What is gout?
Apart from being one of the oldest diseases afflicting man (it dates to ancient Egypt), it is also the most common cause of inflammatory arthritis in men over 40 years of age. In South Africa, the prevalence in postmenopausal women is also continuously on the rise3; however, men are affected more than women1,3.
It is a common condition that accounts for 6 % of total healthcare costs related to the elderly3.
Currently there is no cure for gout1,2,3. The good news, however, is that gout is one of the most treatable forms of arthritis. This can be achieved with a combination of medical and lifestyle interventions2.
What Is pseudogout10?
This condition is commonly mistaken for gout as the symptoms can be similar. Like gout, pseudogout is the result of crystallised deposits causing painful inflammation in a joint. However, in the case of pseudogout, these are calcium deposits rather than uric acid deposits and it occurs more often in the knee than the big toe.
Symptoms and signs of gout
A typical gout attack presents with the sudden onset of severe pain, swelling, warmth, and redness of a joint4,5. This often happens during the night or in the early morning hours3,5.
The joint most commonly affected is the first joint of the big toe3,4.
Gout may, however, affect any joint with the most frequent sites being in the lesser toe joints, the feet, ankles, knees, and elbows1,2,4. In some instances, it may involve more than one joint at the same time4,5.
During an acute gout attack, symptoms in the affected joint may include1,4,5:
- Pain, usually severe
- Swelling in and around the area
- Red, shiny skin over the affected joint
- Heat.
During this time, any light contact with the affected joint is very painful so that even the weight of a bedsheet or wearing a sock can be unbearable5.
Symptoms usually develop rapidly over a few hours but may last days to weeks1,3. An acute attack usually reaches its peak 12 to 24 hours after the start of symptoms, after which it will slowly begin to resolve even without treatment1,3,4,5. Full recovery (without treatment) takes approximately 7 to 14 days3.4. After the attack (also known as a flare) has settled, the skin over the joint may peel5.
Causes of gout
Since ancient times, gout has been thought of as a disease of excess due to its association with a diet rich in meat and alcohol consumption – in fact, it goes by the nickname “the disease of kings”3,6. However, more recent research suggests that genetic predisposition may play a big a role in determining an individual’s likelihood of developing gout3,6,7.
Gout is caused by a build-up of uric acid in the blood stream1. This is known as hyperuricaemia – too much uric acid in the blood2.
Excess uric acid can lead to the formation of uric acid crystals, which then build up in joints and soft tissues, causing the painful symptoms of gout8.
Hyperuricaemia can occur when the body produces too much uric acid (approximately 10 % of cases) or when the body fails to excrete sufficient amounts of uric acid in the urine (approximately 90 % of cases)3,8. Uric acid is produced in the body through the breakdown (or metabolism) of purines, which are found in the body or in various foods (e.g., bacon, venison, seafood and shellfish, and alcohol)2,8.
Not everyone with hyperuricaemia goes on to develop gout2,3. Conversely, blood uric acid levels may be normal in approximately one third of people during an acute gout attack. It seems as if acute changes in uric acid levels are the driving force behind a gout flare rather than the absolute uric acid level3.
In susceptible individuals, the following may trigger an acute gout attack1,2,3,5:
- Trauma/injury
- Surgery
- Dehydration
- Alcohol binge drinking
- Eating a meal with a high purine content (see below) or having foods and drinks high in fructose
- Certain medicines (e.g., those that reduce the excretion of uric acid) including:
- Certain diuretics/water tablets
- Beta-blockers for abnormal heart rhythms or hypertension
- Angiotensin converting enzyme inhibitors for hypertension
- Low-dose aspirin to reduce the risk of blood clots
- Ciclosporin to treat autoimmune conditions such as psoriasis
- Some chemotherapy medicines
- An illness that produces a fever.
