Throbbing toe pain at night

Trying to Sleep Through Gout Pain

If you have ever been jolted out of a sound sleep with throbbing pain in your big toe, you know that a gout flare can make it impossible to get the rest you need. About 50 percent of gout flares begin in the toe, a condition called “podagra.” This gout pain usually starts at night and may be accompanied by fever and muscle aches. Even the weight of a sheet or blanket on your foot can be excruciating.

“Gout occurs when monosodium urate crystals precipitate in bones, joints, or soft tissues. These crystals are more likely to crystallize in lower temperatures. As it generally is colder at night, this may be why many gout attacks begin at night,” says Jennifer Sloane, MD, a rheumatologist at Temple University Hospital in Philadelphia.

The sudden onset of pain in a single joint, with accompanying swelling, redness, and warmth around the joint, is such a classic symptom for a gout flare that most doctors can make the diagnosis over the phone. And, if you have had previous attacks of gouty arthritis, you know right away what’s happening.

What to Do for a Gout Pain Flare

Virtually 100 percent of people with an acute gout flare at night will not be able to go back to sleep. The only real option is to call your doctor and start treatment. You may already have access to gout medication in your medicine cabinet or can get some over-the-counter relief at your pharmacy. Your doctor can prescribe stronger medications if needed. Often, this sudden onset of gout pain responds to treatment within 12 hours.

Because gout pain can be quite severe, it is important to know how to quell it as fast as possible, usually by taking medication as soon as possible.

Here are the basics for treating a gout flare:

  • Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) can work well if you take them early and at a maximum dose; check with your doctor first.
  • Your doctor may advise you to take prescription-strength pain medications if needed.
  • Your doctor may prescribe a drug called colchicine that helps reduce pain and swelling.
  • Steroids may also be used to reduce the inflammation of gouty arthritis.
  • What not to do: Don’t take aspirin because aspirin can increase uric acid in your blood and make the attack worse.

“Nonsteroidal anti-inflammatories, colchicine, and/or corticosteroids can decrease the severity and duration of gout attacks,” says Dr. Sloane. “As all of these medications have possible side effects, none should be taken without first conferring with a physician.”

Can Poor Sleep Trigger a Gout Flare?

Sleep apnea is a fairly common condition in which the airway collapses during sleep, causing short periods of decreased oxygen called hypoxia. Sleep apnea could be another reason why gout attacks happen at night: Decreased oxygen in your blood can lead to increased uric acid. But the link between gout and sleep apnea could also be obesity since both conditions are more common in people who are overweight.

“It is difficult to state whether sleep apnea causes gout,” says Sloane. “There have been no large studies evaluating sleep apnea as an independent risk factor for gout. As patients with sleep apnea are often hypoxic, one could hypothesize that untreated sleep apnea could cause gout.”

Gout likes to attack at night when you are sleeping, and getting back to sleep after a gout flare will be difficult unless your medicine cabinet is well stocked. Talk to your doctor about your risk factors and ask what medications you can be prepared with if a gout flare catches you in the dead of night.

Nerve Entrapment in the Heel – If you have heel pain and you didn’t step on a rock or suffer a fall and bruise your heel, you may be dealing with nerve entrapment in the area. That said, the pinched nerve could actually be located in your back and causing radiating pain to shoot down your leg and into your foot. Either way, pinched nerves often cause pain during excessive, repetitive motion or during prolonged periods of rest. Pinched nerves can cause pain, swelling and numbness in your feet. Exercise, physical therapy, custom foot orthotics and massage therapy can all help relieve symptoms caused by a pinched nerve in your feet.

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Lance Silverman, MD

Dr. Lance Silverman is a board certified orthopaedic surgeon, with specialty training in the management of conditions of the ankle and foot. Treating Minnesotans with Ankle & Foot problems since 2004.

Latest posts by Lance Silverman, MD (see all)

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Commonest Causes of Pain in Toe at Night & Ways to Get Rid of it

Many people commonly experience pain in toe at night and often complain that the toe suddenly goes through excruciating cramping at night. The tingling numbness steals away the power of putting the foot down and walk. Such problems are often ignored, however, if pain in toe at night continues for long, it needs to be attended. Let us understand some of the commonest causes of pain in toe at night and ways to get rid of it.

Toe cramps and pain in toe at night can be due to varying causes, excessive walking and dehydration, wearing misfit shoes, deficiencies of varying minerals such as calcium, potassium, and magnesium trigger toe pain.

