What is Gout?
Gout is a very painful form of arthritis caused by crystals that form in and around the joints.
It’s the most common type of inflammatory arthritis. It’s more common in men and you’re more likely to get it as you get older.
Gout occurs in people who have high levels of urate in their blood, but having urate in your blood doesn’t mean you’ll develop gout. It’s normal and healthy to have some urate in your bloodstream.
Urate is created every day when our bodies break down purines. Purines are chemicals that are naturally created in our body, but they are also present in certain foods.
People used to think that gout was caused by overeating and drinking too much alcohol. While this can make attacks of gout more likely, it’s not the whole story.
In any day, about three-quarters of the urate in our bodies comes from the breakdown of purines produced within our body, while only about a quarter comes from the breakdown of purines in food and drink we consume.
As urate levels build up, your body gets rid of any extra through your kidneys and in your wee. But if your body is making too much urate, or your kidneys are unable to get rid of enough of it, then levels start to rise.
If urate levels stay too high, urate crystals can slowly start forming. They mainly occur in and around firm joint tissues, such as the cartilage. But crystals can also appear under your skin and may even occur in your internal organs, such as the kidneys.
There are various stages through which gout progresses, and these are sometimes referred to as different types of gout.
It is possible for a person to have elevated uric acid levels without any outward symptoms. At this stage, treatment is not required, though urate crystals may deposit in tissue and cause slight damage.
People with asymptomatic hyperuricemia may be advised to take steps to address any possible factors contributing to uric acid build-up.
This stage occurs when the urate crystals that have been deposited suddenly cause acute inflammation and intense pain. This sudden attack is referred to as a “flare” and will normally subside within 3 to 10 days. Flares can sometimes be triggered by stressful events, alcohol and drugs, as well as cold weather.
Interval or intercritical gout
This stage is the period in between attacks of acute gout. Subsequent flares may not occur for months or years, though if not treated, over time, they can last longer and occur more frequently. During this interval, further urate crystals are being deposited in tissue.
Chronic tophaceous gout
Chronic tophaceous gout is the most debilitating type of gout. Permanent damage may have occurred in the joints and the kidneys. The patient can suffer from chronic arthritis and develop tophi, big lumps of urate crystals, in cooler areas of the body such as the joints of the fingers.
It takes a long time without treatment to reach the stage of chronic tophaceous gout – around 10 years. It is very unlikely that a patient receiving proper treatment would progress to this stage.
One condition that is easily confused with gout is pseudogout. The symptoms of pseudogout are very similar to those of gout, although thr flare-ups are usually less severe.
The major difference between gout and pseudogout is that the joints are irritated by calcium pyrophosphate crystals rather than urate crystals. Pseudogout requires different treatment to gout.
Symptoms of gout
When you have gout, urate crystals can build up in your joints for years without you knowing they are there. When there are a lot of crystals in your joints, some of them can spill out from the cartilage into the space between the two bones in a joint.
The tiny, hard, sharp crystals can rub against the soft lining of the joint, called the synovium, causing a lot of pain swelling and inflammation. When this happens, it’s known as an attack or flare of gout.
During an attack of gout the affected joint becomes:
- very painful
The skin over the joint often appears shiny and may peel off a little as the attack settles.
Attacks usually come on very quickly, often during the night. Doctors describe this sudden development of symptoms as ‘acute’.
The attack usually settles after about five to seven days, but it can go on for longer.
If gout is left untreated, attacks can become more common and may spread to new joints.
Attacks typically affect the joint at the base of the big toe and often start in the early hours of the morning. The symptoms develop quickly and are at their worst within just 12 to 24 hours of first noticing that anything is wrong.
Any light contact with the affected joint is very painful – even the weight of a bedsheet or wearing a sock can be unbearable.
Although gout most often affects the big toe, other joints may also be affected, including:
- other joints in your feet
It’s possible for several joints to be affected at the same time. It’s not common to have gout in joints towards the centre of your body, such as the spine, shoulders or hips.
