What to do for gout in foot?

10 Steps to Ease a Gout Attack

  1. See your doctor. “The first thing you need to do is make sure it’s gout. If there is any doubt about the diagnosis, the best test for gout is to remove fluid from the joint and examine it under a microscope,” says Leisen.
  2. Rest. The best place to be during a gout attack is in bed.
  3. Ice it down. Putting ice on the affected joint will reduce the inflammation.
  4. Get naked. At least the part that hurts. Keep the foot bare, and probably your leg, too. The weight of any clothing or bedding material probably will add to your pain.
  5. Watch your diet. Gout can be aggravated by a diet high in animal protein and by alcohol, so limit your intake of meat and avoid alcohol completely during a gout attack.
  6. Stay hydrated. “It’s important to drink enough water during a gout attack,” advises Leisen. This can help flush the uric acid crystals that cause gout out of your system.
  7. Take over-the-counter pain medication. Ibuprofen (Motrin) is a typical non-steroidal anti-inflammatory drug (NSAID) used for management of acute gout pain. “If you don’t have renal disease, NSAIDs are the best drugs for pain management,” says Leisen.
  8. Try steroids. The steroid drug prednisone can be used for patients who can’t take NSAIDs. Prednisone is usually given by mouth with the dose tapered down over 10 to 14 days. If you’re hospitalized, steroids can be given intravenously.
  9. Ask your doctor about gout-specific drugs. Colchicine (Colcrys) is taken orally to relieve an acute gout attack. It works by blocking the uric acid crystals that lodge inside your joint and cause gout. Colchicine is usually effective if taken within 12 to 24 hours of a gout attack. Allopurinol (Zyloprim) may be given to people who have repeated attacks of gout; it interferes with the development of uric acid. Probenecid is a medication that works by helping your kidneys get rid of uric acid. For more on newer drugs to treat gout, see “Get the Latest on Gout Medications.”
  10. Be patient. “Sometimes the best advice is to be patient and wait it out. A gout attack usually clears up within a few days. Take the medicine prescribed by your doctor and stay in bed. You will get better soon,” says Dr. Leisen.

Many patients will go a long time between attacks. In fact, for 62 percent of patients the next attack will be more than a year away, and some won’t have another attack in the next 10 years. However, if you begin to have more frequent attacks, talk to your doctor about which long-term drug therapy might be helpful for you.

The sooner you start treatment and pain management, the more quickly you will be back on your feet.

Gout is actually a form of arthritis that commonly affects the big toe in men. It may cause a sudden burning pain in one of your joints, or stiffness and swelling in one or more joints. Attacks of gout can happen repeatedly unless it is treated. Eventually, gout attacks can cause long-term damage to your tendons, joints, and soft tissues.

Uric Acid Is The Cause

When there is an overabundance of uric acid in the blood it is called gout. Usually, having too much uric acid in the blood is not harmful. In fact many people with high levels in their blood never know about it. When uric acid levels in the blood become extremely high, the uric acid may start to form crystals. These crystals most commonly form in the joints, especially the joints in the big toe. Your odds of experiencing the pain of gout are higher if you are overweight, drink excessive amounts of alcohol, or have a diet that is comprised of meat and fish that are high in chemicals called purines.

Pain And Swelling Are Gouts Calling Cards

The most frequent signs of a gout attack are swelling, tenderness, redness, and a sharp pain in your big toe. These attacks are most common at night when you are sitting still and laying flat on your back. While gout usually manifests in the big toe, you may also experience gout attacks in your foot, ankle, or knees. The attacks can be short or long, anywhere from a few days to weeks and you may not have another attack may for months or years.

Leading A Gout Free Life

In order to avoid gout attacks, your gout physician may prescribe a medication to reduce the buildup of uric acid in your blood. In most cases patients take this medicine for their entire life, but there are things that you can do reduce the chances of needing a lifetime of medication. Pay special attention to what you eat. This can help you manage the buildup and uric acid and reduce the frequency and duration of your gout attacks. Eating appropriate amounts of a healthy variety of foods to keep your weight under control and to get the nutrition you need. Try to avoid frequent or daily meals consisting of meat, seafood, and alcohol. As always you should drink plenty of fluids, especially water.