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Commonest Causes of Pain in Toe at Night

Some of the commonest causes of toe pain at night include the following:

  • Overwork or intense exercises are the common causes of pain in toe at night. During intense workout maximum minerals drain away through sweat. This can easily cause muscle contraction and result in muscle cramps. When you overexert your toe or overstrain the toe and feet muscles, you are likely to experience cramps during night. Cramps and pain are a ways through which the nerves and muscles tell you that they are overstrained and exhausted.
  • Wearing tight fitting or ill-fitting shoes is another commonest cause of pain in toe at night. Restricted blood flow that develops on wearing tight shoes, toe paining may arise. Wearing tight shoes or socks, blood vessels mostly remain restricted, which triggers pain in night.
  • Age factor can also be the cause of toe cramps and pain in toe at night. The people in 50s are likely to lose calcium in bones and weaken the bones, thus causing the cramps. Osteoporosis in menopausal women is another common cause of pain in toe at night.
  • Other causes of pain in toe at night can also include medical conditions like arthritis and gout, or infection.

Other Conditions and Causes of Toe Pain at Night

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Apart from these common causes, there are some health conditions that too can cause toe pain at night.

  • Peripheral Neuropathy: In peripheral neuropathy, it is common to have some numbness in the toe and also in the entire feet. It is also one of the important causes of pain in toe at night. While walking around, the pain gradually subsides, but again comes back when you are lying down. Peripheral neuropathy is an expression of many clinical disorders such as diabetes, immune disorders, vitamin deficiency and even cancer. This disorder triggers disruption in the functioning of nerves in the foot or ankle area. Hence, it is necessary to evaluate the condition properly and get appropriate treatment.
  • Pinched Nerve: A pinched nerve is one of the crucial conditions that results from various health problems and even cause many complications. It is possible that there is nerve entrapment in the lower part of the body but the pain reaches the leg and foot along the sciatic nerve thus generating pain. Pinched nerve may happen for sitting in same position for prolong time span. It is often seen in conditions of the spine, intervertebral disc problems, injuries and infections of the spine or joints and muscles in the legs.
  • Morton’s Neuroma: The condition of thickening of tissues is known as Morton’s Neuroma; often this can be one of the possible causes of pain in toe at night. When the third or fourth bones of the toe is pinched as an effect the nerve is pinched. Inflammation in nerve can cause great tingling and burning sensation. This pain may worsen at night. In such situation ill-fitting shoes can trigger bunions, mallet toes or hammertoes, which too are some of the causes of pain in toe at night.
  • Restless Legs Syndrome: Some people tend to move the legs frequently, jerking the legs and feet, even during the night, which is identified as restless leg movement. It may be sometimes difficult to diagnose restless legs syndrome and it is often ignored by many people. Researchers prove that dopamine imbalance can cause such conditions. This health condition often triggers toe paining in night thus interfering with your sound sleep.

While these are the possible causes of pain in toe at night, the treatment often depends on the exact cause. Knowing some ways to get rid of pain in toe at night can also help in managing the condition.

Effective Ways to Get Rid of Pain in Toe at Night

Here are some of the effective ways to get rid of pain in toe at night.

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Massaging: For many people, massaging turns out to be very effective. Massaging can be done by gently pressing the painful area with the fingers. The touch should be hard and soft, based upon which compression works in reducing pain, massaging should be carried forward. Massage is known to lessen down the muscle tension, which gradually relaxes them and helps boost blood flow.

Stretching: The simple flexion and extension of paining toe can reduce the pain in toe at night significantly. The stretching exercises of the leg and ankle also increase the blood flow to the toe and thus decrease the pain. Simple stretching can be done by extending the legs in the front and moving the ankle up and down. Standing on the toe also helps to stretch the calf muscles and strengthens the foot area. This is one of the most effective ways to get rid of pain in toe at night.

Hot or Cold Compresses: Application of ice packs or warm compresses, can help relax the muscles of foot. Using contrast warm and cold pack for few minutes is also of great help. Ice packs on the painful area help to control inflammation and reduce swelling and pain in toe. This is one of the important effective ways to get rid of pain in toe at night.

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Vinegar: Vinegar contains acetic acid which helps the body in making acetylcholine, which is one of the best neurotransmitter that helps in improving the muscle functionality. So the more acetylcholine, the better muscle function can be traced. Apple cider vinegar also helps a lot.

Fluid Intake: As dehydration is one of the causes of foot cramps, fluid intake is certainly the one of the best ways to get rid of pain in at night. When there is excessive sweating the essential minerals drain away gradually, so there is loss of calcium and salt, together with potassium. So, taking supplements is a good way to make up for the mineral deficiency. Supplements are best taken with medical advice.

Toe Stretchers: Toe stretchers can help in easing pain. By wearing the toe stretcher your pain will gradually be reduced. The stretcher helps in bone alignment and also balances the muscle tension. It is an effective way to get rid of pain in toe at night and is best used with expert’s advice.

