Gout

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Basics of gout

Gout is a disease that causes sudden severe episodes of pain and tenderness, redness, warmth and swelling (inflammation) in some joints.

Gout is a dramatic example of a type of arthritis called crystal arthritis, sometimes called microcrystalline arthritis because the crystals are very small. The crystals form in the joint space. As the body tries to remove the crystals, a painful inflammation occurs.

It usually affects one joint at a time--often the large joint of the big toe. It also can affect other joints such as the knee, ankle, foot, hand, wrist and elbow. In rare cases, it may later affect the shoulders, hips or spine.

Facts and myths

Gout once was mistakenly thought to be a disease of the wealthy because it seemed to be caused by eating rich foods and by drinking too much alcohol. Although diet and excessive drinking do have something to do with gout, they are not the main cause of the disorder. 

Prognosis

Gout affects everyone differently. Some people have one episode and never have any other problems with it. Others have several episodes along with lasting joint pain and damage.

There is no cure for gout, but it can be controlled quite well with medication. Proper treatment can help you entirely avoid attacks and long-term joint damage.

Incidence

Gout affects more than one million Americans from all walks of life. It can occur at any age but the first attack often affects men between the ages of 40 and 50.

Gout affects women as well. In fact, the number of postmenopausal women who have gout is increasing. However, it sometimes is difficult to diagnose gout in these women because they also may have osteoarthritis, a disease that causes the breakdown of joint tissue leading to joint pain and stiffness. Among the affected joints are finger joints, the joint at the base of the thumb and the joint at the base of the big toe. The confusion occurs because urate (the salt of uric acid) crystals tend to deposit in areas where osteoarthritis already has caused joint damage such as in the hands and feet.

Symptoms

Attacks of gout usually develop very quickly. The first attack often occurs at night. You may go to bed feeling fine but then wake up in the middle of the night with extreme joint pain.

During an episode you may notice:

  • sudden, severe joint pain
  • joint swelling
  • shiny red or purple skin around the joint
  • extreme tenderness in the joint area--the area may be so tender that even the touch of a bed sheet may cause severe pain.

An episode of gout can be triggered by:

  • drinking too much alcohol
  • eating too much of the wrong foods
  • surgery
  • a sudden severe illness
  • crash diets
  • injury to a joint
  • chemotherapy

Progression

At first episodes usually are few and far between. They last only a week or so and then everything seems to go back to normal with no symptoms between episodes. If the disease is not controlled by medication, attacks may occur more often and may last longer. Repeated episodes can damage the affected joint(s). If your joints have been damaged, you may have joint stiffness and limited motion after an attack.

Gout generally occurs in three phases:

  1. A sudden onset of joint pain and swelling (often in the big toe) that goes away after five to 10 days (or longer in some instances).
  2. A period of time when there are no symptoms at all, followed by other acute severe attacks.
  3. After a number of years, if not treated, the development of persistent swelling, stiffness and mild to moderate pain in one or more joints after numerous acute (generally severe but short-lived) episodes.

Causes

Click to Enlarge
Figure 1 -
Joint with gout versus
a normal joint

The pain and swelling of gout are caused by uric acid crystals that deposit in the joint. Uric acid is a substance that normally forms when the body breaks down waste products called purines. Uric acid usually is dissolved in the blood and passes through the kidneys into the urine. In people with gout, the uric acid level in the blood is so high that uric acid crystals are deposited in joints and other tissues. This causes the joint lining (the synovium) to become inflamed.

After several years, the uric acid crystals can build up in the joint(s) and surrounding tissues. They form large deposits called tophi that look like lumps just under the skin. Tophi often are found in or near severely affected joints on or near the elbow, over the fingers and toes and in the outer edge of the ear. If the tophi are not prevented or treated, they can damage joints (see figure 1).