Gout attacks are especially common in joints at the ends of your legs and arms, such as in your fingers and toes. This is probably because these parts of the body are cooler, and low temperatures make it more likely for crystals to form.
Similar attacks can be caused by a condition called acute calcium pyrophosphate crystal arthritis. This is also known as acute CPP crystal arthritis, which used to be called ‘pseudogout’.
Urate crystals can also collect outside of the joints and can be seen under the skin, forming small, firm lumps called tophi. You can sometimes see the white colour of the urate crystals under the skin.
The most common areas for tophi are:
- over the top of the toes
- back of the heel
- front of the knee
- backs of the fingers and wrists
- around the elbow
- the ears.
Tophi aren’t usually painful, but they can get in the way of normal daily activities. They can sometimes become inflamed, break down and leak pus-like fluid with gritty white material – these are the urate crystals.
Tophi can also grow within your joints and cause damage to your cartilage and bone. This can lead to more regular, daily pain when you use the affected joints.
Causes of gout
The buildup of uric acid in your blood from the breakdown of purines causes gout.
Certain conditions, such as blood and metabolism disorders or dehydration, make your body produce too much uric acid.
A kidney or thyroid problem, or an inherited disorder, can make it harder for your body to remove excess uric acid.
You’re more likely to get gout if you:
- are a middle-aged man or postmenopausal woman
- have parents, siblings, or other family members with gout
- eat too much purine-rich food, such as red meats, organ meats, and certain fish
- drink alcohol
- take medications such as diuretics and cyclosporine
- have a condition like high blood pressure, kidney disease, thyroid disease, diabetes, or sleep apnea
In some people with gout, diet is the cause. Find out which foods are especially high in gout-producing purines.
Even though your kidneys can be completely healthy, sometimes the genes you’ve inherited make it more likely that your kidneys don’t flush urate out as well as they should. This is the most common cause of primary gout, especially when several family members are affected, such as your parents or grandparents.
Gout is much more common in people who are overweight. The more overweight you are, the more urate your body produces, and this may be more than your kidneys can cope with.
Being overweight also makes it more likely that you’ll have:
- high blood pressure
- type 2 diabetes
- high cholesterol
- fats in your blood.
These conditions can all lower how much urate is filtered out by your kidneys.
Gender and age
Gout is about four times more common in men than women. It can affect men of any age, but the risk is greater as you get older.
Women rarely develop gout before the menopause. This is because the female hormone oestrogen increases how much urate is filtered out by the kidneys. But after the menopause, oestrogen levels go down and urate levels go up.
Taking certain medications
Some medications can reduce your kidneys’ ability to get rid of urate properly. These include diuretics, also known as water tablets, and several tablets for high blood pressure, including beta-blockers and ACE inhibitors.
Several different conditions are linked to raised urate levels. This could be because they affect the way the kidneys filter urate, or because they cause more urate to be produced in the first place.
For some conditions, the link with gout is less clear, and may be due to many different factors.
Common conditions associated with gout include:
- chronic kidney disease
- high cholesterol and fats in the blood
- high blood pressure
- type 2 diabetes
What can trigger a gout attack?
Several things can cause the crystals to shake loose into your joint cavity, triggering an attack. These include:
- a knock or injury to the joint
- an illness that may make you feverish
- having an operation
- having an unusually large meal, especially a fatty meal
- drinking too much alcohol
- starting urate lowering therapy, especially at a high dose, or not taking your treatment regularly each day.
What are treatments and home remedies for gout?
When gout is mild, infrequent, and uncomplicated, it can be treated with diet and lifestyle changes. However, studies have shown that even the most rigorous diet does not lower the serum uric acid enough to control severe gout, and therefore medications are generally necessary. When attacks are frequent, uric acid kidney stones have occurred, tophi are present, or there is evidence of joint damage from gout attacks, medications are typically used to lower the uric acid blood level.