Taking Tea: Chamomile tea, green tea can relax the body and mind, thus effective to get rid of pain in toe at night. This is particularly more useful in case of muscle cramps, nerve problems and restless leg syndrome.

These are simple home remedies and ways to get rid of pain in toe at night. However, if these do not seem to work or if the pain continues for long, it is important to seek medical advice and plan appropriate treatment.

Gout Attacks Twice as Likely at Night

A landmark study published online December 11 in Arthritis & Rheumatism by Hyon K. Choi, MD, DrPH, from Boston University School of Medicine, Massachusetts, and Sydney University, Australia, and colleagues confirmed the widely held assumption that gout is more likely to flare at night and challenged the common impression that attacks are more likely after alcohol or purine dietary indulgence.

Dr Choi, currently director of Clinical Epidemiology at Massachusetts General Hospital/Harvard Medical School in Boston, told Medscape Medical News that the 2.36-fold greater risk for nocturnal gout attacks has direct implications for clinicians treating patients with gout. “Prophylactic measures that prevent gout flares, especially at night, are likely to be more effective. For example, prophylactic drugs for gout flares, particularly those with short half-lives, may be timed appropriately to optimize their benefits,” Dr Choi said.

Gout expert H. Ralph Schumacher Jr, MD, professor of medicine at the University of Pennsylvania and at the VA Medical Center, Philadelphia, Pennsylvania, commented to Medscape Medical News, “This is a beautiful study that confirms a widely held impression with carefully obtained prospective data. The only surprise was how undertreated this population was (less than 45% on allopurinol and about a quarter on prophylactic colchicine). I don’t see any uric acid levels on these people. Conceivably, people with better-managed gout might have different patterns as well as fewer flares.”

Dr Choi’s team used data from the Boston Online Gout Study to examine risk for acute gout attacks in relation to time of day. The researchers prospectively recruited 724 patients with gout who were followed for 1 year via the Internet in a case-crossover study. Patients reported date and time of attack onset, symptoms, medication use, and possible risk factors (such as alcohol or seafood consumption) during the 24 and 48 hours before the attack. Most participants were white (89%) and male (78%).

The risk for gout flares was 2.36 times higher overnight than in the daytime and 1.26 times higher overnight than in the evening. The patients reported 1433 acute gout attacks, of which 733 occurred overnight (midnight to 7:59 am), 310 occurred between 8:00 am and 2:59 pm, and 390 occurred between 3:00 pm and 11:59 pm.

The differences in nocturnal risk persisted even among patients who had no alcohol intake and low purine intake during the prior 24 hours. These associations remained after accounting for sex, age, body mass index, and use of diuretics, gout medications, and nonsteroidal anti-inflammatory drugs (NSAIDs). During the gout flare, or the “intercritical periods” between attacks, alcohol consumption was reported by approximately 68% of participants, diuretic use by 29%, allopurinol use by 45%, NSAID use by 54%, and colchicine use by 26%. Most of the gout attacks were in the lower extremities (92%), and 90% were treated with colchicine, NSAIDs, systemic corticosteroids, intra-articular corticosteroids, or a combination.

The mechanism underlying the increased risk for nocturnal gout flare is unknown, but suspects include lower body temperature at night (leading to higher risk for uric acid crystallization), dehydration during sleep or periarticular dehydration resulting from sleep position, and a nighttime dip in blood cortisol levels.

The researchers suggested that sleep apnea might be a factor because the associated hypoxia enhances nucleotide turnover and generates purines that can be metabolized to uric acid. Dr Choi noted that sleep apnea affects roughly one third of obese men who have multiple comorbidities, which also describes the typical patient with gout. In a general population study presented at the American College of Rheumatology (ACR) 2014 Annual Meeting, Dr Choi reported that patients with sleep apnea had a 20% increased risk of developing gout.

Dr Schumacher commented, “On the role of sleep apnea, I would be really interested if they had enough night workers who sleep during the day to see if they also flare during sleep. There is a suggestion of a second small increase in flares in the late afternoon or evening. Might those be related to daytime microtrauma as a different mechanism?”

Dr Choi noted that sleep apnea is common and that the associated hypoxia is treatable with noninvasive ventilation continuous positive airway pressure, which might be a useful subject for further study in the management of patients with gout.

This study was funded by grants from the National Institutes of Health, the Arthritis Foundation, and the American College of Rheumatology Research and Education Fund. The authors and Dr Schumacher have disclosed no relevant financial relationships.