Uric acid crystals can form stones in the kidneys, in the ureters (tubes connecting the kidneys and bladder) or in the bladder itself. Several factors may cause the formation of these deposits. For example, the deposits may be caused by not drinking enough liquids. Because of this lack of fluid, the urine is unable to dissolve all the uric acid. Deposits also may form as a result of metabolic abnormalities such as the body's inability to make urine-less acid. In other instances, diet may be the culprit. With some people, a diet rich in foods that further increases the production of uric acid may increase their chances of developing kidney stones. If your doctor suspects that diet is a contributing factor, you may be asked to collect several urine samples. Tests then will be conducted to determine the amount of uric acid your body produces. These tests are particularly helpful because some people with gout produce and eliminate a large amount of uric acid. These people may be more likely to develop kidney stones. People with gout also may have high blood pressure or kidney infections. Since these problems can cause kidney damage, your doctor will check for signs of these problems and treat them if they occur.

Almost all people with gout have too much uric acid in their blood, a condition called hyperuricemia. However, there are many people who have hyperuricemia but not gout. Hyperuricemia is caused by one or both of the following:

  • The kidneys can't get rid of uric acid fast enough.
  • The body makes too much uric acid.

Hyperuricemia often is caused by using diuretic medications ("water pills"). Diuretics are used to get rid of excess body fluid and to lower high blood pressure. However, diuretics can hamper the kidneys' ability to remove uric acid, thus raising uric acid levels in the blood.

Other factors such as inherited traits and environmental factors (such as weight, alcohol use and diet) also can play an important role in causing gout.

Diagnosis

To diagnose gout, your doctor will examine you and ask you to describe your symptoms. Your doctor may take blood tests to measure the amount of uric acid in your blood. Remember: A high level of uric acid in your blood doesn't necessarily mean you have gout nor does a normal level mean you don't have gout.

Your doctor may check for other types of arthritis such as CPPD deposition disease and infectious arthritis. These conditions resemble gout but are not caused by uric acid crystals. To determine which type of arthritis you might have, your doctor may have to remove fluid from an affected joint and examine it for crystals.

Treatment

Treatment for gout mainly consists of taking medication(s) and watching your diet.

The goals of treatment are to relieve pain, shorten the duration of inflammation during an acute attack, prevent future attacks and prevent joint damage.

Diet

There are many myths about diet and gout. Here are the facts:

  1. Obesity can be linked to high uric acid levels in the blood. If you are overweight, work with your doctor to develop a weight-loss program. Don't fast or try to diet too severely because that can raise your uric acid level and make the gout worse. If you are not overweight, watch your diet carefully so you don't become overweight.
  2. Usually, you can eat what you like within limits. If you have kidney stones due to uric acid, you may need to avoid or limit foods that raise your uric acid level such as those listed below. Talk to your doctor about what foods you may have to avoid.

You may need to completely avoid these foods which may raise uric acid levels:

  • Brains
  • Kidney
  • Broths, gravies
  • Sardines, anchovies
  • Liver
  • Sweetbreads

You can drink coffee and tea. However, talk to your doctor about drinking alcohol. Too much alcohol may raise your uric acid level and bring on a gout episode. Drink at least 10-12 eight-ounce glasses of non-alcoholic fluids daily, especially if you have had kidney stones. This will help flush the uric acid crystals out of your body.

Medications

Using medications for gout can be complicated. The treatment needs to be tailored for each person and may have to be changed from time to time. People who have hyperuricemia, but no other problems, usually do not require medications.

Medications are used to:

  • Relieve the pain and swelling of an acute attack--these medications include nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, corticosteroid drugs and/or adrenocorticotropic hormone (ACTH).
  • Prevent future episodes--these medications include colchicine, probenecid, sulfinpyrazone and allopurinol.
  • Prevent or treat tophi--these medications include probenecid, sulfinpyrazone and allopurinol.
  • Prevent uric acid kidney stones (with allopurinol).

All of these drugs are powerful so you need to understand why you are taking them, what side effects may occur and what to do if you have any problems.

Medications to treat acute attacks

Colchicine has been used to treat gout for over 2,400 years. It relieves the pain and swelling of acute attacks. It usually is taken by mouth in several small doses every day. It works best if taken during the first two days of an attack. When taken by mouth, colchicine can cause diarrhea, nausea and abdominal cramps. If side effects occur, stop taking the drug and notify your doctor. To prevent future episodes, you may have to continue taking a small dose of colchicine after the attack has cleared.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are sometimes used to relieve the pain and swelling of an acute attack. They usually begin working within 24 hours after you start taking them. These medications are as effective as colchicine but may have less frequent side effects. However, side effects from NSAIDs may include stomach upset, headache, skin rashes and sometimes ulcers.