Medications for the treatment of gout generally fall into one of three categories: uric-acid-lowering medications, prophylactic medications (medications used in conjunction with uric-acid-lowering medications to prevent a gout flare), and rescue medications to provide immediate relief from gout pain.
Urate-lowering medications are the primary treatment for gout. These medications decrease the total amount of uric acid in the body and lower the serum uric acid level. For most patients, the goal of uric-acid-lowering medication is to achieve a serum uric acid level of less than 6 mg/dl. These medications also are effective treatments to decrease the size of tophi, with the ultimate goal of eradicating them. Uric-acid-lowering medications include allopurinol (Zyloprim, Aloprim), febuxostat (Uloric), probenecid, and pegloticase (Krystexxa).
Prophylactic medications are used during approximately the first six months of therapy with a medication to lower high levels of uric acid to either prevent gout flares or decrease the number and severity of flares. This is because any medication or intervention that either increases or decreases the uric acid level in the bloodstream can trigger a gout attack. Colcrys (colchicine) and any of the NSAIDs (nonsteroidal anti-inflammatory drugs) such as indomethacin (Indocin, Indocin-SR), diclofenac (Voltaren, Cataflam, Voltaren-XR, Cambia), ibuprofen (Advil), or naproxen sodium (Aleve) are frequently used as prophylactic medications to prevent gout flares during uric-acid lowering. By taking one of these prophylactic or preventative medications during the first six months of treatment with allopurinol, febuxostat, or probenecid, the risk of having a gout attack during this time is decreased. Prophylactic medications are not used in combination with Krystexxa.
The third category of medications are those used during attacks of acute gout to decrease pain and inflammation. Both colchicine (Colcrys) and NSAIDs can be used during an acute gout attack to decrease inflammation and pain. Corticosteroids such as prednisone, methylprednisolone (Medrol), and prednisolone (Orapred), also can be used during an acute gouty flare. However, the total dose of steroids is generally limited due to potential side effects such as cataract formation and bone loss. Steroid medications are extremely helpful in treating gout flares in patients who are unable to take colchicine or NSAIDs.
Gout home remedies
Home remedies for an acute gout attack include drinking plenty of water. Over-the-counter NSAIDs (nonsteroidal anti-inflammatory drugs), such as ibuprofen (Advil, Motrin) and naproxen sodium (Aleve), can be used when there are no contra-indications, such as decreased kidney function or stomach ulcers.
Home remedies may be very beneficial for the management of chronic gout, as well. The dietary modifications detailed above can be very effective in certain patients. Drinking plenty of water to remain well-hydrated can be beneficial in preventing gout attacks.
Do gout medications have any side effects?
- Gout medications are well tolerated by most people. However, like other medications, they have potential side effects.
- Allopurinol is well tolerated by most people, but in some people, it can cause an allergic rash. Very severe rashes rarely can occur after taking allopurinol, and any allergic type rashes that develop while a patient is taking allopurinol are taken seriously.
- Colchicine (Colcrys) can cause signs and symptoms such as nausea, diarrhea, and rarely muscle weakness and abnormal blood counts.
- Probenecid is generally well tolerated but should not be used in patients who have uric acid kidney stones, as it can worsen the kidney stones and potentially harm the kidneys in these patients.
- Febuxostat (Uloric) can cause liver abnormalities, nausea, and rash.
- NSAIDs can cause irritation of the stomach and ulcers in some cases. The liver and the kidneys are periodically monitored in patients taking NSAIDs over the long term.
- Krystexxa is administered as an intravenous infusion. Severe allergic reactions have been reported in a minority of people receiving Krystexxa.
What foods should people with gout eliminate from their diet?
Uric acid is formed when proteins in the food we eat, called purines, are broken down. Therefore, there has been a great deal of interest in dietary management of gout by avoiding high-purine (purine-rich) foods. However, a diet very low in purines is extremely difficult to follow, because purines are a natural part of many healthy foods. Even when a diet very low in purines is followed strictly, the uric acid level in the bloodstream is only slightly lowered.