Treating A Gout Attack

The methods of stopping an attack of gout can vary depending on the severity of pain. Your orthopedic physician may give you a shot of corticosteroids. They may also prescribe other types of medications that are specifically designed to treat gout. To ease the pain during a gout attack, rest the joint that hurts. Non-steroidal anti-inflammatory medicine may also be prescribed to help reduce the pain. The good news is that following treatment, relief from the pain and discomfort of a gout attack often begins within 24 hours. It is important to still make an appointment with your orthopedic physician even if your pain from gout is gone. The buildup of uric acid that led to your gout attack can still harm your joints. An orthopedic physician will help you get relief from the pain of gout attacks and learn ways to prevent flare-ups in the future.

This information is not intended to provide advise or treatment for a specific situation. Consult your physician and medical team for information and treatment plans on your specific condition(s).

Gout – symptoms, diagnosis, treatment

Gout is a common form of arthritis that can affect toe, foot, ankle, knee, hand and elbow joints. Symptoms include pain, swelling and shiny redness over the affected joints.

Treatment of acute gout attacks is designed to relieve pain and inflammation, primarily through medication. Diet and other lifestyle changes can help prevent future attacks.

General information

Gout is a form of arthritis (inflammation of the joints) that can cause sudden, severe attacks of pain in the joints. The most common place for gout to develop is the ball of the big toe but other joints can be affected. It is unusual for gout to affect more than one or two joints at a time.

Gout is common in New Zealand, with an estimated prevalence of 2.7% for the overall population and a prevalence of 3.75% in people aged 20 years or older.

Gout most commonly affects adult men (particularly after age 40) and is uncommon in women until after menopause. It is estimated to affect adult men 3.5-times more than women and is more common in people of Maori and Pacific Island ethnicity.

Without treatment gout may take up to a week for symptoms of an attack to subside. At first, the time period between attacks can be as long as several months or even years. However, over time attacks tend to occur more frequently and be more severe.

Left untreated over time gout can lead to joint and kidney damage and, in conjunction with other risk factors such as high blood pressure and diabetes, can increase the risk of heart disease, stroke, and kidney failure.

Causes

Gout is caused by raised levels of uric acid in the blood. Uric acid is produced naturally in the body. Normally it stays dissolved in the blood and is excreted by the kidneys as a component of urine.

However, accumulation of uric acid in the blood can cause crystals of uric acid to form and deposit in the joints, causing gout.

A number of risk factors are related to the development of gout. These include:

  • Obesity
  • High alcohol intake
  • A genetic predisposition
  • High intake of foods rich in purines (eg: some seafoods and meats)
  • Certain medicines eg: diuretics (fluid tablets)
  • Injury to a joint
  • Long-standing kidney disease.

High uric acid levels are more likely to be caused by the body not eliminating uric acid properly (due to obesity, kidney problems or genetics) than by what a person eats and drinks.

Maori and Pacific people are at higher risk of getting gout because they have genes that make it harder to eliminate uric acid from their bodies.

Occasionally there is no obvious cause for an attack of gout.

Signs and symptoms

Gout develops quickly, often within 12 to 24 hours, and tends to come and go. Signs and symptoms of a gout attack include:

  • Severe pain and tenderness in the affected joint
  • Swelling of the affected joint
  • The skin over the joint may feel hot and tight and may look shiny and red
  • Limited range of motion in the affected joint.

Some people may also experience nausea, a loss of appetite, and a slight fever.

Diagnosis

Gout can be difficult to diagnose because the symptoms may mimic those of other conditions such as joint infection.

A blood sample may be taken to check for alterations in normal blood levels and a raised uric acid level. Results of this test may not always be helpful, however, as they often indicate normal uric acid levels during an attack of gout. This is likely to be because the excess uric acid has moved out of the blood and has settled as crystals in the joints.

To make a definitive diagnosis of gout the doctor may take a sample of fluid from the affected joint. This is performed using a local anaesthetic and involves inserting a needle inserted into the affected joint and removing a small amount of fluid. The fluid is then sent to a laboratory where it is tested for the presence of uric acid crystals. If they are present, then gout is confirmed. X-rays of the affected area may also be taken to check for joint damage.

Treatment and prevention

Medical treatment is aimed at relieving the pain and inflammation of acute attacks and preventing the occurrence of future attacks. Diet and lifestyle changes also help to prevent future attacks of gout.

