- What You Can Do
- Gout Complications and Related Conditions
- What Is the Definition of Tophaceous Gout?
- What Causes Tophaceous Gout and Tophi Deposits?
- Treatment for Tophaceous Gout and Tophi
- Treating Gout and Tophi With Surgery
- The Link Between Gout and Kidney Stones
- The Link Between Gout and Chronic Kidney Disease
- Gout: Joint pain and more
- Myths and realities
- The chemical culprit
- 8 Gout Complications You Need to Know About
- Common Gout Complications and Comorbidities
- Keep Reading
- Arthritis / Acute Gout Attack
- Chronic Tophaceous Gout
- Asymptomatic Hyperuricemia
- Diagnosis of Gout
- What is gout?
- What causes gout?
- What are the symptoms of gout?
- Stages of gout
- How is gout diagnosed?
- How is gout treated?
- Can gout be prevented?
- Related Content
What You Can Do
If you think your condition is getting worse, talk to your doctor. He will give you medicine to keep your uric acid levels low and to try to prevent future attacks and complications.
Allopurinol (Aloprim, Lopurin, Zyloprim) treats chronic gout by lowering the uric acid produced in your body.
Febuxostat (Uloric) also lowers uric acid production but would be used with caution if you are at risk for heart or blood vessel disease.
Once you start taking these medicines, you’ll need to take them for life so that your uric acid stays at the right levels.
Probenecid and lesinurad (Zurampic) help the body get rid of more uric acid in your urine. Pegloticase (Krystexxa) and rasburicase (Elitek) can break down uric acid into a substance that your body can get rid of. They are only for very severe gout that doesn’t get better with usual treatments.
Scientists are also testing new treatments for chronic gout. At the same time, researchers are getting a better understanding of how the body makes and breaks down uric acid. Insights from this research could lead to new treatments in the future.
A new study found that people with gout have a 25 percent greater likelihood of dying prematurely than people without gout. The findings also show that this increased mortality rate has not improved over the past 16 years, unlike the mortality rate for people with rheumatoid arthritis (RA).
Gout, which affects more than 4 percent of adults in the United States, is the most common form of inflammatory arthritis. It 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. Gout is also associated with other illnesses, such as cardiovascular disease and metabolic syndrome.
The study, published online recently in Annals of the Rheumatic Diseases, looked at data available in The Health Improvement Network (THIN) – an electronic medical record database in the United Kingdom that includes information on more than 10 million people.
The researchers identified more than 103,000 people with gout from the database. Each person with gout was matched – based on age, sex and what calendar year they were entered into the database – with up to five people without gout (for a total of nearly 515,000 matched controls). The researchers then divided the participants into two groups based on the gout patients’ year of diagnosis, forming an early group (1999–2006) and a late group (2007–2014). They then looked at how many people in each group died every year.
After taking into account age, sex, body mass index, cigarette use, alcohol consumption, medication use, and additional illnesses, the researchers found that people with gout had higher mortality rates compared to those without gout in both the early and late groups. All other things being equal, for every person without gout who died of any cause, 1.25 people with gout died in the early group. In the late group, that number was 1.24. Mortality rates were nearly equal in the two groups, indicating that the mortality gap did not improve over time.
Contrast with RA Mortality
Lead study author Hyon K. Choi, MD, director of the gout and crystal arthropathy center at Massachusetts General Hospital in Boston, says the lack of improvement in gout’s mortality rate is in stark contrast to what has happened to mortality rates in rheumatoid arthritis. Dr. Choi’s group conducted a similar study of RA, also published recently in Annals of the Rheumatic Diseases, using the same database and the same time period.
They found that in the early group, people with RA were 56 percent more likely to die prematurely compared to those without RA. But in the late group, the mortality rate of people with RA was much lower: They were 29 percent more likely to die prematurely.
Dr. Choi says the improvement is most likely due to better treatment options available for people with RA and a trend for doctors to use medications earlier and more aggressively in order to reach certain treatment goals – an approach called “treat to target.”
N. Lawrence Edwards, MD, vice chairman and professor in the department of medicine at the University of Florida in Gainesville agrees. He says, “When you treat-to-target for rheumatoid arthritis, you really get to the basis of inflammation. Why that hasn’t happened with gout is very important. It is because we do an absolutely crummy job as a profession of treating-to-target with gout. We do a very good job at treating to target with RA.”
Gout is Undertreated
Drs. Choi and Edwards both say that gout tends to be taken much more lightly than RA as an inflammatory disease.
Dr. Edwards says that gout, roughly four times more common than RA, is a chronic inflammatory condition but people tend to think of it as intermittent episodes of a painful joint. In truth, inflammation is always at work in the joints of people who have gout. Even when the symptoms of an acute gout attack get better, inflammation continues.