Arthritis Rheum. Published online December 11, 2014. Abstract

Gout Attacks Strike Mostly at Night

Most people who have experienced a painful gout attack are well aware that they tend to cause a rude awakening by occurring in the middle of the night.

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Gout attacks commonly strike in the middle of the night or early in the morning.

But there weren’t any scientific studies to back up the anecdotal timing of gout attacks—until now.

See Gout Symptoms

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Nighttime gout attack 250% more likely

A recent study published in Arthritis & Rheumatology followed a group of more than 700 gout patients and tracked when their attacks occurred over a 1-year period. The results revealed that attacks were 250% more likely to occur between midnight and 8 a.m. than during the day.1 This was true for participants regardless of gender, age, weight, or medication use.

See Gout Causes and Risk Factors

Experts still aren’t sure why nighttime is such a consistently risky time for gout attacks. It may have to do with overnight dehydration or falling levels of the hormone cortisol.

But they are hopeful that the study findings can help inform doctors and patients about the best times of day to take medications that can prevent gout attacks, like allopurinol and colchicines.

See Gout Prevention

Take steps to prevent gout attacks

In the meantime, there are steps you can take to reduce your risk of experiencing the unpleasant late-night surprise of a gout attack:

  1. Take your medication.

    If you have a prescription for a medication like allopurinol or probenecid, take it faithfully. These medications are proven to help prevent attacks by removing uric acid from your system. If you don’t have a prescription, ask your doctor if it’s right for you.

  2. Steer clear of purines.

    Food and drinks high in purines include:

    • Alcohol, especially beer
    • Organ and game meats
    • Seafood
    • Lentils and dried beans
    • Certain vegetables like spinach and mushrooms
    • For a complete list, read Gout Prevention Diet
  3. Drink lots of water.

    Staying hydrated helps the kidneys and flushes uric acid out of your system.

If you do wake up to a gout attack underway, you can treat it with rest, ice, and pain medications.

See 6 Ways to Deal with Painful Gout Attacks

Learn more:

All About Gout – Symptoms, Diagnosis, Treatment

5 Unusual Gout Symptoms

  • 1.“Nocturnal risk of gout attacks.” Arthritis Rheumatol. 2014 Dec 11.

Among patients with gout, the risk of an attack was more than doubled during the night compared with the daytime hours, researchers reported.

Historical data has suggested that attacks often occur at night, and plausible mechanisms for increased nocturnal risk have been advanced.

“Despite these intriguing possibilities and anecdotal observations, no study has investigated the potential varying levels of the risk of gout attacks associated with the time of day. Accurate understanding about the circadian variation of gout attacks could have practical implications about effective timing of anti-gout prophylactic measures,” the researchers wrote.

Choi’s group prospectively recruited 724 patients with gout for an Internet-based, case-crossover study in which patients acted as their own controls.

This study design has been shown to be useful in evaluating the effects of short-term risk factors on outcome events.

All participants were adults, reported having had a physician’s diagnosis of gout, and had at least one attack within the previous year.

At the time of enrollment, participants provided sociodemographic information, data relating to gout such as the age at onset and medication use, and details about other medical history.

Then, when they experienced a gout flare, they were asked to report the time of the attack, location of the pain and other symptoms, possible risk factors for the attack, and medications used during the 24 and 48 hours before the episode.

Patients’ mean age was 54, 78% were men, and most were white. A total of 68% drank alcohol, and median body mass index was 30.6 kg/m2.

Median disease duration was 5 years.

Diuretics were used by 28.6%, allopurinol by 45.4%, nonsteroidal anti-inflammatory drugs (NSAIDs) by 54.3%, and colchicine by 25.6%.

During a year of follow-up, the 724 participants reported 1,433 gout flares. Most involved the lower extremity, and particularly the metatarsophalangeal joint.

Treatments used for the attacks included NSAIDs, corticosteroids, colchicine, or combinations of these drugs.

During the first 8-hour period of the day (midnight to 8 a.m.), there were 733 attacks. In the second and third periods there were 310 and 390, respectively.

The significantly higher risk between midnight and 8 a.m. persisted among various subgroups (P<0.0001 for all):

The results were similar in various subanalyses, such as for patients experiencing a first attack, those with specific features such as podagra and redness, and including only those patients who used anti-gout medications during the episode.

“These findings provide the first prospective evidence for a substantially increased risk of gout attacks during the night and through early morning hours,” Choi and colleagues stated.

Among the potential reasons for this time of day being risky are the lower body temperature that might encourage the formation of uric acid crystals, and joint dehydration from lying down.

In addition, circulating levels of cortisol are at the lowest between midnight and 4 a.m., which could contribute to the onset.