Treatment of acute attacks:

The more promptly that effective treatment is commenced, the more quickly the attack can be controlled. The different types of medications used include:

  • Medications to reduce pain – particularly non-steroidal anti-inflammatory medications (NSAIDs) like ibuprofen. Taken early in the attack, they can reduce the duration and severity of the attack. Paracetamol, taken in conjunction with other medications, can also help in reducing pain. Aspirin should be avoided as it can reduce the amount of uric acid excreted by the body.
  • Colchicine – this medication helps to block production of uric acid. It is most effective when taken early in an attack. However, it can have side effects such as diarrhoea if too much is taken. Dosage instructions should be followed carefully.
  • Corticosteroids – such as prednisone may be given in tablet form to help reduce pain and inflammation. Corticosteroid injections directly into the joint may also be effective.

Drinking extra fluid (preferably water) while taking these medications is recommended. The affected joint should also be rested and elevated.

Preventing future attacks:

Preventing attacks of gout is as important as treating the symptoms of an acute attack. Ways in which gout can be prevented include use of medications and lifestyle changes.

Medications – the mainstay drug for people with gout is allopurinol, which acts to reduce uric acid production. People who cannot take allopurinol because of side effects or other reasons may be prescribed alternative medications which either reduce uric acid production or increase the excretion of uric acid by the kidneys.

In the initial stages of treatment with medications to prevent gout, attacks may occur more frequently and may be more severe. For this reason, the dosage of the medications may be low to start with and is then gradually increased. These medications should only be discontinued on the advice of a doctor as stopping and starting them can also bring on a gout attack.

Dietary modifications – changes in diet are aimed at restricting or avoiding foods high in purines. Purines are substances found in some foods and produce uric acid when broken down by the body. Foods high in purines include:

Limiting alcohol intake – is also important. Alcohol causes the body to lose fluid (by increasing urine output and drawing water from the blood), thus increasing the uric acid levels in the blood. Beer is rich in purines so should be avoided.

Drinking plenty of non-alcoholic fluids – especially water (eight to 10 glasses a day) is recommended. This will help to flush the uric acid crystals out of the body. Soft drinks, fruit juice and drinks sweetened with fruit sugar (fructose) are best avoided as they can increase uric acid levels.

Maintaining a healthy body weight – will help to reduce stress on affected joints and decrease the likelihood of developing gout.

Complications

If uric acid levels remain raised for long periods of time, or there are frequent recurrent attacks of gout, deposits of uric acid salts may form around the affected joint and appear on the skin as chalky coloured nodules. These are called tophi and may also appear in other areas of the body such as the ears.

Recurrent severe attacks of gout and the development of tophi can cause permanent damage to the joints. Surgery may be required to restore joint function. This may involve joint replacement surgery.

Damage to the delicate filters within the kidneys and the development of kidney stones can also occur if uric acid levels in the blood remain raised for long periods of time. This in turn can impair kidney function. To prevent the complications of gout it is important to carefully follow the treatment instructions given by a doctor to deal with gout attacks quickly, and prevent them from recurring.

Further information

For further information and support contact your doctor, practice nurse, or:

Arthritis New Zealand
Free phone: 0800 663 463
Email: [email protected]
Website: www.arthritis.org.nz

Last Updated: May 2019

How to Get Rid of Gout Tophi Naturally

Tophi gout is that painful stage in gout where horrible-looking ‘lumps’ appear at the joints. And if left untreated they can cause some serious issues. Luckily, there are drugs that can help, but they can have side effects, and, they need to be taken regularly. But, there are natural treatment alternatives for tophi gout you should discuss with your doctor.

Tophi (tophaceous) gout is caused by the build-up of uric acid salts (monosodium urate crystals) in and around the joints affected by gout. This usually happens as a result of prolonged, frequent, and repetitive gout attacks arising from elevated uric acid levels in the bloodstream.

They are normally seen as chalky-colored, bulging lumps under the skin at the joint(s) affected. And although by far the most common joint for gout is the big toe, tophi can appear in almost any joint. They can also be seen at the ear ridges.

Apart from the fact that they are horrible and unsightly, untreated tophi can eventually lead to serious complications such as permanently damage to joints and surrounding tissue. They can also become ulcerated and septic, so septicemia is a possibility that would need urgent medical attention.

Since tophi is caused by continuously elevated uric acid levels, the key is to reduce those levels and keep them at a level that prevents tophi forming. Of course, this also means that recurring gout attacks are prevented.

There are various drugs available (such as allopurinol) that can help to lower and maintain uric acid at healthier levels. And they seem to work pretty well. But, they are only effective whilst being taken. Once they are stopped there is nothing to prevent uric acid levels rising again. Which is why many sufferers end up taking them for years on end. And, unfortunately, they do have some nasty side effects for many people.