Dr. Edwards notes, “We’ve known for decades that just having a chronic inflammatory condition puts you at risk for earlier death.”
Dr. Choi explains that the vast majority of people with gout should be receiving urate-lowering medication. However, only a small proportion actually receives treatment, and even fewer stay on it long enough and consistently enough to dissolve the uric acid crystals that trigger the chronic, underlying inflammation.
Lessen Your Risk of Early Death
On average, having gout raises a person’s risk of dying earlier than a similar person without gout by 25 percent. To lessen that risk, gout patients need to work with their doctor to lower uric acid levels to the target of <6 mg/dl – and keep it there throughout life, Dr. Edwards says. In addition, people with gout need to control medical conditions that go along with gout (comorbid conditions), such as hypertension, heart disease and kidney disease.
So if you have gout, here’s what you need to do to ensure you live the longest, healthiest life you can:
- Take your gout medications and other medications as directed
- Get screened and treated for comorbid conditions
- Attain and maintain a healthy weight
- Exercise regularly
- Follow a gout-friendly diet
Dr. Choi urges, “Remember that gout is treatable and even curable with medication and other appropriate treatment. Work with your physician to lower uric acid levels – medication primarily, lifestyle changes, and management of comorbidities.”
Author: Beth Axtell for the Arthritis Foundation
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Gout Complications and Related Conditions
Chronic, untreated gout can lead to joint damage and deformity.
Uric acid crystals can form kidney stones, a complication that occurs in about 15 percent of people with gout. W.D. Auer/Alamy
For some people, gout can be chronic, which means multiple, severe gout attacks several times a year.
Chronic gout, sometimes called gouty arthritis, can lead to a number of serious complications if left untreated. (1)
Complications of gout include:
- Joint damage
- Joint deformity
- Loss of mobility or range of motion
- Bone loss
- Tophi (chalky lumps or deposits that form underneath the skin)
- Kidney stones
- Chronic kidney disease
What Is the Definition of Tophaceous Gout?
Gout is a painful form of arthritis that occurs when too much uric acid builds up in the body. Uric acid is a normal waste product in the blood that comes from the breakdown of certain foods. (2)
Having too much uric acid in the body is called hyperuricemia.
Some people who have repeated gout flares or too-high levels of uric acid for several years develop a form of gout called tophaceous gout.
What Causes Tophaceous Gout and Tophi Deposits?
People with this kind of gout get tophi. Tophi are hard uric acid deposits that form beneath the skin. Tophi look like chalky lumps under the skin.
They can be found on or near the elbow, finger, or toe joints. Tophi can also appear on the outer part of the ear.
Tophi can destroy bone and cartilage, leading to joint damage and deformity, according to the Cochrane Database of Systematic Reviews. (3)
They can swell during a gout attack and pop through the skin and become infected.
With treatment, tophi can dissolve and eventually disappear.
Not everyone with gout develops tophi.
Certain groups share a higher risk for tophaceous gout, according to the physician-run website UpToDate. (4) Those at risk for tophaceous gout include:
- Organ transplant recipients who receive certain types of medication to prevent transplant rejection
- People who can’t take uric-acid-lowering medicines (because of kidney failure or drug allergy)
- Postmenopausal women, especially those taking a diuretic. (Diuretics, used to treat high blood pressure, can raise uric acid levels.) (4)
Treatment for Tophaceous Gout and Tophi
Treatment for tophaceous gout typically involves long-term therapy with one or more uric-acid-lowering medications. (5)
Achieving and maintaining a uric acid level of 6 milligrams per deciliter (mg/dl) of blood or below can help reduce the risk of future gout flares. (6) These medications will also cause tophi to dissolve and disappear.
Uric-acid-lowering medications take time. It may take several months of treatment before uric acid levels start to go down.
Some uric-acid-lowering medications for gout include:
- Probalan (probenecid)
- Cozaar (losartan)
- Aloprim or Zyloprim (allopurinol)
- Uloric (febuxostat)
- Zurampic (lesinurad)
- Krystexxa (pegloticase)
Drinking plenty of water, exercising, maintaining a healthy weight and avoiding foods and beverages that trigger gout attacks (alcoholic and sugar-sweetened drinks, red meats, organ meats, certain kinds of seafood) can also help lower uric acid levels.
Treating Gout and Tophi With Surgery
Uric-acid-lowering drugs can reduce the size of tophi over time. Some people may opt to have tophi surgically removed for cosmetic reasons. (7)
Your doctor may recommend surgical removal for tophi if they are causing mechanical problems with your joints.
Surgery for gout can help to reduce joint problems caused by tophi, including difficulty walking or nerve damage from tophi pressing against a nerve.
Tophi can erode through the skin, causing chronic ulcers that can become infected. These may require surgical removal.