“Of note, the same mechanism has been linked to typical morning stiffness in rheumatoid arthritis patients (i.e., the nocturnal dip in cortisol levels contributing to a decreased ‘anti-inflammatory’ milieu and leading to increased inflammatory symptoms in the morning),” the authors explained.

Sleep apnea — common among obese men — also may contribute, they noted. “Hypoxia associated with sleep apnea can enhance nucleotide turnover, thereby generating purines, which are metabolized to uric acid.”

In addition, sleep studies have revealed that individuals who become hypoxic during sleep typically have high levels of uric acid as shown by increases in the ratio of uric acid excretion to creatinine.

“As sleep apnea is particularly common among those with the typical profile of gout patients, and as the associated hypoxia is treatable (e.g., with continuous positive airway pressure), clarification of the role of sleep apnea on recurrent gout attacks among gout patients in future studies could add considerably to the effective management of gout,” they wrote.

A limitation of the study was the lack of specific information about sleep apnea in this cohort.

The study was funded by the Arthritis Foundation, the American College of Rheumatology, and the NIH.

The authors disclosed no relevant relationships with industry.

2014-12-11T13:30:00-0500

  • Primary Source

    Arthritis and Rheumatology

    Source Reference: Choi H, et al “Nocturnal risk of gout attacks” Arthritis Rheum 2014; DOI: 10.1002/art.38917.

THURSDAY, Dec. 11, 2014 (HealthDay News) — Acute gout attacks occur two times more often during the night and early morning than during the day, a new study finds.

“It is speculated that lower body temperature, nighttime dehydration, or a nocturnal dip of cortisol levels may contribute to the risk of gout attacks at night,” study author Dr. Hyon Choi, of Massachusetts General Hospital/Harvard Medical School, said in a journal news release.

“Despite the possibility of a nighttime link to gout, no study prior to our current investigation has looked at the association between gout attack risk and the time of day,” Choi added.

More than 8 million Americans have gout, according to the American College of Rheumatology.

The current study included more than 700 gout patients. Their average age was 54. They were mostly white, and mostly male, according to the study.

The researchers tracked their health for one year. During that time, there were almost 1,500 acute gout attacks.

Of those, more than 700 occurred between midnight and 7:59 a.m. Around 300 happened between 8 a.m. and 2:59 p.m. And, almost 400 attacks occurred between 3 p.m. and 11:59 p.m., according to the findings in the journal Arthritis & Rheumatology.

Compared to daytime, the risk of an acute gout attack was more than twice as high overnight.

The increased risk was seen even among patients with low purine intake in the 24 hours prior to an attack, the researchers found. When breaking down purines, the body produces uric acid. Acute gout attacks are triggered by the crystallization of uric acid within joints. Certain foods are high in purines, including organ meat, seafood and alcohol.

“Our findings provide the first prospective evidence that the risk of gout flares is higher during the night and early morning hours than during the day,” Choi concluded. “As a result of our study, measures that prevent gout flares, especially at night, may be more effective.”

Gout Symptoms

Joint Pain, Inflammation, and Other Symptoms

By Floranne C. Ernste, MD and

Gout, considered one of the most painful forms of inflammatory arthritis, has inflicted pain on humanity for thousands of years—from Egyptian royalty to the English aristocracy. In fact, excruciating pain and inflammation—typically in your big toe—are the classic symptoms of a gout attack. Today, gout is the most common inflammatory arthropathy in the United States, where it affects approximately 4% of adults.

Rest assured, most people with gout will experience only one acute gout attack in their life. With an acute gout attack, symptoms will go away within a few days, and you may never have another attack again.

But for some people, gout can be a progressive condition. These people can have frequent gout attacks, and the attacks generally last longer than the initial attack. People with frequent gout attacks can go on to develop chronic gout, and these people will most likely experience joint damage. They’ll have to take medications long-term to prevent gout attacks.

Although everyone is different, and it’s difficult to predict when a gout attack will occur, it’s important to be aware of the warning signs of a gout attack, especially when you have chronic gout. This article will address how to recognize an acute gout attack, and it will also cover common chronic gout symptoms.

Common Symptoms of a Gout Attack
As mentioned above, pain and inflammation are the most common symptoms of a gout attack. Gout-related pain is sometimes described as sharp, throbbing, and crushing. The pain usually occurs without warning—it can wake you up in the middle of the night, or you might notice it first thing in the morning.

When you have a gout attack, the pain is constant, and the severity of the pain can fluctuate throughout the attack. Although attacks usually last about 3 to 5 days, the pain is most severe within the first 24 hours after the attack begins. After the pain goes away, you may notice some discomfort in the affected joint. This discomfort can last from a few days to a few weeks.