Which is why more and more people are turning to more natural alternatives to get rid of tophi gout. There are many natural remedies that can help to neutralize and lower uric acid levels. There are also remedies that have natural anti-inflammatory properties. Typical are herbs such as alfalfa, burdoch and buchu. Also things like natural kidney cleanses.

But underpinning the whole natural approach is your diet. Since uric acid is actually produced by the breakdown of purines in our bodies and food, gout sufferers, and especially those with tophi gout, need to go on a low-purine diet. Otherwise you are just producing more and more uric acid which your kidneys can’t process and excrete efficiently enough.

Dietary information is too detailed to go into here but, generally speaking, gout victims need to avoid high-purine foods within the following groups; red meats, gravy, meat extracts, poultry, fish, shellfish, vegetables, etc. plus, yeast products and alcohol.

How to Get Rid of Gout

Table of Contents

How to Get Rid of Gout and Other Gout Remedies

Gout is a condition that, when left untreated, can develop into chronic, recurring symptoms that significantly affect quality of life. Gout is caused by the buildup of uric acid crystals in a joint and, as the condition progresses, multiple joints are often affected. These needle-like crystals cause intense pain, swelling, redness, and warmth at the affected site. The big toe is the most commonly affected joint, but gout is also found in the mid-foot joints, ankles, knees, and wrists.

Unfortunately, there are currently no known gout cures available to patients. However, there are many remedies for gout that can significantly decrease the severity and duration of gout attacks. It is important to act fast when the symptoms of gout appear so that interventions can be taken before the pain and discomfort intensifies. Early treatment can also prevent bone, nerve, and tissue damage that is associated with severe, chronic gout. Read on to find out how to get gout relief.

How Do You Know if You Have Gout?

Gout has several distinctive qualities that can help distinguish it from similar conditions such as rheumatoid arthritis and septic arthritis. Primarily, a gout attack will have a very rapid onset, generally developing and worsening over a few hours. It is common for a gout attack to creep up in the middle of the night, causing pain intense enough to wake you up from dead sleep. If your joint pain has developed slowly over days or weeks, it is unlikely that you have gout.

The affected joint or joints can also give you clues as to whether you have gout. If the big toe is affected, and especially if it is the only joint affected, you can suspect that you experiencing a gout attack. If multiple joints are affected, especially if the same joints on both sides of your body are affected, it is more likely that you suffering from a different condition, such as rheumatoid arthritis.

You can also look at your recent past for events that tend to precede a gout attack. Minor trauma to the joint can disturb uric acid crystal deposits and trigger an attack. Additionally, a long weekend of indulging in alcohol and foods high in purines (e.g. red meat, organ meat, oily fish, high fructose corn syrup) can trigger a gout attack.

How is Gout Diagnosed?

The most accurate test examines the synovial fluid of the affected joint through a procedure known as arthrocentesis. Your physician will use a needle to extract a sample of your synovial fluid, and then it will be sent to a laboratory to be examined for the presence of uric acid crystals. The test or medical center may refer to these crystals as monosodium urate (MSU) crystals. If, instead of MSU crystals, arthrocentesis reveals calcium deposits, a different disease called pseudogout is the more likely culprit. Alternatively, if arthrocentesis reveals the presence of bacteria, it is a likely indicator of an infection or septic arthritis.

A blood test can also be administered to check uric acid levels. This diagnostic test is less accurate, but it is also less invasive and may be favorable for some patients. The test is usually done during the asymptomatic period between gout attacks in order to get the most accurate reading.

In some cases, primarily when a recurrent gout attack is suspected, x-rays may be taken to look for the presence of tophi (more information on tophi below). These clumps of uric acid crystals will appear on an x-ray before they are readily apparent to the naked eye.

How Long Does a Gout Attack Last?

Once a gout attack begins, the symptoms tend to intensify over the next eight to twelve hours. Once the symptoms have reached their peak, they will ease after a few days and ultimately resolve within a week to ten days. Initial attacks will generally resolve with or without treatment. Subsequent attacks tend to require dedicated treatment. Regardless, it is recommended that you seek treatment as soon as you suspect you may be dealing with gout in order to help relieve symptoms and manage pain, and to avoid potential long term damage to the joint.