Tophi removal is a relatively simple procedure. Your doctor will make a small incision on the skin over the tophi, remove the mass, and then suture the wound.
People with severe joint damage or bone loss around the joint may need additional joint replacement surgery.
The Link Between Gout and Kidney Stones
Excess uric acid can build up in the blood and form painful, spiky crystals. This may happen if the body is making too much uric acid or if the kidneys are having a hard time filtering it out.
In people with gout, the joints are the most commonly affected part of the body.
These spiky, urate crystals may also cause a stone to form in the kidney or other parts of the urinary tract.
Kidney stones can get stuck in the urinary tract and cause severe pain in the side of the abdomen or back. They pass out of the body in urine.
Kidney stones caused by uric acid crystals occur in about 15 percent of people living with gout. (4)
Uric acid gets excreted by the kidneys. Some medications aim at lowering uric acid levels by increasing the amount of uric acid excreted by the kidneys. These medications may increase the risk of kidney stones in some people. (4)
Talk with your doctor if you are using a uric-acid-lowering drug and are developing kidney stones. Your doctor may opt to put you on a different medication.
The Link Between Gout and Chronic Kidney Disease
There’s a relationship between gout and chronic kidney disease.
Chronic kidney disease is a condition in which you slowly lose kidney function over time. The kidneys are important because they help remove waste products (such as uric acid) and urine from the body. (8)
If the kidneys aren’t working properly, uric acid can build up in the body. That’s why kidney disease sometimes leads to high uric acid in the blood. High uric acid can cause gout.
One way that gout may contribute to chronic kidney disease is through kidney stones. People with recurrent kidney stones are at an increased risk for chronic kidney disease.
The National Kidney Foundation recommends that people with gout get checked for chronic kidney disease. (9) Your doctor may take blood and urine samples to test for it.
Doctors commonly use two tests to help diagnose the condition. A simple blood test, called a GFR, measures how much blood your kidneys filter each minute. A urine albumin test, or ACR, can help detect kidney damage. (9)
Gout: Joint pain and more
Published: December, 2007
It starts with a bang, often in the dead of night. The pain is severe, almost unbearable, and fever may make you feel even worse. Lying still helps a bit, but even the touch of a sheet can be excruciating. And, worst of all, your distress may be greeted with a sly smile instead of supportive sympathy. You are suffering from gout, a common disease that’s often misunderstood.
Myths and realities
Gout is an old disease, and erroneous beliefs about it are almost just as old. The name, in fact, is based on a misconception It’s derived from a Latin word that means “a drop”; ancient physicians chose the name because they believed the pain resulted from a drop of “a bad humor.” Over the centuries, gout was considered a rich man’s disease, a product of overeating, excessive drinking, and corpulence. Modern research, however, shows that gout has no relationship to wealth or social status and little to diet and drink. But one traditional view has proved correct: Gout is a man’s disease, occurring seven to nine times more often in men than women. It’s also a common disease, striking an estimated 3.4 million American men annually. That makes gout the most prevalent form of inflammatory arthritis in men older than 40.
The chemical culprit
Gout is caused by an accumulation of uric acid. Uric acid has no useful function in the human body; it is simply a breakdown product of purines, a group of chemicals present in all body tissues and many foods. In normal circumstances, the body rids itself of uric acid by excreting it in the urine, keeping blood levels low. But some men have inherited a metabolic glitch that allows blood uric acids to rise; 90% of the time it’s because the kidneys don’t excrete enough uric acid, but sometimes the body just produces too much of the pesky chemical. Certain medications, such as low-dose aspirin, thiazide diuretics, and niacin, can also increase uric acid levels. Binge drinking, prolonged fasting, kidney disease, lead toxicity, extreme muscular exertion, and leukemia and lymphomas are much less frequent causes of high uric acid levels.
These high levels lead to gout — but not right away. In fact, uric acid levels are typically elevated for 20 to 30 years before they cause any trouble, which is why gout usually occurs in middle-aged and older men. Uric acid levels are normally below 7 milligrams per deciliter (mg/dL). The higher the level, the more likely an attack of gout; men with levels above 10 mg/dL have a 90% chance of developing gout. But gout can also be triggered by a rapid drop in uric acid levels, which is why up to 30% of men with gout have normal uric acid levels at the time of an attack.
An attack of gout occurs when excess uric acid is deposited in a joint and forms urate crystals that irritate the joint lining. White blood cells try to help; they gobble up the crystals, but they are not equal to the task. The white blood cells are themselves damaged, releasing chemicals that cause inflammation, swelling, and pain.
Gout is painful, very painful.