In addition to the pain, you may also notice that the affected joint is stiff, swollen, warm, red, and very tender. Those are signs of inflammation.

In addition to pain and inflammation, there are some other signs and symptoms of a gout attack you should look for.

  • Only 1 joint is affected: Your first gout attack generally affects only 1 joint (most often in the big toe, ankle, or knee), but other joints can be affected, too. You can also develop gout in the insteps of the feet, heels, elbows, wrists, and fingers. If you have more than 1 gout attack, the joint that’s affected typically doesn’t change. For example, if you have a gout attack in your toe, the next time you have an attack, it will likely be in that same toe. However, as you’ll read about later on, if gout becomes chronic, more joints can become involved.
  • Fever: Some people have a fever during a gout attack.

Not everyone who has a gout attack will have all of these symptoms. You may have just a couple of symptoms.

How to Recognize Chronic Gout
Again, it’s still possible to experience gout attacks with chronic gout. When you have chronic gout, you can have flares—a period of time when your symptoms intensify. Therefore, you need to be able to recognize the signs of a gout attack and work hard to prevent attacks.

In general, your doctor can make a chronic gout diagnosis if you experience 2 or more acute gout attacks within a 12-month period. Remember, pain and inflammation aren’t constant when you have chronic gout, but both symptoms do flare when you have a gout attack.

Additionally, your doctor will look at your uric acid levels. Extremely high levels of uric acid (greater than 12 mg/dL) may help your doctor with a chronic gout diagnosis. (In general, uric acid levels should be about 4 to 5 mg/dL). High levels of uric acid can also cause uric acid crystals to collect in your kidneys, which can lead to kidney stones—another chronic gout symptom.

Another sign of chronic gout is tophi. Tophi are chalky deposits of uric acid that look like little lumps under the skin of the affected joint. They usually develop only after you’ve had gout for several years.

Furthermore, multiple joints can be involved with chronic gout, and these joints can become damaged over time if gout is left untreated. Range of motion can also decrease in these joints. Your doctor can spot the first signs of joint abnormalities in imaging tests such as x-rays.

What to Do If You Have Gout Symptoms
If you develop gout symptoms such as sudden, excruciating pain in one of your joints, call your doctor. Although an acute gout attack will go away on its own even if you don’t treat it, gout that’s left untreated can eventually lead to more severe pain and joint damage. Recognizing the signs and symptoms of a gout attack can help you prevent future attacks.

Updated on: 11/18/15 View Sources

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Continue Reading: Gout Causes

The red, hot, swollen joints that signal acute gout attacks are nothing new to most hospitalists. They have appeared on inpatient wards in increasing numbers as gout has nearly doubled in the last 15 years in the general population, said James O’Dell, MD, FACP, president of the American College of Rheumatology.

“While we used to say was 1% to 2%, it’s at least double that now,” said Dr. O’Dell, who is also chief of rheumatology at the University of Nebraska Medical Center and the Omaha Veterans Administration.

Photo by Thinkstock.

At the root of gout is hyperuricemia, which may lead to the accumulation of monosodium urate crystals in the joints and nearby tissues. Acute attacks occur frequently among inpatients, triggered by blood volume changes with surgery, fluid shifts, medication changes, or other factors. However, patients also may arrive in the emergency department with an acute attack.

Despite its prevalence, gout often is not identified or treated properly. If it were, a lot of pain and expense could be avoided, Dr. O’Dell said.

“We know exactly how to take care of gout in 99% of patients, and if those fairly simple things are followed, 99% of gout patients will do extremely well and not have lots of morbidity, hospitalizations, and costs associated with their gout,” Dr. O’Dell said.

Making the diagnosis

A patient’s history can provide the first clues to diagnosing an acute gout attack. He or she may have a personal or family track record of gout and acute attacks in the hospital. The medication history may signal red flags, as well, such as chronic gout therapy that was discontinued on admission. The disease is linked to obesity, metabolic syndrome, diabetes, heart failure, cardiovascular disease, hyperlipidemia, diuretic use, hypertension, and kidney disease, so any of those can be an indicator.

Synovial fluid aspiration is considered the gold standard for diagnosis, experts said. This analysis—which includes culture, crystal analysis and cell count—determines whether the patient has gout, septic arthritis, pseudogout (calcium pyrophosphate deposition), a combination of those or other conditions, thus enabling prompt treatment.

“Ultrasonography and other techniques show promise, but in the vast majority of clinical situations are not appropriate for diagnosis or available at this time,” Dr. O’Dell said.