Gout Treatments and Medications

Since there is no cure for gout, the majority of gout treatments during a flare up focus on the alleviation of pain and the control of inflammation. Your doctor can prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) such as:

Never take aspirin (e.g. Bayer) as a pain reliever during a gout attack – it can affect the levels of uric acid in the body and ultimately worsen an attack.

If you suffer from chronic gout, your primary care physician may prescribe you a gout specific medication such as:

  • Allopurinol (Aloprim, Zyloprim) – used to help control uric acid levels by reducing the amount made by the body. This medication does not relieve pain, so you may continue taking NSAIDs, as well. Allopuriol can take several weeks before it begins to be effective. While your body is adjusting to the medication, be aware that you may see a temporary increase in gout attacks, but this does not necessarily mean that it is not working.
  • Colchicine (Colcrys) – used to both treat episodes and prevent future flare-ups. Colchicine lowers uric acid levels and decreases swelling. Fascinatingly, treatment involving this extract from the autumn crocus (Colchicum autumnale) has been around for centuries, with it first being described as a treatment for gout in the first century AD.
  • Febuxostat (Uloric) – Febuxostat is a xanthine oxidase inhibitor that was just approved for use by the FDA in 2009. This drug inhibits xanthine oxidase, which is an enzyme that is involved in the metabolism of purines or creation of uric acid. By inhibiting the conversion of purines into uric acid, it decreases the amount of uric acid produced by the body.
  • Probenecid (Benemid, Probalan) – used to prevent gout; it will not help treat an active episode and may make it worse. Probenecid is part of a class of medications known as uricosurics. These types of medications lower the levels of uric acid in the body by acting on the kidneys and increasing their ability to process uric acid.
  • Pegloticase (Krystexxa) – used to treat severe, refractory (treatment resistant) gout when other treatments have been unsuccessful or cannot be tolerated. It converts uric acid into allantoin which can then be excreted in the urine. Pegloticase is administered by a healthcare practitioner through an injection.

What Happens When Gout is Left Untreated?

When gout is left untreated for several years, or when medical interventions prove unsuccessful, the uric acid deposits may accumulate into large clumps known as tophi. Approximately 12-35% of patients with gout ultimately develop tophi. Tophaceous gout ranges from mild to severe cases, with mild cases growing slowly and only affecting one joint, and severe cases often affecting 4 or more joints with rapid growth and ulceration of the overlying skin. In severe cases, the patient is at additional risk of developing infections within the joint. Additionally, tophi that are left untreated can deform bones, damage tissue, and compress nerves.

For many tophaceous gout patients that have not sought out treatment previously, the introduction of one of gout-specific medications that lower uric acid, listed above, can help with breaking down and getting rid of the tophi. However, a subset of patients have shown not to respond to these treatments. In other cases, the tophi may be particularly severe and debilitating, making waiting for medicinal treatment to become effective too hard (e.g. risk of permanent joint destruction or neuropathy/nerve damage). In these scenarios, surgery is often recommended.

Remedies for Gout Pain

In addition to the medication interventions that your doctor recommends, there are several non-medicinal remedies that can help to relieve symptoms and help prevent recurring attacks:

  • Keep the affected area warm – while using a cold pack may provide temporary pain relief, and you will often see it recommended on various healthcare sites, studies show that cold temperatures actually facilitate the development of uric acid crystallization. If you choose to use cold packs for pain relief, be aware that you may be exchanging long term benefits for temporary relief.
  • Rest – resting the joint will help prevent the pain from worsening. Stay off of your feet as much as possible, and considering using a cane or crutch to help support your weight when moving around.
  • Elevate – if your foot or other lower extremities are affected, elevate the affected site above your heart while you are resting.
  • Hydrate – not only will staying well hydrated help to flush uric acid from your system, it will also help to prevent the development of kidney stones.
  • Relax – stress can aggravate your gout and contribute to the severity of the gout attack.

Preventing Recurring Attacks

Lifestyle changes have the greatest potential to decrease the incidence of recurring attacks. If you have experienced gout, especially more than a single episode, you can benefit from changes to your daily habits and diet:

  • Strictly adhere to any medication regimens that your doctor prescribes.
  • Stay active and exercise. If you are obese, losing weight will lower your risk as well. Consult with your doctor to discuss safe ways of slowly losing weight.
  • Avoid foods high in purines, such as red meat, organ meat (e.g. liver or kidney), high fructose corn syrup and other foods high in fructose, oily fish, and shellfish
  • Limit alcohol intake and stay well hydrated.
  • Eat cherries or drink cherry juice – cherry juice has been shown to decrease the likelihood of recurrent gout attacks. This is due to anthocyanins, which are a pigment in the plant with powerful antioxidant and anti-inflammatory properties.
  • Manage stress – activities such as yoga or meditation can help you keep your daily stress levels in check, and avoid triggering a recurrent gout attack.

