Gout
POverview of Gout
Gout is a type of inflammatory arthritis that causes pain and swelling in your joints, usually as flares that last for a week or two, and then resolve. Gout flares often begin in your big toe or a lower limb. Gout happens when high levels of urate build up in your body over a long period of time, which can then form needle-shaped crystals in and around the joint. This leads to inflammation and arthritis of the joint. When the body makes too much urate, or removes too little, urate levels build up in the body. However, many people with high levels of serum urate will not develop gout.
Areas of the body that can be affected by gout include:
- Joints.
- Bursae, cushion-like sacs between bones and other soft tissues.
- Tendon sheaths, membranes that surround tendons.
- Kidneys, because the high uric acid levels can lead to stones.
Gout is a disease that can move through several stages:
- Hyperuricemia, when you have elevated levels of urate in your blood over a long period of time and even crystals in the joint, but you do not have symptoms.
- Gout flares, when you have periodic attacks of intense pain and swelling in your joints.
- Interval or intercritical gout, which is the time between gout attacks when you do not have any symptoms.
- Tophi, a late stage of gout when crystals build up in the skin or other areas of the body. Depending on their location, tophi can permanently damage your joints and other internal organs such as the kidneys. Proper treatment can prevent the development of tophi.
With early diagnosis, treatment, and lifestyle changes, gout is one of the most controllable forms of arthritis. Many people avoid gout flares and can decrease the severity of their symptoms, and can even become gout free.
Who Gets Gout?
Many people develop gout. It is more common in men than in women. Gout usually develops in middle age. Women usually do not develop gout before menopause, which is why women tend to develop the disease at a later age than men. Less frequently, younger people develop the disease; however, if they do, the disease tends to be more severe.
Symptoms of Gout
The most common symptom of gout is pain in the affected joint. Many people have their first flare of gout in one of their big toes, but it can also affect other joints in your body. Gout flares often start suddenly at night, and the intense pain may be bad enough to wake you up. In addition, your joint may feel swollen, red, and warm.
Gout flares usually occur in one joint and can be triggered by certain foods, alcohol, certain medications, physical trauma, or certain illnesses. Flares typically get better over a week or two, and in between, you usually don’t have symptoms. Some people may have frequent flares, while others may not have another flare for years. However, over time, if left untreated, your flares may happen more often and last longer.
If gout is untreated over long periods of time, tophi can develop. A tophus is the buildup of needle-shaped crystals that cause hard lumps to form under the skin, in and around the joints and other organs. Tophi start out as painless; however, over time, they can become painful and can cause bone and soft tissue damage and misshapen joints.
Some people with gout may be more likely to have or develop other conditions or complications, especially with the heart and kidneys. Common conditions include:
- Hypertension (high blood pressure).
- Chronic kidney disease.
- Obesity.
- Diabetes.
- Nephrolithiasis (kidney stones).
- Myocardial Infarction (heart attack).
- Congestive heart failure.
Cause of Gout
Gout happens when urate, a substance in your body, builds up and forms needle-shaped crystals in your joints. This leads to pain, swelling, redness, and changes in the movement and use of the affected joint. However, not everyone with high urate levels develops gout.
Urate comes from purines, which are found in your body’s tissues and many foods. When purines break down, they become urate. Normally, urate passes out of your body in urine. However, when too much is made or too little is removed, urate builds up in your blood and needle-shaped crystals form in your joints, causing inflammation that is experienced as gout flares that cause pain and swelling.
Researchers continue to study how genes and environmental factors contribute to a buildup of urate in your blood. However, certain factors may increase your chances of developing gout, including:
- Having high urate levels.
- Having a family history of gout.
- Being male.
- Having menopause.
- Increasing age.
- Drinking alcohol.
- Drinking sugar-sweetened beverages, such as soda.
- Having an unhealthy diet and eating foods that are rich in purines (usually from animal sources), a substance that breaks down into urate.
Some health conditions may increase your risk of developing gout, such as:
- Overweight or obesity.
- Metabolic syndrome, a name for a group of conditions that include high blood pressure, high blood sugar, abnormal cholesterol levels, and excess body fat around the waist.
- Chronic kidney disease, a condition that develops when your kidneys are damaged and cannot filter blood the way they should.
- High blood pressure.
- Conditions that cause your cells to turn over rapidly, such as psoriasis or some cancers.
- Rare genetic conditions (Kelley-Seegmiller syndrome or Lesch-Nyhan syndrome) that lead to increased urate.
Some medications can increase your risk of developing gout, such as:
- Diuretics, which help your body eliminate excess fluid.
- Low-dose aspirin.
- Niacin, a vitamin, when taken in large amounts.