General risk factors for gout include:
- Having a close relative with gout1
- Obesity, high blood pressure, and/or diabetes, heart failure, metabolic syndrome, or insulin resistance1,2,5
- Kidney disease or poor kidney function1,2,5
- Male gender – gout is about four times more common in men than in women2,5. Women tend to develop gout only after their menopause, as the female hormone oestrogen increases the amount of uric acid that is filtered out by the kidneys. After menopause, when oestrogen levels drop, uric acid levels increase5.
- Osteoarthritis (please see the ARTHRITIS section on this website for more information)5.
Complications of gout
Gout is a condition characterised by acute attacks (or flares) interspersed with periods when there are no symptoms, known as remission2. If left untreated, gout and/or hyperuricaemia (high blood levels of uric acid) may sometimes lead to further problems such as1,5:
- Tophi, which are small firm lumps of uric acid crystals under the skin (please see below for more information)
- Kidney stones
- Permanent joint damage
- Narrowing of the arteries, which may increase one’s risk of stroke, heart attacks or other heart problems
- Osteoarthritis when the urate crystals and tophi cause joint damage (please see the ARTHRITIS section on this website for more information)
- An increased risk of developing kidney disease or worsening of existing kidney disease
- Mental health problems, such as depression
- Underactive thyroid gland
- Erectile dysfunction
- An increased risk of some cancers, especially prostate cancer.
Most of the damage and complications caused by gout can be prevented or halted with medication to lower urate levels coupled with a healthy diet and lifestyle5.
Tophaceous gout
Some people only have acute gout attacks once or twice a year (or once or twice in a lifetime), but others may go on to develop a chronic, relapsing problem with multiple severe attacks. These attacks may occur at short intervals, sometimes without complete resolution of inflammation between flare-ups. This is called chronic gout and it may lead to significant destruction and deformity of a joint. Frequently, this type of gout is accompanied by the formation of tophi, which are hard, uric acid deposits under the skin.
They are the hallmark of chronic tophaceous gout and can contribute to bone and cartilage destruction.
They can be found around joints, near the elbow, the pinna (cartilage portion) of the ear, heels, knees, and forearms. While they are mostly painless, they may interfere with everyday tasks if they develop at the ends of fingers or around the toes. With treatment, tophi can be dissolved and may completely disappear over time1,4.
It normally takes several years for tophi to develop. In some instances, however, someone may develop tophi before experiencing the first attack. Tophi are indicative of severe disease and, in some instances, may require surgical removal1.
Diagnosis
It is important to see your general practitioner or healthcare provider and to have the diagnosis confirmed when you first experience symptoms of gout1. This is because other conditions that require urgent treatment, such as an infection in a joint (known as septic arthritis), may give rise to similar symptoms1,3.
Your doctor will assess your symptoms and perform a physical examination2. Your doctor may also request some additional tests:
- Joint (synovial) fluid test: A thin needle will be inserted into the joint space to aspirate the fluid normally surrounding the bone ends. This fluid will then be examined in a laboratory and the presence of uric acid crystals will confirm the diagnosis. The fluid will also be examined for the presence of bacteria or pus to rule out septic arthritis3,5. If tophi are present, the doctor may opt to rather take a sample from one of them5.
- Blood tests: This is to check the level of uric acid in your blood. While a high concentration will support the diagnosis, it must be borne in mind that approximately one third of patients may have normal uric acid levels during an acute attack3,5.
- X-rays: This is not commonly used to diagnose gout, but it may be used to rule out other conditions or to check whether the joint has been damaged2,3,5.
- Ultrasound: An ultrasound scan may detect crystals in the joint that were not visible during the physical examination5.
- Computed tomography (CT) or magnetic resonance imaging (MRI) may help to identify gout early, or to detect joint damage and the presence of crystals in the joint3,5.
Gout can only definitively be diagnosed during an acute attack when the joint is hot, swollen, and painful and when a laboratory test confirms the presence of uric acid crystals in the affected joint2.
Treatment
The treatment of gout requires a multifactored approach that includes medication to alleviate pain during an acute attack as well as medication and lifestyle interventions to help prevent recurring attacks in the long term1,2.