While the treatments listed above all have proven effectiveness, consulting a physician for an accurate diagnosis before using home treatment is usually the best course of action. If you or a loved one are experiencing gout-like symptoms, you can make an appointment with your primary care physician or visit an urgent care center in order to be properly diagnosed.

Gout

Background

Gout is a common disorder, which affects around 1% of the population. It is caused by excess uric acid, which exists as ionised urate in the blood. Saturated plasma urate (blood levels above 0.42 mmol/L) may slowly form monosodium urate (MSU) crystals that are deposited in the joints, kidneys, and soft tissues, eventually resulting in arthritis, kidney damage, and lumps under the skin respectively.

In healthy individuals, uric acid / urate is formed after eating certain high-protein foods. Usually most of the uric acid is then excreted by the kidneys in the urine. Excess urate in the blood can result from:

  • A diet that is high in animal-based protein, especially meat and seafood.
  • Moderate to high alcohol intake, especially of beer.
  • High intake of fructose, a sugar found in sugar-sweetened soft drinks and fruit juices (apples and oranges).
  • Being overweight – gout is associated with the metabolic syndrome.
  • Some medications, including diuretics, low-dose aspirin and ciclosporin.
  • Kidney disease can reduce urinary excretion of uric acid.
  • Overproduction of uric acid can occur in disorders that cause high cell turnover, such as some myeloproliferative disorders (excessive numbers of cells produced by the bone marrow) and some types of anaemia (haemolytic anaemia and pernicious anaemia).

Other risk factors for gout include:

  • Having a family history of gout.
  • Age – in general, uric acid levels are elevated for 20 years before gout develops. In men uric acid levels rise at puberty so gout is often diagnosed in their 4th to 6th decade of life. Oestrogen protects young women from gout; uric acid levels rise at menopause and gout is often diagnosed in their 6th to 8th decade of life.

Clinical features of gout

In most cases, the first attack of gout presents with extreme pain and swelling in a single joint, often the big toe (podagra). The pain begins abruptly and the joint is red, hot, and extremely tender. Occasionally the first attack of gout affects multiple joints simultaneously. Patients may have a fever, particularly if many joints are involved. Untreated attacks of gout usually last 7-10 days, following which the patient may be symptom-free until the next attack.

Acute gout

Initially, attacks of gout may be months or years apart. An attack of gout can be brought on by:

  • A sudden increase in blood urate level, e.g. after an episode of binge-drinking, eating a large quantity of high-protein food, dehydration, trauma, or starting a medication that raises uric acid.
  • A sudden decrease in blood urate level, e.g. after starting a medication that lowers uric acid.

If gout remains untreated, the following complications can occur:

  • Attacks become more frequent, last for longer, and involve more joints.
  • Collections of MSU crystals, called tophi, develop in the soft tissues and appear as firm lumps under the skin. Tophi generally develop around 10 years after the first attack of gout in untreated patients and are commonly found around the elbows, hands, and feet. Tophi contain a white pasty material and as they enlarge they work their way towards the skin surface to drain. Small sinus tracts (tunnels) may develop and secrete white pasty material. Alternatively a large blister may form, which ruptures leaving a continuously draining ulcer.
  • Tophi develop in and around the joints leading to joint destruction and chronic (long-term, continuous) joint pain and stiffness.
  • Panniculitis (inflammation of the fat under the skin) is a rare complication of gout. This presents as nodular (lumpy) lesions of the legs that ulcerate and drain a fluid that contains MSU crystals.
  • MSU crystals can be deposited in the kidneys producing inflammation and scarring (called chronic urate nephropathy). Kidney stones are also common in patients with gout.
Gouty tophi

More images of gouty tophi …

How is the diagnosis of gout made?

  • Gout is diagnosed in the initial attack by using a needle and syringe to extract a small sample of fluid from around the affected joint space. MSU crystals can be identified under the microscope. This test is also important to rule out other causes of an inflamed joint, such as infection.
  • If a biopsy sample is taken, the specimen should be placed in alcohol, as formalin dissolves urate crystals.
  • Joint x-rays may show findings consistent with gout, but these findings are not diagnostic on their own. Furthermore, early on in the disease, x-rays may be normal or show soft tissue swelling only.
  • Urate levels may be elevated in the blood, but this finding alone is not diagnostic. In some cases, the level may even be below urate saturation.

