Gout: Everything You Need To Know

What is Gout?

Gout is a form of arthritis that causes redness, swelling and pain in joints. It has been known for more than 2000 years. It usually affects a single joint with each episode, most often the big toe, but can affect other joints also. Gout is known as a condition that affects primarily older people but there are cases of it causing trouble for young people too (Harry Kewell at the last world cup for example). Around 90% of Gout attacks occur in men over the age of 40, with most attacks occurring in men closer to 70. Fortuneately gout is the one form of rhuematism that has the most satisfactory treatment.

What Causes Gout?

Gout occurs when there is a build up of uric acid in the blood stream, and it accumulates in the fluids around joints. Uric acid is a waste product from many foods that we eat, and is transported via the blood stream to the kidneys, where it is excreted in urine. When this process is impaired, gout can result. Uric acid crystals can also collect in the kidneys, causing kidney stones. Gout does not always occur in people who have hyperuricemia, and people who have gout do not always have excessive levels of uric acid. There are a number of risk factors, but in most cases the cause of gout is unknown.

Many conditions are strongly associated with gout including diabetes, high blood pressure, heart disease, obesity and kidney disease. There are also a number of triggers that may cause acute attacks including stress, infection, minor trauma, heavy consumption of alcohol or surgery.

Some of the risk factors associated with hyperuricemia (too much uric acid) and gout:
•    Genetics- the impairment in the excretion of uric acid is thought to be heridetary.
•    Gender and age- it is more common in men, and also becomes more likely as you get older.
•    Weight- being overweight means there is more tissue available for breakdown or turnover and can lead to excissive uric acid production.
•    Alcohol consumption- excessive consumption can interfere with the removal of uric acid.
•    Diet- eating too many foods that are rich in purines has been thought to cause or aggravate gout in some people.
•    Kidney problems- will impact on your ability to excrete uric acid
•    Long term use of certain medications- diuretics, aspirin, immunosuppressants may act on the kidneys affecting the excretion of uric acid.
•    Anemia- low number of red blood cells
•    Psoriasis- skin condition causing inflammation
•    Exposure to lead- has been linked to gout

Signs and Symptoms

Gout generally has four stages.

In the first stage the patient has elevated levels of uric acid with no other signs or symptoms. No treatment is required in this stage and not all patients with the increased levels of uric acid will go on to develop gout.

The second stage is called acute gouty arthritis. In this stage the patient experiences a sudden onset of heat, redness, swelling and pain in a joint, caused by the formation of uric acid crystals within the joint. This usually occurs in the big toe, and can be so painful that even a bed sheet resting on the toe can be excruciating. If left untreated, the symptoms usually clear up within 10 days; however immediate treatment can provide relief within hours. The pain and swelling will disappear, but an acute attack almost always strikes again in the same or another joint.

After the initial attack of acute gouty arthritis, signs and symptoms usually disappear and the patient goes into the third stage of gout, which is interval or intercritical gout. The patient usually has another attack within 2 years. If left untreated, the interval between the attacks can shorten and it can start to affect more joints.

If left untreated for several years the condition can progress to the final stage of chronic tophaceous gout. In this stage there is chronic inflammation and swelling and permanent damage to the joints caused by the formation of uric acid crystals in the joints. These masses of crystals are caused tophi and can cause disfigurement.

Diagnosis

Diagnosis usually involves a physical examination and question about family and personal medical history. Gout is often suspected if the patient describes some of the classic symptoms of gout such as a sudden swelling and pain in joints, particularly in the big toe.

To confirm, gout or rule out other conditions, some synovial fluid can be taken and examined for the presence of uric acid crystals.

Urine can be analyzed to see how much uric acid is being excreted. This can also be used to detect kidney stones.

Blood test can also be done to measure the amount of uric acid in the blood. This is not a definitive diagnosis, as hyperuricemia does not always correlate to gout, but it can give an indication and help to rule out other conditions.

X-ray is used to assess joint damage, particularly in patients with repeated episodes of acute gouty arthritis.

Diagnosis can be difficult, especially as someone with gout may not necessarily have an elevated level of uric acid in the blood. However, once gout is diagnosed it is important to start treatment immediately to ensure the best possible outcome for the patient.

Treatment

The main form of treatment for gout is medication. Medication is taken to relieve joint pain and inflammation.

Some medications taken to treat acute gouty arthritis include:

•    Non Steroidal Anti Inflammatory Drugs (NSAIDs)- reduce inflammation and reduce joint pain.
•    Corticosteroids
•    Colchicine

Like all drugs there are side effects and they must be carefully prescribed. Physicians must know of any other medication being taken to ensure there are no harmful interactions. If these drugs are taken soon enough, they can get the attack under control within hours.

Once the acute attacks are under control the treatment for gout focuses on lowering the amount of uric acid in the blood and preventing further attacks.

Medications that reduce uric acid in the blood:

•    Uricosurics- help the kidneys excrete uric acid. In a lot of cases the build up of uric acid in the blood is due to the kidneys not being able to excrete it effectively. In this situation uricosurics are helpful.
•    Allopurinol- this acts to decrease the amount of uric acid by reducing the bodies production of it. This is a reliable way of reducing uric acid in the blood, but it does cause some side effects including nausea, vomiting and diarrhea.

To be effective these medications must be taken consistently and long term. Stopping often means the levels of uric acid will creep up again, often resulting in gout.

Prevention

The best way to prevent gout is to ensure that uric acid levels are kept within the normal range.

Some ways to help achieve this include:

•    Maintain a healthy body weight.  A good diet and regular exercise should do the trick.
•    Avoiding excessive consumption of foods with purines. Purines are in all meat, fish, and poultry with some foods containing more than others. A balanced diet is the best plan of attack.
•    Limiting or avoiding alcohol. Excessive alcohol consumption can inhibit the excretion of uric acid.
•    Drink plenty of fluids. Dilutes uric acid concentration in the blood and urine.
•    Avoiding the use of an affected joint until the inflammation and swelling has gone down.

When gout is properly treated the outcome is usually good, with relief from the symptoms and patients going on to live normal, pain free lives.