Managing an acute attack
During an acute attack, the aim of treatment is rapid relief of pain, inflammation and reduced function1. It is generally recommended that treatment should commence within 24 hours of symptom onset9.
NSAIDs1,3,5,9
Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, diclofenac or piroxicam, are considered first-line treatment. These medicines have an anti-inflammatory effect that reduces pain and swelling1,3. Naproxen is preferred in someone with associated heart disease3. Best outcomes are achieved when they are taken at the first signs of an attack and, if known with gout, you may benefit from keeping a supply on hand5.
Colchicine1,3,5,9
Colchicine is an option for someone unable to take NSAIDs or if NSAIDs are not effective. It will help to reduce the inflammation associated with a gout attack1,5. As with NSAIDs, colchicine tablets should be taken at the earliest signs of an attack, and it may be best to have a supply readily available5.
Colchicine in high doses may cause nausea, stomach pain and diarrhoea (runny stomach)1. Gut-related side effects may limit its use3.
Corticosteriods1,3,5,9
If NSAIDS or colchicine do not work or if someone cannot take them, a short course of corticosteroids may provide relief. These medicines are usually not used over the long-term, however, because of their side effects, which include weight gain, thinning of the bones, easy bruising, and muscle weakness1,5.
Corticosteroids can also be injected directly into the affected joint where it will provide rapid relief of pain and inflammation3,5. This is a preferred option if gout is limited to a single joint only9.
Doctors may sometimes recommend a combination of NSAIDs with either colchicine or corticosteroids if one medicine does not seem to be sufficiently effective on its own5.
Helpful hints for managing an attack at home5:
- Keep the area cool with an ice pack or a bag of frozen peas wrapped in a towel
- Rest the affected limb
- Consider using a bed cage to support the bedsheets above the feet/body so that the sheets do not strain the affected joint.
Medicines and lifestyle changes to prevent further attacks
Medicines to lower uric acid levels, known as urate-lowering therapy (ULT), are the recommended treatment option for people with recurrent attacks (two attacks per year), tophi, destructive changes on X-rays, or those with complications of gout (such as kidney injury or kidney stones)1,3. These medicines have to be taken daily for the rest of one’s life to prevent gout attacks but will be of limited value to reduce the pain and symptoms of an acute attack1. ULT options include:
Allopurinol1,2,3,5,9
Allopurinol is the medicine of choice and works by reducing the amount of uric acid the body produces. Tablets are taken once daily and you may require blood tests to help identify the right dose to effectively lower your uric acid levels1.
Some people may experience an acute attack of gout soon after treatment with allopurinol has been initiated and it may take a year of two before no further attacks occur. You must persevere with treatment to prevent the complications of gout1. Allopurinol is usually well-tolerated, but some patients may experience a rash, indigestion, headaches, or diarrhoea (a runny stomach)1.
Other medicines1,5
Medicines such as sulfinpyrazone are mostly reserved for people who are unable to take allopurinol. Sulfinpyrazone works by increasing excretion of uric acid through the kidneys.
Lifestyle changes1
Adopting a healthy lifestyle can go a long way towards reducing the frequency and severity of gout attacks.
Recommended lifestyle changes include:
- Avoiding foods containing high levels of purine (e.g., red meat, offal, oily fish, seafood, and foods containing yeast extract)1,2
- Avoiding sugary drinks and snacks, especially those containing fructose1,3
- Maintaining a healthy weight to reduce pressure on joints1,2,3. Crash diets should be avoided, as these can precipitate gout attacks3.
- Regular exercising1 as every minute of activity counts and any activity is better than none2. Recommended moderate, low-impact activities include walking, swimming, or biking2.
- Drinking plenty of water1 to try and produce more than 2 litres of urine per day3
- Cutting down on alcohol, especially beer and spirits (hard liquor) – it is also particularly important not to binge drink1,2,3.
- Ensuring adequate intake of vitamin C1 in divided doses of 500 mg to 2000 mg per day3. High doses of vitamin C may cause gut side effects and carry a risk of kidney stone formation3. Doses above 1000 mg per day will require a doctor’s prescription.