What is the treatment for gout?

The treatment of gout is divided into 3 phases: treatment of the acute attack, uric acid-lowering therapy, and prevention of acute flares.

Treatment of an acute attack of gout

Options for treatment to relieve the pain of an acute attack of gout include:

  • NSAIDs (non-steroidal anti-inflammatory drugs) – These are generally the medicines of choice for most patients who do not have underlying health problems. Aspirin should be avoided as it can alter urate levels and worsen the attack.
  • Corticosteroids – If only one joint is involved, corticosteroids can be injected directly into the joint space. Otherwise, oral prednisone 20-40mg daily is prescribed for 10-14 days.
  • Colchicine – Up until recently, colchicine was the treatment of choice for acute gout. However, due to recent safety concerns, colchicine is now only recommended if NSAIDs or corticosteroids are inappropriate. High dose colchicine therapy is no longer recommended because of its toxicity.

The above medicines do not prevent joint damage, tophi, or kidney disease.

Medicines to reduce uric acid

Long term management of gout focuses on lowering urate levels, aiming for levels under 0.36 mmol/L, or better still, under 0.30 mmol/L. These medicines can prevent attacks of gouty arthritis and prevent MSU crystals from being deposited in the tissues. Medicines that lower urate levels should not be started during an acute attack of gout; instead they should be started a few weeks after the attack has resolved.

Allopurinol

Allopurinol is an effective uric-acid lowering therapy, but it has a number of side effects and interactions with other medicines.

Dermatological side effects of allopurinol range from a mild morbilliform eruption (measles-like rash, which resolves when the drug is discontinued) to Stevens-Johnson syndrome / toxic epidermal necrolysis and drug hypersensitivity syndrome. Drug hypersensitivity syndrome is rare but potentially very severe. It usually occurs within the first 6 weeks of therapy but some cases have been reported up to 12 weeks after starting allopurinol.

The dose of allopurinol should start low at 100mg daily. The dose should be increased every 3-4 weeks, while monitoring blood urate level – aiming for a fall of under 0.04 mmol/L each month and eventual level below 0.36 mmol/L. Some patients may require doses of 600 to 900 mg daily to achieve this. The dose should be lower in those with kidney disease.

Febuxostat

Febuxostat (trade name Adenuric®) is a new medication for gout that may be used to reduce urate levels in patients with poor kidney function or intolerant of allopurinol. Phase III clinical trials have reported febuxostat to be more effective than allopurinol at a dose of 300mg. It is funded in New Zealand for treatment–resistant patients or those unsuitable for allopurinol, with Special Authority criteria.

Probenecid

Probenecid is an alternative uric acid lowering medicine with fewer significant side effects than allopurinol.

It is important to drink plenty of fluids while on probenecid, to flush out the uric acid and prevent crystals forming within the kidneys or urinary tract.

The starting dose of probenicid is usually 250 mg twice daily but it may need to be increased to up to 1 g twice daily.

Benzbromarone

Benzbromarone is a new medication for gout that may be used to reduce urate levels where allopurinol and/or probenecid are contraindicated, not tolerated, or are ineffective. Liver function must be monitored on benzbromarone, as it is reported to cause hepatic toxicity.

Prevention of acute flares

Acute flares of gout can be precipitated by the sudden reduction in blood urate that occurs when uric acid lowering medicines are started. For this reason it is important to take a low (preventative) dose of a NSAID or colchicine to reduce the likelihood of a flare developing. In patients unable to take either of these medicines, an oral corticosteroid can be considered. Patients who have only occasional attacks of gout, may only need to take these medicines for 2-3 weeks. Whereas patients with multiple tophi may need to continue treatment for months.

General measures in gout

Although lifestyle changes rarely result in adequate reduction in plasma urate without medication, the following are recommended.

  • Weight loss in obese patients
  • Reduction in alcohol intake
  • Avoidance of soft drinks sweetened with fructose
  • Restrict intake of liver, kidneys, fish, yeast extracts, red meat
  • Consider alternative medication if on diuretic for hypertension

Stop treating gout and start curing it, physician urges

LAS VEGAS – Brian F. Mandell, MD, PhD, of Cleveland Clinic, has a message about one of the most devastating conditions that rheumatologists see: Gout isn’t just a treatable disease. It’s a curable one.