- Cyclosporine, which is an immunosuppressant for people who have organ transplants and is approved to treat some autoimmune diseases.
Diagnosis of Gout
Gout tends to be relatively straightforward to diagnose. However, a few conditions can mimic gout. To help diagnose gout, your health care provider may:
- Ask you to provide your medical history, including:
- Your symptoms.
- Any risk factors you have.
- Any medications you have taken.
- Examine the affected joints.
- Order a laboratory test to check urate levels in your blood.
- Take a sample of fluid from one of your painful joints, a swollen bursae (fluid-filled sac that cushions the joint), or a tophus to look for urate crystals using a special microscope.
- Order an ultrasound or special CT scan to check for urate crystal buildup in the affected joint as well as to diagnose other conditions that may be causing the symptoms.
Treatment of Gout
Depending on your symptoms and the cause of your gout, treatment plans may differ from person to person. However, the goals for treating gout are the same for each person and include:
- Reduce the pain from gout flares.
- Prevent future flares.
- Prevent and resolve tophi to stop damage to your joints.
- Care for other conditions or complications that happen with gout, such as heart and kidney diseases.
When you have gout, your doctor may recommend medications to manage the underlying cause of gout and treat active gout flares.
To treat a gout flare, your doctor may recommend medications including:
- Over-the-counter or prescription anti-inflammatory medications, which can reduce pain and swelling.
- Colchicine, which helps to relieve gout pain. This medication works best when taken when symptoms first appear.
Corticosteroids, which can help decrease inflammation, provide pain relief, and reduce joint swelling. Corticosteroids may be given by mouth or injected directly into the affected joint. Because they are potent medications, your doctor will prescribe the lowest dose possible to achieve the desired benefit.
Another key step to treating gout is managing hyperuricemia, which is the underlying cause of gout. There are medications available to lower urate levels, including:
- Xanthine oxidase inhibitors, which help prevent the production of urate.
- Uricosuric agents, which help the kidneys flush more urate out of the body.
- Uricase, which breaks down urate into a form that is easily removed from the body. This medication is recommended for people who have not responded to other medications.
Other treatments may include making diet and lifestyle changes to reduce risk factors you can control.
Who Treats Gout?
Health care providers who may provide treatment for gout include:
- Rheumatologists, who specialize in arthritis and other diseases of the bones, joints, and muscles.
- Primary care providers (PCPs), such as internists, who specialize in the diagnosis and medical treatment of adults. Most people with gout are managed by their PCPs.
- Dietitians, who can teach you about how to follow a healthy diet to improve your health.
- Nurse educators, who specialize in helping people understand their overall condition and set up their treatment plans.
- Pharmacists, who dispense medications and teach people about the medications, including the importance of taking them as prescribed.
Living With Gout
There are many things you can do to help manage gout. You can make some lifestyle changes to help you have fewer gout flares and manage your symptoms, such as:
- Losing weight. If you are overweight or obese, losing weight through a reduced calorie diet and increased exercise helps reduce urate levels, which can help stop or lower the number of flares you have.
- Making diet changes to help reduce blood urate levels and gout flares, such as:
- Drinking fewer alcoholic beverages. This includes nonalcoholic beer.
- Avoiding sugar-sweetened drinks, such as soda.
- Avoiding red meats and organ meats (liver, kidney, tongue, and sweetbreads) that are higher in purines and may increase the risk for other health conditions.
- Avoiding certain seafood, such as shellfish (shrimp and lobster), sardines, and anchovies.
- Following the Dietary Approaches to Stop Hypertension (DASH) eating plan. This diet is particularly helpful for the many gout patients who also have high blood pressure. The DASH eating plan can help improve high blood pressure and may help lower blood urate levels. By lowering urate levels, this plan may help prevent gout flares. The DASH eating plan includes:
- Eating plenty of vegetables, fruits, and whole grains.
- Eating low-fat or fat-free dairy products, poultry, and oils.
- Limiting foods high in saturated fats.
- Limiting sugar-sweetened foods and drinks.
- When you have a gout flare, you can do the following to help reduce symptoms from the flare:
- Applying ice to the affected area to help reduce swelling and pain.
- Elevating the affected limb, if possible, to help reduce swelling.
- Resting the affected joint.
- When gout is associated with frequent flares or tophi, lifestyle changes alone are not sufficient to manage gout and medications to lower urate levels in your blood are the mainstay for managing gout. Taking the medications prescribed for this purpose by your doctor regularly is the key to preventing gout flares from occurring and preventing or reducing tophi. Nevertheless, maintaining healthy weight and diets are also important to help lower the risk of cardiovascular complications, which are common among gout patients.
Always talk with your doctor before making any changes to your diet or medications.
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