The most common manifestation of gout is acute arthritis, severe pain in a joint. In most cases, it strikes one joint at a time; in half, it’s the first joint in the large toe. Other frequent sites include the forefoot, instep, heel, ankle, and knee. Gout is uncommon in the upper body, but it can strike fingers, wrists, and elbows. At any site, the attack usually begins abruptly, often at night. Within hours, the joint becomes red, swollen, hot, and painful. The pain and tenderness can be so severe that even gentle pressure from bedding is a problem. And even though only one small joint is affected, the inflammation can be intense enough to cause fever, muscle aches, and other flu-like symptoms.
Without treatment, gout can also cause long-term arthritis, with chronic swelling and permanent joint damage. Urate crystals can build up to a remarkable degree, producing large, even grotesque, deposits called tophi in joints and other tissues. Crystals may also be deposited in the kidneys, and they may precipitate in the urine, forming kidney stones.
Gout is easy to recognize in the big toe, where it causes the characteristic inflammation called podagra. Doctors can often make the diagnosis over the phone, and most men with gout can diagnose themselves — particularly in their second or third attack of this recurring disease. But in other joints the diagnosis can be tricky. It’s simple to measure the level of uric acid in the blood; a high level supports a diagnosis of gout, but it’s not definitive, since many healthy men have high levels and some men with gout have normal levels. Other diseases can mimic gout, including rheumatoid arthritis, infections, and pseudogout, which is caused by crystals of another chemical (calcium pyrophosphate). If the diagnosis is in doubt, doctors can remove a small amount of fluid from the inflamed joint; in cases of gout, the fluid contains white blood cells and uric acid crystals, which can be seen through a special polarizing microscope.
Gout responds very well to nonsteroidal anti-inflammatory drugs (NSAIDs) if two rules are observed. First, the NSAID should be started as promptly as possible, and second, it should be used at the maximum recommended dose. Many physicians prescribe indomethacin (Indocin) at a dose of 50 milligrams (mg) three or four times a day, but the other prescription and over-the-counter NSAIDs are also effective. One exception: Aspirin should not be used for gout because it can raise uric acid levels. After two to three days at full strength, the NSAID dose can be reduced by half, and in most cases, treatment can be stopped after just five to seven days.
Men who can’t take NSAIDs because of gastritis, peptic ulcers, or bleeding can get relief from a closely related drug, the selective COX-2 inhibitor, celecoxib (Celebrex). And if this new drug can’t be used, an old standby, colchicine, can help, though it’s fallen out of favor because it often produces vomiting or diarrhea in the high doses needed. Fortunately, a brief course of prednisone or a similar steroid will usually do the job for men who can’t take NSAIDs or celecoxib. Steroids can also be given intravenously to people who can’t take oral medications, and they can be injected directly into the inflamed joint to provide rapid relief.
Joints that are inflamed should be rested, but men can resume their normal activities as soon as their gouty attacks settle down.
For centuries, diet was the mainstay of prevention, but since only about 10% of the body’s uric acid is derived from dietary sources, it didn’t work very well. Still, every little bit helps. Four reports from Harvard’s Health Professionals Follow-up Study show the best way to get that help. The first report implicates red meat and seafood as the villains and low-fat dairy products as the heroes. Although certain vegetables are also high in purines (see sidebar), the study did not confirm previous observations that linked veggies to gout.
High-purine foods that may increase the risk of gout
All meats, especially organ meats
Meat extracts and gravies
Seafood, especially sardines and anchovies
Yeast and yeast extracts
Beans, peas, and lentils
Spinach and asparagus
Modified from Emmerson BT, New England Journal of Medicine, Vol. 334, No. 7, pp. 445–51.
The second Harvard report identifies beer as a culprit but exonerates wine; spirits were associated with a slight increase in risk. The third study tells us that men who lose 10 pounds of excess weight and keep it off reduce their risk of gout by 39%. And the newest study tells us that long-term coffee consumption appears to reduce the risk of gout. Even if coffee is not your cup of tea, a high fluid intake is important to help prevent uric acid kidney stones. But a 2007 study cautioned against a high consumption of sugary drinks, which were linked to high uric acid levels in men.
Although months or years can elapse between attacks, more than 75% of patients with gout have several episodes. Men whose attacks are infrequent don’t need any preventive medication, but they should have an NSAID on hand to use at the first sign of another attack. If episodes occur often, if they prove hard to treat, or if very high uric acid levels predict frequent attacks, medications can help.
There are three ways to prevent gout:
Anti-inflammatory medication. Taken daily, low doses of NSAIDs (indomethacin, 25 mg twice a day, for example) or colchicine (0.6 mg once or twice a day) can prevent acute attacks.