Dr. Brian F. Mandell

Still, research shows time and time again that physicians manage gout “horrendously,” he told colleagues at the annual Perspectives in Rheumatic Diseases held by Global Academy for Medical Education. “The problem really lies with us,” he said. “We need to do a better job.”

At issue, he believes, is a failure to consider the basic workings of gout when making treatment decisions and advising patients. Lowering serum uric acid (SUA) via medication works, he said, but physicians too frequently don’t go far enough with this approach.

Gout appears to be on the rise in the United States, reflecting increases in related conditions such as obesity and diabetes. A study published this year found that the rate of new-onset gout more than doubled in Olmsted County, Minn., from 1989-1992 to 2009-2010, reaching an adjusted rate of 137/100,000 (J Rheumatol. 2018 Apr;45:574-9).

According to Dr. Mandell, various mysteries regarding gout still need to be cleared up. For one, does resolution of gout also resolve conditions related to hyperuricemia, such as onset of hypertension, progressive chronic kidney disease, and nonalcoholic fatty liver along with higher all-cause mortality?

“We don’t know from interventional studies whether these are as reversible as the gouty arthritis,” he said.

It’s also unknown why so many hyperuricemic patients don’t get flares, with one study estimating that about 50% don’t get them over 15 years (Arthritis Rheumatol. 2017;69: Abstract 2843).

One fascinating theory, Dr. Mandell said, suggests “the microbiome is playing a huge in the body’s response to deposits of crystals.”

Fortunately, he said, other mysteries about gout are being solved.

It’s now clear that lowering SUA below 6 mg/dL with medication will reduce flares, Dr. Mandell said. He pointed to a 2017 study of 314 patients with early gout that found 63% of patients who took febuxostat (Uloric) lowered their SUA below 6 mg/dL, compared with just 6% of the placebo group. The overall percentage of patients who had at least one gout flare over 2 years was 29% in the febuxostat group vs. 41% in the placebo group (Arthritis Rheumatol. 2017;69:2386‐95).

It’s also clear that maintenance of lower SUA levels is crucial to prevent recurrence, Dr. Mandell said.

So why is management of hyperuricemia so poor? He ticked off various possible explanations: Maybe it’s the medications. Or perhaps patient compliance is low.

But the drugs are fine, he said, although he cautioned that too-rapid lowering of SUA levels can provoke attacks. He pointed to a 2014 study that suggests allopurinol can help nearly all patients get their SUA below 6 mg/dL, and in the study, the drug was “generally well tolerated” (Semin Arthritis Rheum. 2014 Aug;44:25-30).

As for compliance, Dr. Mandell said, it can be boosted by patient education. The problem, he said, is that physicians are failing patients by not up-titrating allopurinol despite evidence that this approach works.

He added that hyperuricemia can be managed even in patients on diuretic therapy (Arthritis Res Ther. 2018;20:53).

What about patients who are intolerant to allopurinol or don’t fully respond to it on the SUA front? Dr. Mandell said he likes to try febuxostat, although he noted that it’s tremendously more expensive than allopurinol in the United States with a price that could be 10 times higher.

The nonscored design of febuxostat pills makes dose adjustment difficult in patients, he said, and there are concerns about heart-related and all-cause deaths.

Lesinurad (Zurampic) may be helpful for patients with hyperuricemia that doesn’t response to high doses of xanthine oxidase inhibitors (XOI) or if they’re intolerant to lower inadequate doses, he said. Avoid the drug in patients with chronic kidney disease, he cautioned, and be aware that it’s not approved as a monotherapy. Instead, it’s approved by the Food and Drug Administration for use with an XOI.

As for other gout issues, Dr. Mandell said pegloticase (Krystexxa) via infusion can help patients who don’t respond to an XOI but infusion reactions can occur (mainly in nonresponders), and it’s extremely expensive (about $20,000 per month).

He added that anti–IL-1 therapy is effective in hospitalized patients with gout and doesn’t exacerbate other conditions.

Dr. Mandell disclosed various links to drug makers that produce treatments for gout. He has served as clinical investigator for Horizon, has been a consultant to AstraZeneca, Ironwood, and Horizon, and has received honoraria (unrestricted grants) for continuing medical education activities from Takeda and Horizon. He also reported soliciting advertisements for a journal and educational grants for CME activities.

Global Academy for Medical Education and this news organization are owned by the same parent company.

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