, also seems to decrease the risk of gout attacks.

    There are many dietary supplements that claim to “cure” gout, yet “nothing that is sufficient for the patient with established gout has been found to completely eradicate this disorder,” says Putterman.

    Do I need to give up alcohol?

    There is a known link between gout attacks and alcohol, especially beer, which is high in the purines that cause increased uric acid levels. Putterman is aware that eliminating alcohol completely can be difficult for some patients and suggests moderation. It’s better to spread out intake over the course of your week rather than drink heavily on any given night, a scenario that’s more likely to cause a gout flare.

    There are a number of ways to help control gout. Work with your doctor to get the answers you need and explore all of your options for both lifestyle modifications and medications.

    Gout

    Lifestyle changes

    Certain lifestyle changes can also help reduce your risk of experiencing further attacks of gout, including:

    • avoiding foods containing high levels of purine (the chemical involved in the production of uric acid), such as red meat, offal, oily fish, seafood and foods containing yeast extract.
    • avoiding sugary drinks and snacks – these are associated with an increased risk of gout
    • maintaining a healthy weight – follow a balanced diet; don’t crash diet or try high-protein, low-carbohydrate diets
    • taking regular exercise – try activities that don’t put too much strain on your joints, such as swimming
    • drinking plenty of water – keeping yourself well hydrated will reduce the risk of crystals forming in your joints
    • cutting down on alcohol – avoid beer and spirits in particular and don’t binge drink

    There’s some evidence to suggest that taking regular vitamin C supplements can reduce gout attacks, although the effect may only be small. Talk to your GP first if you’re thinking about taking vitamin C supplements, as they aren’t suitable or safe for everyone.

    Gout

    What is gout?

    Gout is a form of arthritis that causes sudden, severe attacks of pain, tenderness, redness, warmth, and swelling (inflammation) in some joints. It often affects one joint at a time, but may affect a few or even many. The large toe is most often affected, but gout can also affect other joints in the leg (knee, ankle, foot) and less often in the arms (hand, wrist, and elbow). The spine is rarely affected.

    How frequent are gout attacks?

    In the initial period, gout attacks may occur rarely, such as once or few times every several years. Later these can becomes more frequent and may occur several times a year.

    Gout attacks can recur from time to time in the same or different joints.

    The initial attack may last up to one week, and at times up two weeks unless it is treated.

    Over time, gout attacks may occur more often, involve more joints, have more severe symptoms, and last longer. Repeated attacks can damage the joint. Lumpy collections of uric acid called tophi can develop near joints, in the skin, or erode into the bones.

    Who is affected by gout?

    Gout affects more than one million Americans, including:

    • Men of all ages (may start in young men) and postmenopausal women
    • People who are overweight
    • People who frequently drink alcohol
    • People whose diet is rich in organ meats, shellfish, and animal meats

    When gout affects women, it is usually after menopause. Younger patients may be affected by gout if they have been taking certain medicines for long periods of time, are transplant patients, frequently drink alcoholic beverages, have chronic kidney disease, or have certain genetic disorders.

    What causes gout?

    Gout results from excessive amount of uric acid in the body that leads to an abnormal deposit of uric acid crystals (also known as monosodium urate crystals) in the joints and soft tissue. The collection of uric acid in the soft tissue leading to a lump is called tophus (tophi for multiple lumps). Uric acid crystals can also form in the kidney, causing kidney stones.

    Monosodium urate is formed from uric acid, a natural chemical in the body. Uric acid comes from the natural breakdown of RNA and DNA (the genetic material in cells). Alcohol and certain foods contain large amounts of uric acid, especially red meats and internal organs (such as liver and kidneys), some shellfish, and anchovies. However, most meats contain uric acid. Patients who eat more meat and fish (and less dairy) or drink more beer and liquor are more prone to gout. A family history of gout may be a risk factor for developing gout, but is not the case in all patients. Certain medications can increase the risk for gout, such as diuretics. Avoiding alcohol and consuming a diet low in animal meats and higher in vegetables and fruits has been shown to help reduce the level of uric acid in the blood and the likelihood of developing gout attacks. Insuring adequate hydration with water and maintaining normal kidney function is important.

    Uric acid in low amounts remains dissolved in the blood, and would be less likely to lead to a gout attack. Uric acid in high amounts (higher than 6.8 mg/dL) can lead to crystals that could deposit in joints and make a person more likely to develop gout.

    The level of uric acid in your blood can change depending on:

    • The kidney function (the lower the kidney function, the higher the urate levels)
    • What you eat
    • How much alcohol you drink
    • What medicines you are taking
    • How much water you drink (hydration)
    • Your weight and metabolic risk factors

    The above mentioned are considered modifiable risk factors.

    Not everyone with high levels of uric acid will develop gout. Having a strong family history of gout may increase one’s risk for gout, but this does not mean that everyone with a family history of gout will have the disorder. Often, the effect of heredity is modified by the risk factors mentioned above that affect uric acid, as well as male sex and age.

    What are the symptoms of gout?

    • Sudden, intense joint pain, which often first occurs in the early morning hours
    • Swollen, tender joint that is warm to the touch

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