Medication to promote uric acid excretion. Probenecid (Benemid) is the traditional choice; the usual dose is 250 to 500 mg two or three times a day. A rash and intestinal upsets are the most common side effects. Since the drug increases uric acid in the urine, it can predispose a person to kidney stones, and it should be avoided in patients with kidney disease. Since it lowers blood uric acid levels, it can trigger gout early on, so men should always take an NSAID or colchicine during the first two to three months of probenecid therapy. Aspirin is a poor choice, however, because it blocks the activity of probenecid.
Medication to reduce uric acid production. Allopurinol (Zyloprim) is the only currently available drug in this category, and it is the treatment of choice for men with chronic gouty arthritis or uric acid kidney stones. The typical dose is 300 mg per day, but some men need more, others less. The most common side effects are rash and intestinal upset; severe allergic reactions can occur, but they are rare. Because allopurinol produces such a rapid decrease in uric acid that it can precipitate gout, men should always take colchicine or an NSAID for the first two to three months of therapy. Febuxostat, a new drug to lower uric acid production, may soon be available.
Gout is an old disease that has plagued men for centuries. Thomas Sydenham, a great 17th-century physician, wrote, “Gout, unlike any other disease, kills more rich men than poor, more wise men than simple.” But the modern era has witnessed major changes in gout. It never kills, and it rarely results from errant behavior. Moreover, wise men need not fear the disease; instead, they can learn to treat and prevent attacks themselves with just a little help from a physician wise to the ways of gout.
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8 Gout Complications You Need to Know About
Common Gout Complications and Comorbidities
1. Gout and Tophi
Tophi develop in up to about one-third of people who have gout. Tophi are clumps of urate crystals and inflammatory cells that form under the skin when you have gout. They are more likely to occur in people with gout for a longer period of time or whose gout is not well-controlled. Gout tophi can occur in the hands, feet, wrists, ankles, eyes, ears, nose, and even heart valves.
Gout tophi feel like hard bumps beneath the skin. “They can be painful due to their size, like walking on a marble. But they can also be painless,” says John Fitzgerald, MD, a rheumatologist who practices in Los Angeles and Santa Monica, California and whose research focuses on gout.
Gout tophi aren’t just an aesthetic problem. As tophi grow, they can erode the joints and surrounding skin and tissue, causing damage and eventual joint destruction. “They can start to get bigger and burst open through the skin,” says Dr. Khanna. Tophi are also prone to infections that require antibiotics. If gout tophi get infected or too large, they need to be surgically removed.
Keeping uric acid levels at a healthy level is the best way to prevent gout tophi. “By treating the hyperuricemia , you prevent crystal growth/deposition. Lowering uric acid can make the tophi crystals dissolve,” says Dr. Fitzgerald.
2. Gout and Kidney Stones
Kidney stones are one of the most common gout complications. They affect about one in five people with gout. If urate crystals collect and build in your urinary tract, they can form kidney stones. Symptoms of kidney stones include:
- Severe pain in the side and back below the ribs
- Pain when urinating
- Pink, red, or brown urine
- Pain that radiates to the lower abdomen and groin
“The pain in the back and into the groin may be extremely severe,” says Daniel Furst, MD, a UCLA and University of Florence rheumatology professor who practices in Los Angeles and Seattle. “Women compare it to the pain of childbirth.” For people with a history of kidney stones, doctors usually recommend passing about 2.5 liters of urine a day. Your doctor may ask that you measure your urine output to make sure that you’re drinking enough water.
To prevent uric acid stones from gout, doctors commonly prescribe the uric acid-lowering medication allopurinol. “It reduces production of urate and thus reduces the amount of urate both in the joints and in the urine,” says Theodore R. Fields, MD, FACP, rheumatologist at Hospital for Special Surgery in New York City. In some cases, allopurinol and an alkalizing agent may dissolve the uric acid stones. To help prevent calcium stones from forming, your doctor may prescribe a thiazide diuretic or a phosphate-containing preparation.
3. Gout and Kidney Disease
One in 10 people with chronic kidney disease have gout, and an even higher percentage of people with gout have kidney disease. “Uric acid is processed through the kidneys,” says Dr. Khanna. “As we grow older, the kidneys can’t process as much uric acid,” says Dr. Khanna. Damage from urate crystals can lead to kidney disease over time, especially if gout is not well-treated.
Initial symptoms of kidney disease include tiredness, weakness, and decreased energy, says Dr. Furst. However, the kidneys are amazing in their ability to compensate for problems in their function so chronic kidney disease may progress without symptoms for a long time. When decrease in kidney function is severe, people can have symptoms like ankle swelling, nausea, fatigue, and loss of appetite.
That’s why ongoing monitoring of kidney function in gout patients is so important. “It’s important to pick up changes in kidney function early in gout, so that efforts can be made to preserve remaining function, such as by controlling blood pressure,” says Dr. Fields. “Gout medications may need dosage adjustment if kidney function changes.”
