Gout

About

Gout

What is gout?

Gout is a very common type of inflammatory arthritis. It typically presents with acute flare-ups of sudden onset, severe pain, swelling, and inflammation of a joint, most commonly the big toe. This arthritis develops due to increased levels of uric acid in the blood, depositing in and around the joint. Usually, these flare-ups can last for a few days or a few weeks. It initially starts in one joint at a time and can spread to other joints like the midfoot, ankle, knee, elbow, and hand. Unlike many of the other arthritic conditions, this is an extremely controllable and manageable disease with a healthy lifestyle and medications.

Who can develop gout?

Gout is a common type of arthritis that can affect anyone. Men tend to be more impacted by this type of arthritis than women as the female hormone estrogen protects against gout. When women enter menopause (and have a significant decrease in estrogen), they are more likely to develop gout. Gout can occur at any age, even in children, but it is more common in middle-aged people, especially if you are overweight (BMI greater than 25). If you don’t know what your BMI is, go to: https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm to calculate it.

Where does gout occur?

This type of arthritis differs from other types of arthritic conditions as it usually only affects one joint at a time. Common locations where gout can be found include the great toe, ankles, knees, elbows, wrists, or fingers, and the longer you have gout, the more likely it is to involve more joints.

Causes

What is the cause of gout?

Gout is believed to develop from an accumulation of urate crystals in the joints and soft tissues. Urate crystals build up in the body, usually due to kidney problems, as the kidneys usually filter and excrete uric acid in the blood. Uric acid forms naturally within the body from the breakdown of our cells when they die. Uric acid can also build up in the body from overproduction related to certain medical conditions like blood cancers, skin conditions like psoriasis, and from purines found in certain foods we eat (red & organ meats) and alcoholic beverages. When there is an increase of uric acid in the blood, needle-like crystals precipitate in the joint, like making rock candy, and triggers inflammation and severe joint pain and swelling.

What risk factors are there for developing gout?

There are many risk factors associated with the development of gout. They include:

  • Sex- Men are known to develop this type of arthritis more than women due to their increased levels in the body.
  • Genetics- People with a family history of gout are more prone to develop gout as well.
  • Age- Gout appears to affect older individuals that are usually at least middle-aged. 
  • Weight gain- Being overweight (BMI greater than 25) has been linked to the development of gout due to the body producing more uric acid than needed. If you want to find out your BMI, go to: https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm to calculate it based upon your height and weight.
  • Kidney Disease - If you have chronic kidney disease from high blood pressure, diabetes, or kidney stones, you are also at risk for developing gout,
  • Food- Meals high in purine, such as red meat and seafood, have been linked to contributing to the development of gout. 
  • Alcohol- There is evidence that increased alcohol consumption increases the chance for some people to develop gout.
  • Drinks- Drinks with high sugar content have been known to be associated with the development of gout-like sodas.

What are the different types of gout triggers?

  • Traumatic events- trauma such as fractures or surgery can increase uric acid levels in the body, causing an acute gout attack.
  • Alcohol
  1. Beer
  2. Wine 
  • Medications - do NOT stop any medication before speaking with your doctor
  1. Aspirin
  2. Blood pressure medications 
  • Foods high in purine
  1. Red meat
  2. Seafood
  • Illnesses
  1. Obesity
  2. High blood pressure
  3. Kidney disease
  4. Diabetes
  5. Metabolic disorders
  6. Congestive heart failure
  7. Dehydration

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Symptoms

What are the symptoms of gout?

The most common symptom of gout is abrupt and intense pain. People will often describe the pain as so severe that it wakes them up in the middle of the night. The worst of the symptoms usually occur within the first 12 hours of onset. The pain may linger for days to weeks, but the pain may not be as severe later on. Of course, there are many other symptoms associated with gout that include:

  • Stiffness
  • Swelling
  • Redness
  • Joint deformity
  • Warmth

If you want to know if your symptoms could be due to gout, visit the gout calculator website: https://goutclassificationcalculator.auckland.ac.nz/ You may need the help of your doctor to use this site.

Can other health problems arise from gout?

Yes. Gout can cause other health complications such as:

  • Kidney stones- crystals developed during gout flare-ups may get trapped in the urinary tract causing painful stones to develop that may cause blood in your urine.
  • Tophi- hard nodules under the skin due to deposits of urate crystals from untreated gout may develop. Usually, these nodules are painless. However, they can cause severe joint damage and typically take many years of uncontrolled gout (10 or more) to form.

Diagnosis

How is gout diagnosed?

The most accurate way to diagnose gout is with a joint aspiration (sticking a needle into a swollen joint) and analyzing the fluid under a microscope for gout crystals. Proper diagnosis can also be made from a thorough medical history and physical exam from a healthcare provider such as ours at TeleMed2U. The healthcare provider will review your symptoms, medication list, and review other medical problems that may be associated with gout. It is important that a trained specialist for gout does an evaluation for the (4) stages of gout and to rule out other inflammatory conditions that can mimic gout but are treated differently. The four stages of gout are 1) asymptomatic hyperuricemia, 2) acute gout attack, 3) inter-critical period (in between gout attacks), and 4) chronic gout.

Are there any diagnostic tests that can be performed to confirm gout?