Serum urate levels are unreliable in making the diagnosis and they should not be used alone for this purpose, according to Brian F. Mandell, MD, PhD, professor and chairman of the department of medicine at the Cleveland Clinic Lerner College of Medicine.

“The serum urate level can be normal or low at the time of an attack, and it is frequently elevated in hospitalized patients for many reasons, but unrelated to whether a patient is experiencing a gout attack,” Dr. Mandell said.

It’s important to distinguish between attacks of gout and pseudogout, which can appear similar on clinical examination. Both are marked by hot swollen joints, fever and malaise, and both are more likely to flare after surgery. Gout is more common in the first toe, ankle, or mid-foot, but either condition can appear in a number of joints. While treated the same in the short term, long-term management is different.

Infection is a major concern in the differential of acute gout. “If somebody comes in with a red hot joint, exquisitely painful, and they don’t want to move it, the number one thing on your list of concerns should always be septic joint,” Dr. O’Dell said.

Swift diagnosis with aspiration is essential for septic joint, so the patient can begin antibiotic treatment immediately. Staphylococcus aureus is one of the most common causes of septic joints in otherwise healthy patients and destroys joint cartilage very quickly if not treated right away, he added.

Managing an acute flare

A common reason gout is mismanaged is because physicians confuse treatment of an acute attack with management of hyperuricemia.

“The worst thing you can do with a patient with acute gout is try to address the predisposing hyperuricemia—meaning starting the patient on a uric-acid-lowering agent—while he’s still having signs of acute inflammation,” said Tim Bongartz, MD, an assistant professor of rheumatology at Mayo Clinic in Rochester, Minn. “This can result in prolongation of the hospitalization, worsening of the flare and a lot of trouble.”

Acute attacks usually are managed with nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine or steroids (oral or intraarticular), depending on the patient’s comorbidities and potential medication interactions, he said.

Patients may be able to provide some treatment guidance. “If they have a history of gout in the past and they have been treated with a certain type of treatment, I usually ask what their response was,” said Seoyoung C. Kim, MD, a rheumatologist at Brigham and Women’s Hospital in Boston.

Physicians often prescribe oral NSAIDs for gout patients who don’t have kidney problems, congestive heart failure, or gastric ulcers; who are not taking anticoagulants; and who do not have other contraindications. Examples include 500 mg of naproxen twice a day or 50 mg of indomethacin three times per day, Dr. O’Dell said.

“If you want more frequent dosing, you can do ibuprofen 600 mg or 800 mg three to four times a day, if they have a pretty good kidney function and are otherwise not contraindicated for NSAIDs,” said Dr. Kim, who also prescribes naproxen sometimes.

Some physicians, including Dr. Bongartz, try to avoid using NSAIDs, however, because of potential kidney side effects.

If a patient has normal kidney function, no biliary disease, and no potential drug interactions, some clinicians use a short course of colchicine, beginning with 1.2 mg and adding 0.6 mg an hour later. In the results of the AGREE trial, published April 2010 in Arthritis & Rheumatism, this regimen provided significant (but not total) pain relief over 24 hours to patients taking the medication very soon after the onset of gout pain. It may not be enough to completely resolve the attack in all patients, however, and increasing the dose can cause diarrhea—a particular problem for patients with lower-extremity joint pain who cannot move quickly, Dr. Mandell noted.

Colchicine also interferes with two important pharmaco-metabolic pathways, Dr. Bongartz said. “Several drugs are excreted through these pathways, and you have a lot of interaction when you’re using colchicine,” he said. Cyclosporine, some antibiotics, and antifungal agents can potentially interact with colchicine, he added.

“Either patients are already on these agents in the hospital or there’s always a risk that somebody puts them on them and isn’t aware of these potential interactions. So colchicine is also something I’m trying to avoid,” Dr. Bongartz said.

If only one joint is affected and infection has been ruled out with a culture, intraarticular injection of steroids may be used when patients are taking a variety of other medications, he said. “Usually within 24 hours the patient does have significant relief,” Dr. Bongartz said.

Dr. Mandell agreed and cautioned that he would be reluctant to inject steroids if a patient was being treated for pneumonia, for example, until he knew the infection hadn’t settled in the joint.

If systemic corticosteroids are used, they’re most effective at moderate to high doses, with doses depending on the patient’s condition. Although the medication can raise blood sugar levels, inpatients can be monitored for this. When administering corticosteroids, it’s essential to treat the patient until the attack is completely resolved so it does not return. After complete resolution, Dr. Mandell begins tapering the drug over approximately five days.

“More recently, data and experience are accumulating that antiinterleukin-1 medications can be very effective, very rapidly in treating and resolving acute attacks of gout,” Dr. Mandell said. A medication like anakinra has no side effects in terms of kidney function or heart function, he added. “We do worry about coincident infection, if that’s going on, and that would be my main concern,” he said.