The following dietary principles are important in the management of gout:
- Gout is associated with obesity, and significant weight loss can dramatically improve the management of gout. A calorie-reduced diet is helpful for weight loss.
- A diet low in saturated fat, with increased protein and replacement of refined carbohydrates (for example, sugar, white bread, potatoes) with complex carbohydrates (such as vegetables and whole grains) reduces the serum uric acid.
- Decreased consumption of seafood and red meat.
- The consumption of low-fat dairy products decreases the risk of gout.
- Drinking beer and liquor increase the risk of gout. However, drinking wine does not appear to increase the risk of gout.
- In one study, consumption of fresh cherries was associated with a 35% decreased risk of gout. Some people believe that black cherry juice or dried cherries have the same effect, but this has not been proven.
- Drinking beverages sweetened with sugar or high fructose corn syrup increases the risk of gout.
What complications are associated with gout?
Longstanding untreated gout can cause irreversible joint damage.
Uric acid can deposit in the kidneys and cause kidney stones and decreased kidney function.
Uric acid can deposit in the soft tissues, especially around joints, and cause nodules known as tophi, which can be large and unsightly.
What is the prognosis of gout?
Gout is a chronic condition. Left untreated, patients may suffer from recurrent painful and disabling acute attacks of gout. Joint damage and other complications of gout may occur. However, excellent treatments for gout are available, and most patients respond very well to gout treatment with a good prognosis.
Is it possible to prevent gout?
Some of the risk factors for gout are genetic, and those are not preventable. However, many of the risk factors for gout, such as obesity and diet, are controllable. Maintaining a healthy weight and a diet low in refined carbohydrates and low in saturated fat and red meat may prevent gout.
What is the latest research on gout?
Research is being done on using medications that block a chemical signal known as interleukin-1 to treat gout flares in patients who do not respond to other therapies. Anakinra (Kineret) and canakinumab (Ilaris) are two medications that block interleukin-1. They are currently used for other conditions and are under investigation for use in gout flare-ups.
There is ongoing research in using a specialized CT scan known as a dual energy CT scan to diagnose gout. There is also a great deal of research investigating the various uric acid transporter genes that are responsible for uric acid metabolism.
What is the difference between acute and chronic gout?
- Usually only 1-3 joints are affected.
- You will only feel symptoms during attacks.
- Attacks may last from a few days to a week.
- After attacks, you will not feel symptoms.
- You may start by having acute gout but worsen to chronic gout over time if attacks happen more often.
- Chronic gout is having 2 or more gout attacks per year.
- Often more than one joint is affected.
- Some people with severe chronic gout have only short breaks in between attacks and feel symptoms of gout most of the time.
- Chronic gout can lead to permanent joint stiffness, damage, and deformity.
What causes gout?
Gout is caused by having too much uric acid in your blood. Uric acid is made when your body breaks down chemicals called purines.
Who is at risk for gout?
Anyone can get gout, but it is more common in men than in women. Gout is more common in adults than in children.
How can I manage gout attacks?
Gout attacks, also called flares, or flare-ups, can come on suddenly and be extremely painful.
Why do gout attacks happen more at night?
Gout attacks happen more at night and in the early morning rather than during the day. You may have an attack start during your sleep. The reasons this happens are not entirely known, but some of the leading ideas are dehydration, lower body temperature, and changes in hormone levels during sleep.
What are the complications of gout?
Gout does not only cause pain. Having gout, and especially chronic gout, can lead to serious health problems over time if left uncontrolled.
What are the treatments for gout?
Taking too many medicines or taking certain medicines at the same time can be dangerous, so it is very important to talk to your doctor about how many medicines you can take.
Is gout preventable?
Gout is usually not preventable through lifestyle changes alone. Many people with gout need medicines to get their gout under control.
What is the best diet for gout?
Certain foods and drinks are better than others for controlling gout.
Gout and kidney disease
Most commonly, kidney disease can cause gout. However, gout may also lead to kidney disease. Since uric acid is filtered through the kidneys, the two diseases are related.
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