4. Gout and Heart Disease
Gout and cardiovascular disease commonly occur together. In a study published in the Journal of the American Heart Association, researchers from Duke University studied data from more than 17,000 patients, including 1,406 who had gout at the start of the study and were being treated for cardiovascular risk factors. After following patients for an average of 6.4 years, researchers found that the risk of dying of cardiovascular disease or having a heart attack or stroke was 15 percent higher among those with gout than in patients who never developed gout. Patients who had gout at any point during the study had a two-fold increased risk of heart failure death compared to people who never developed gout.
Gout causes inflammation in the joints and the rest of the body; inflammation is also a risk factor for heart disease. Heart disease prevention strategies include maintaining a heart-healthy diet, regular exercise, and better cardiovascular risk assessment. Your doctor may recommend more frequent screening tests or more aggressive management of other heart disease risk factors that also occur with gout, such as high blood pressure.
5. Gout and Diabetes
A study published in the journal the Annals of the Rheumatic Disease found that gout may be independently associated with an increased risk of type 2 diabetes. Scientists aren’t exactly sure why gout and diabetes are related, though inflammation may be a common factor. If you’re overweight or obese, you’re more likely to have both gout and type 2 diabetes. Excessive alcohol consumption can also contribute to both gout and diabetes.
Maintaining healthy eating and exercise habits can prevent and manage diabetes and gout. Foods low in calories and fat but high in fiber (fruits, veggies and whole grains) can help lower your risk of diabetes. Drink at least eight cups of water a day; staying hydrated can help you keep healthy blood sugar levels. If you’re overweight, aim to lose weight. Cardio and strength training exercise is especially beneficial for lowering blood sugar levels.
6. Gout and Sleep Issues
Since gout attacks often happen at night, people with gout are awoken from sleeping. Pain from gout can prevent you from falling back to sleep. That sleep deprivation can lead to increased stress, mood swings, fatigue, and other health problems. In a survey of gout patients published in the journal Arthritis Research & Therapy, nearly a quarter of respondents described frequent sleep disorders and daytime sleepiness.
Gout is also connected with obstructive sleep apnea, a condition that occurs when your airway becomes temporarily and briefly blocked while you sleep. People with obstructive sleep apnea are often known to also have high uric acid levels, a gout risk factor. In a study published in the journal Arthritis & Rheumatology, researchers found that those with sleep apnea were at an increased risk of developing gout.
Symptoms of sleep apnea include daytime sleepiness, fatigue, snoring, difficulty concentrating, restlessness during sleep, and gasping for air while sleeping. People with sleep apnea experience many small interruptions in breathing while they sleep, and this lowers the level of oxygen in their blood. This is thought to affect a process that elevates the production of uric acid in the body, which raises gout risk.
7. Gout and Mental Health
The chronic pain associated with repeated gout attacks can lead to stress, anxiety, and depression. Gout can cause severe pain that can make it tough for you to get around, go to work, and complete daily tasks. That impact on your daily life can impacts patients’ mental, social, and physical well-being.
“It’s not just about functionality and disability, but also how patients view themselves,” says Dr. Khanna. “I talk to patients about the fact that gout is treatable, and it’s possible to stay completely flare-free if they take their medications.”
8. Gout and Bone Loss
When you have gout, you’re more prone to osteopenia and osteoporosis factures. A study in the journal Medicine found that the overall rate of bone fracture in people with gout was nearly 23 percent, which was higher than that of those without gout.
In the early phases of thinning bones, called osteopenia, and even in more advanced osteoporosis, people don’t have symptoms unless they develop a bone fracture. “That’s why it’s important for women at the time of menopause and men with gout or other osteoporosis risk factors at least by age 65 to get a bone density test,” says Dr. Fields. “This will detect bone thinning and lead to treatment.”
If you have gout and other osteoporosis risk factors, ask your doctor about when you should start screening for bone mineral density. If you’re found to have thinning bones, you may be prescribed medications to prevent further bone loss, such as bisphosphonates. These include alendronate (Fosamax), risedronate (Actonel), bandronate (Boniva), and zoledronic acid (Reclast).
- 6 Diseases that Can Mimic Gout (and Delay a Diagnosis)
- The Gout Risk Factors and Causes You Need to Know About
- What’s the Difference Between Gout and Pseudogout?
Arthritis / Acute Gout Attack
Gout is a form of arthritis, hence it causes pain and discomfort in the joints. A typical gout attack is characterized by the sudden onset of severe pain, swelling, warmth, and redness of a joint. The clinical presentation of acute gouty arthritis is not subtle with very few mimics other than a bacterial infection.
The joint most commonly involved in gout is the first metatarsophalangeal joint (the big toe), and is called podagra. Any joint may be involved in a gout attack (and it may be more than one) with the most frequent sites being in the feet, ankles, knees, and elbows.