Doctors teach many people with gout how to begin treatment on their own. When a gout episode begins, call your doctor and begin taking your medication. Your doctor may suggest that you keep a supply of medication on hand to take at the first sign of trouble.

Medications that control uric acid levels

The medications listed below are used to treat or prevent tophi and to prevent future gout episodes. (In addition, allopurinol is used to prevent kidney stone formation.) However, these medications do not relieve the pain and inflammation of an acute attack. These medicines start working slowly over many months. They may cause you to have more gout episodes when you first start taking them, so you may have to take colchicine or an NSAID at the same time for the first three to six months to prevent such attacks. Many people with gout do not require these medicines. If you must take them, however, you'll probably have to do so for the rest of your life in order to prevent future problems.

Allopurinol (Lopurin, Zurinol, Zyloprim) reduces the amount of uric acid in your blood and urine by slowing the rate at which the body makes uric acid. It is the best medicine for people who have kidney problems or kidney stones caused by uric acid.

Occasional side effects include skin rash and stomach upset. Stomach problems usually go away as your body adjusts to the drug. In rare cases, this drug can cause a severe allergic reaction. If you have a skin rash along with hives, itching, fever, nausea or muscle pain, contact your doctor right away. This drug also may make some people drowsy or less alert. Make sure you know how you react to this medicine before you drive or operate machinery.

Some drugs lower the uric acid level in your blood by increasing the amount of uric acid passed in your urine. They help dissolve tophi and prevent uric acid deposits in joints. The drugs commonly used to lower uric acid levels in gout are probenecid (Benemid, Parbenem, Probalan) and sulfinpyrazone (Anturane). They usually are taken by mouth on a daily basis. Your doctor will adjust the amount of medication you take based on your blood uric acid level. When a normal level of uric acid is reached, no more crystals will be deposited in your joint(s). Those already present will start dissolving.

Common side effects include nausea, skin rash, stomach upset or headaches.

While the skin rash sometimes can be serious, other side effects usually are not serious and may go away as your body gets used to the medicine. If any side effects continue to bother you, contact your doctor.

Take these medications with plenty of liquids. Do not take aspirin with these drugs because it blocks their effects on the kidneys. Read the labels of any prescription or over-the-counter medicines you take to be sure they don't contain aspirin.

Tips for taking Probenecid, Sulfinpyrazone or Allopurinol

At first, probenecid or sulfinpyrazone may increase your risk for kidney stones by increasing the uric acid content of the urine. To prevent this problem, keep your urine diluted by drinking 10-12 eight ounce glasses of fluid every day.

Probenecid, sulfinpyrazone and allopurinol also may cause you to have more frequent gout episodes at first. During this time, you may have to take colchicine or an NSAID for the first three to six months to prevent an episode.

Take your medicine exactly as your doctor instructs. In order to be effective, these medicines must be taken continuously. This will help your body get rid of excess uric acid and will keep the uric acid level from rising again.

Do not take double doses of your medicine. If you forget to take a dose, take it as soon as possible. However, if it is almost time for your next dose, skip the dose you missed.

Talk with your doctor about all the drugs you're taking. This includes over-the-counter drugs such as aspirin or diuretics. Some of the gout medications will not work properly if you are taking other drugs at the same time. Don't start any new drugs without being sure they will work properly with the ones you're already taking. The amount of medications you take will depend upon your symptoms and laboratory test results. You may only need to take one drug. On the other hand, it may be necessary to take a combination of the drugs listed here. Not all people with gout require these drugs. Whether you take these drugs depends on your doctor's judgment and your willingness to make a lifelong commitment to taking daily medications.

Surgery

Surgery is rarely used to treat gout. If you have large tophi that are draining, infected or are interfering with the movement of your joints, you and your doctor may decide to have them surgically removed. There are several kinds of operations that can be done to relieve pain and improve the function of the affected joints.

Credits

Some of this material may also be available in an Arthritis Foundation brochure. 

Adapted from the pamphlet originally prepared for the Arthritis Foundation by Louis A. Healey, Jr., M.D. and Herbert S. Diamond, M.D. This material is protected by copyright.