There are some blood tests, diagnostic images, and joint analysis tests that can be used to confirm gout. Tests used to help with diagnosis includes:

  • Joint fluid analysis- this test involves removing fluid from the inflamed joint with a needle so that the fluid can be examined microscopically for uric acid crystals.
  • Uric acid- is usually elevated in patients with gout. However, during a gout flare, the blood uric acid can be falsely low, confusing the picture. The best time to measure your uric acid level is between your gout attacks. If you have an elevated uric acid level ( greater than 6.5) and are asymptomatic (never had any gout symptoms) you have asymptomatic hyperuricemia or the stage BEFORE acute gout.
  • X Rays- used primarily for joint examination to see the extent of damage from arthritis. 
  • MRI- helps with determining the severity of the disease, especially in later stages.
  • Ultrasound- helpful with evaluation of crystals in joints and nodules from tophi.

Treatment

What are treatment options for gout?

There is no cure for gout. If you already have joint damage, this cannot be reversed. However, there are treatment options available to help manage your symptoms, improve your function and prevent further joint damage. Treatments are usually more successful when gout is diagnosed and treated early. TeleMed2U rheumatologists recommend that the treatment of any form of arthritis start with a “S.E.N.S.E.”-ible approach. Here are the different types of treatments available for gout: 

  • Stress management - Managing your stress on a daily basis is very important to control your joint pains. Reducing stress on your joint(s) is also important. This can be done by: 
  1. Modification of activities- restrictions may need to be made about the amount of time or type of activities done while at work or playing certain sports, especially during an acute gout attack.
  2. Physical and/or occupational therapy- known to be beneficial with developing a fitness program to improve flexibility, range of motion, and reduce pain. Therapists can also help with assistive devices and help patients learn to use them effectively. Examples include braces, canes, walkers, crutches, or wheelchairs. 
  3. Weight loss program- recommendations for weight loss may be explored if weight may be an issue, especially if it affects a weight-bearing joint (knee) that is arthritic.
  • Exercise- staying active may be recommended by your physician, and suggestions on low-impact exercise may be explored to improve symptoms.
  • Nutrition - Eating less processed, more whole foods (fruits & vegetables) to help with weight loss is important for the management of all chronic diseases.
  1. Supplements- there has been evidence that certain supplements like tart cherry extract may help gout: https://theralogix.com/products/cerasus-cq-tart-cherry-supplement 

*To learn how you can customize your own lifestyle management program to lose weight and control your chronic diseases with fewer medications, make an appointment today with our integrative rheumatologist, Dr. Barry Shibuya.

Currently, there is no cure for gout. The goal for treatment is to manage the pain from current flare-ups and to also prevent any future episodes and permanent joint damage. This usually involves medications and lifestyle modifications, as noted above. Treatment for gout is very manageable if done early and effectively.

Here are the different types of medications currently available for acute gout flare-ups: 

  • Colchicine- an anti-inflammatory specifically for gout. It is known to cause gastrointestinal (GI) distress, so it may not be the best option for those already suffering from GI conditions.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs)- both over-the-counter and prescription preparations can be used for acute flare-ups to treat the symptoms of gout. 
  • Corticosteroids- a stronger anti-inflammatory that can be used in a pill form or injected directly into the inflamed joint.

Here are medications for gout flare prevention:

  • Medications that lower blood uric acid
  1. Febuxostat (Uloric)
  2. Alopurinl (Aloprim, Lopurin, Zyloprim)
  3. Pegloticase (IV Krystexxa) 

To learn more about how to treat difficult to control gout, please visit: https://www.yourgouttreatment.com/ 

  • Medications that increase urinary excretion of uric acid
  1. Probenecid (Probalan) - do NOT take if you have had kidney stones

If medications fail, what are other treatment options available?

Many non-surgical treatments can be used for the management of an acute gout attack, such as rest, ice, and elevation. However, lifestyle changes may be key to preventing future gout flare-ups, especially when medications fail, as mentioned above. Examples include:

  • Exercise- developing an exercise routine to lose weight has shown to reduce urate levels preventing gout flare-ups.
  • Diet changes
  1. Reducing alcohol intake
  2. Avoiding drinks or foods with high sugar content such as soda and desserts
  3. Avoiding red meat, seafood, or organ meats

Gout is a very manageable type of arthritis when managed appropriately by experienced healthcare professionals. These professionals may include dieticians, rheumatologists, or primary care physicians. If you continue to suffer from gout flare-ups, our specialist at TeleMed2U may be able to help develop a more effective treatment plan for you.

References

Centers for Disease Prevention and Control. (2020, July). Gouthttps://www.cdc.gov/arthritis/basics/gout.html 
Mayo Clinic. (2021, March). Gout. https://www.mayoclinic.org/diseases-conditions/gout/symptoms-causes/syc-20372897 
National Institute of Health. (2020, February). Gout. https://www.niams.nih.gov/health-topics/gout

Information

Medically reviewed by:

Dr Roy Kedem, MD

Dr Roy Kedem started his premedical studies at Harvard, and research in genetics and gene sequencing at Harvard, Beth Israel. He attended medical school in the UK at the Cambridge Overseas Medical Program in 1998.  Dr Kedem then completed his residency in Internal Medicine at Columbia College of Physicians and Surgeons in Stamford, Connecticut and his fellowship in Hospital Medicine at the Cleveland Clinic in Cleveland, Ohio.

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