An acute gout attack will generally reach its peak 12-24 hours after onset, and then will slowly begin to resolve even without treatment. Full recovery from a gout attack (without treatment) takes approximately 7-14 days.
An accurate and colorful discription of a gout attack was elegantly written in 1683 by Dr. Thomas Sydenham who was himself a sufferer of gout:
The victim goes to bed and sleeps in good health. About 2 o’clock in the morning, he is awakened by a severe pain in the great toe; more rarely in the heel, ankle or instep. This pain is like that of a dislocation, and yet the parts feel as if cold water were poured over them. Then follows chills and shiver and a little fever. The pain which at first moderate becomes more intense. With its intensity the chills and shivers increase. After a time this comes to a full height, accommodating itself to the bones and ligaments of the tarsus and metatarsus. Now it is a violent stretching and tearing of the ligaments– now it is a gnawing pain and now a pressure and tightening. So exquisite and lively meanwhile is the feeling of the part affected, that it cannot bear the weight of bedclothes nor the jar of a person walking in the room.
Chronic Tophaceous Gout
Some patients only experience acute gout attacks which may be limited to 1-2 times per year (or even 1-2 times in lifetime). However, for some patients, gout can be a chronic, relapsing problem with multiple severe attacks that occur at short intervals and without complete resolution of inflammation between attacks. This form of gout, called chronic gout, can cause significant joint destruction and deformity and may be confused with other forms of chronic inflammatory arthritis such as rheumatoid arthritis. Frequently, uric acid tophi (hard, uric acid deposits under the skin) are present and contribute to bone and cartilage destruction. Tophi are diagnostic for chronic tophaceous gout. Tophi can be found around joints, in the olecranon bursa, or at the pinna of the ear. With treatment, tophi can be dissolved and will completely disappear over time.
Tophi at helix of ear.Large tophaceous deposits surrounding joints.
It is important to recognize that although almost uniformly all patients with gout have hyperuricemia (high levels of uric acid in the blood)…all patients with hyperuricemia do not have gout. Although most patients will have elevated levels of uric acid in the blood for many years before having their first gout attack, there is no current recommendation for treatment during this period in the absence of clinical signs or symptoms of gout. This is termed ‘asymptomatic hyperuricemia’. The risk of a gout attack increases with increasing uric acid levels, but many patients will have attacks with “normal” levels of uric acid and some will never have an attack despite very high levels of uric acid.
Diagnosis of Gout
A diagnosis of gout can be made with the documentation of the presence of uric acid crystals in synovial fluid or from a tophaceous deposit. In the setting of an acute gout attack, aspiration of joint fluid (by using a needle to draw fluid out of the swollen joint) and examination of the fluid under polarized light can yield the definitive diagnostic finding of needle shaped negatively-birefringent uric acid crystals (yellow when parallel to the axis of polarization). Intracellular crystals within a neutrophil are characteristic during an acute attack.
As the clincal features of acute gout and a septic joint (bacterial infection) can be very similar, arthrocentesis is important to rule out infection by sending the joint fluid for culture in these circumstances. Importantly, gout and infection can co-exist in the same joint (they are not mutually exclusive) and consideration should be made for sending joint fluid for culture even in a patient with an established history of gout if they are at risk for infection.
Tophi can be aspirated or the tophaceous material expressed and examined under polarize microscopy as well to confirm a diagnosis of chronic tophaceous gout.
Serum uric acid concentrations may be supportive of a diagnosis of gout, but alone the presence of hyperuricemia or normal uric acid concentrations do not confirm or rule out the diagnosis of gout as frequently uric acid levels may be normal during an acute gout attack.
What is gout?
Gout is a type of inflammatory arthritis that causes sudden, severe attacks of pain, swelling, and redness in the joints. Although gout typically affects the big toe, other joints can also be involved. Usually, the first episodes of gout affect only one joint, but as the disease becomes more severe, the episodes can affect several joints at the same time. If left untreated, joint damage can occur. Men are more likely to get gout, but women become increasingly susceptible to gout after menopause.
What causes gout?
Gout pain occurs when excess uric acid, one of the body’s normal waste products, accumulates because the body makes too much of it or fails to excrete it. In healthy individuals, uric acid dissolves in the blood and passes through the kidneys before it is excreted in urine. With gout, uric acid forms into crystals that accumulate in the fluid that lubricates your joints.
Gout is strongly associated with the following risk factors:
- Gender: Men get gout more than women and they tend to be diagnosed at younger ages than women. The onset of gout among men is typically between the ages of 30-50 years, although it may begin earlier for those with a genetic predisposition. Women are more likely to experience gout after menopause.
- Obesity: Being overweight or having metabolic syndrome is associated with gout.