For inpatients who have no symptoms of acute gout currently, but mention a history of frequent gout attacks or attacks during past hospitalizations, clinicians may want to prescribe 0.6 mg of colchicine once or twice a day during the hospital stay to prevent an acute attack, Dr. Kim said.

Hospitalists dealing with this condition also may want to consult a rheumatologist, Dr. Bongartz said. “Apart from the very simple big toe flare of gout in the hospitalized patient, I think hospitalists shouldn’t be reluctant to involve a rheumatologist in the treatment of these patients—if one is available—just given the complexity of the different agents and the potential mistakes you can make with using these agents the wrong way,” he said.

Follow-up care

Arranging for adequate follow-up after gouty flare should be considered part of inpatient treatment, Dr. Bongartz said.

“You’re not done by successfully terminating the flare while the patient is in the hospital,” he said. “A lot of work will need to be done once the patient has left.”

For starters, the hospitalist needs to inform the patient’s primary care physician about how gout was diagnosed and treated. He or she also needs to ensure that the patient will receive prophylactic uric acid-lowering therapy after leaving the hospital, with the goal of lowering the level to less than 6 mg/dL over a few weeks, Dr. Bongartz said.

“Then usually prophylactic therapy has to be continued for about six months after the patient reaches this goal of below 6 mg/dL, because we have this paradox, a fact of uric acid-lowering therapy, that initially patients will actually be at a high risk of having flares during that uric acid-lowering phase,” he said.

A patient must continue chronic gout therapy (allopurinol or colchicine) if he or she was taking such medication before admission, unless there is an acute medical issue that precludes use of the medication, Dr. Kim said.

Pseudogout is usually treated with chronic antiinflammatory therapy as needed, and possibly colchicine to decrease the frequency of attacks and to treat attacks when they occur. Uric acid-lowering therapy is not effective for pseudogout, Dr. Mandell said.

Patients are important partners in long-term gout management, experts said. They need to understand the difference between an acute attack and treatment of the underlying problem. If they don’t understand the treatment process, they often mistakenly wait to take allopurinol until they have an acute attack.

“That’s exactly the wrong thing to do,” Dr. O’Dell said. “They need to be taking on a very chronic basis. they wouldn’t have those flares.”

Diane Donofrio Angelucci is a freelance writer in Clarksboro, N.J.

© andreas160578/ These are the five common causes why your feet during the night.

Nighttime foot pains cause extreme discomfort and disturb your sleep. The culprit behind these episodes may be wearing footwear that is too small for your size. Other times, it may be a sign that you are actually suffering from something worse than just foot pain.

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Excessive Alcohol Consumption

Nighttime foot pains may be caused by excessive alcohol consumption. This unhealthy vice leads to alcoholic neuropathy which causes burning feet, weakened muscles, muscle spasms and loss of muscle function, as per Health Line.

Peripheral Neuropathy

According to the National Institute of Neurological Disorders and Stroke, peripheral neuropathy is a nerve disorder that causes pain and numbness in your hands and feet. The disorder results from suffering diabetes, certain cancers, immune disorders, kidney failure and vitamin deficiency. These diseases cause partial to complete interruption of a nerve fiber called axon in your foot or ankle. The uncomfortable sensations subside when you walk around but come back when you are immobile.

Morton’s Neuroma

This is the thickening of the tissues around the nerves in your feet leading to your toes. OrthoInfo pointed out that the condition affects your third and fourth toes when you experience excessive pressure, trauma or irritation. It is also more common among women than men.

Symptoms include a burning or tingling sensation, numbness and cramping which worsens during the night. Oftentimes, Morton’s neuroma is caused by wearing footwear that is too tight for your feet. Bunions and mallet toes or hammertoes also cause this condition.

Pinched Nerve

When your nerves are entrapped, you feel a throbbing pain in your foot that gets worse during the night. Medline Plus linked this to a compressed nerve root in the lower back that travels along the sciatic nerve, which extends to the back of each leg up to the toes.

A pinched nerve may also be caused by holding your body in one position for longer periods which causes swelling and numbness. The painful sensations also get worse at night.

Restless Leg Syndrome

The National Sleep Foundation claimed that one in 10 people suffers from Restless Legs Syndrome, a condition that causes nighttime foot pain. It is caused by an imbalance in dopamine responsible for transmitting brain and nerve signals throughout the body. This is a genetic condition more common in adult women.

It is a common illness among those who suffer from diabetes, rheumatoid arthritis, kidney failure and iron deficiency.

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