- Diet: A diet high in fructose, meat (especially red meat and organ meat), some types of seafood, and excessive alcohol consumption (especially beer and spirits) increases your risk of gout.
- Concurrent diseases: Medical conditions such as diabetes, high blood pressure, high cholesterol, and chronic kidney disease are associated with an increased risk of gout. Medications used to treat some of these conditions also affect blood levels of uric acid. Joint trauma or surgery can trigger a gout flare-up.
- Genetic Predisposition: Gout is rare in children, unless they have an inherited genetic disorder that predisposes them to gout.
What are the symptoms of gout?
- Joint pain: Sudden and severe joint pain that can last a week or longer. Initial gout attacks involve one joint but subsequent attacks can involve more joints.
- Joint changes: The affected joint or joints become warm, swollen, red, and/or tender.
- Limited mobility: With joint pain and swelling, the joint can become stiff and range of motion can become more limited.
- Urate crystals: Hard lumps of urate crystals can form beneath the skin (known as tophi).
- Kidney stones: Over time, the same urate crystals that form in the joints can be found in the kidneys. Kidney stone symptoms include pain (sometimes excruciating, from the lower back to the groin), difficulty urinating, and a frequent urge to urinate but with minimal amounts of urine produced.
Stages of gout
Gout is a chronic disease that if left untreated, may get worse over time and cause joint damage. By recognizing the symptoms early and seeking a physician’s care, you can reduce the chances of gout reaching later stages.
- Acute Gouty Arthritis: Urate crystals in the joint cause inflammation, resulting in a sudden onset of severe pain and swelling. An acute gout attack can last a week or longer. Commonly, the gout attack will affect the big toe joint, but other joints, such as the knee, may be involved.
- Intercritical and Recurrent Gout: After the pain of an acute flare has gone away, gout can enter a stage during which the disease is inactive. In this stage, urate crystals can continue to be deposited in tissues with resulting damage. Subsequent gout attacks may not occur for months or even years; however, as the disease progresses, attacks can recur more frequently, last longer, and be felt in multiple joints.
- Chronic Tophaceous Gout: This is the most destructive stage of the disease and occurs after many years of recurrent gout attacks. Having chronic gout means the disease has caused permanent damage to the affected joints, producing persistent inflammation, joint deformity, and extensive deposits of crystallized uric acid (tophi). Tophi can be found on the ears or joints, and can damage surrounding tissues to cause deformities.
How is gout diagnosed?
If you have symptoms of gout, your doctor may refer you to a rheumatologist. Your rheumatologist will ask you a number of questions about your symptoms, medical history, family history, medications, and diet. After speaking with you, your physician will use one or more of the following tests to help diagnose gout:
- Joint fluid analysis: Using a needle, joint fluid is removed from the inflamed, painful joint. The joint fluid is then examined under a microscope to see if there are urate crystals present. This is a definitive way of diagnosing gout.
- Blood tests: Your blood can be tested to measure levels of uric acid. This is not a definitive diagnostic test because some people have high uric acid levels without experiencing gout, and others have normal uric acid levels with symptoms of gout.
- Imaging: X-ray imaging of the joints can sometimes show gout-related joint damage. Ultrasound is another imaging tool for evaluating the soft tissue and bone to detect urate crystals. In some instances, MRI may be used to identify tophi, inflammation, or joint injury, and dual imaging CT scans can find urate deposits.
How is gout treated?
Gout treatment involves managing the flare up and treating the underlying problem to prevent future episodes. The initial treatment goal is to reduce pain and inflammation quickly and safely.
Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and/or corticosteroids may be used. Specific treatment of gout varies based on co-existing medical conditions and other medications you are taking.
After treating the pain and inflammation of a gout flare up, it is important to decrease your uric acid levels to prevent future gout attacks and joint damage. Your rheumatologist will work with you to find a balance of medications and lifestyle changes to help lower your uric acid levels.
Medications can be effective for treating gout pain and lowering your uric acid levels, but lifestyle changes are also important. Diet modifications and maintaining a healthy weight can lower uric acid levels in your blood.
Foods to avoid or limit
Avoiding or limiting the following foods can reduce your chances of triggering a gout attack:
red meat, organ meats (such as liver and sweetbreads)
particularly beer but also spirits and wine
shellfish and other fish with high purine content (such as sardines)
sugary drinks or foods high in fructose
Foods and supplements that are encouraged
Consuming the following foods or supplements, in addition to keeping well hydrated, may decrease your risk of having a gout attack:
- Low fat or non fat dairy products
- Cherries, cherry juice concentrate
- Vitamin C
Can gout be prevented?
The best way to minimize your risk of developing gout and complications from gout is by following a healthy lifestyle: stay well hydrated, maintain a healthy body weight, and eat a low-purine diet.
- Adult Rheumatology
- Pediatric Rheumatology