Arthritis

Gout Information, Symptoms and Treatment

An Overview of Gout

Gout is considered one of the most intensely painful types of inflammatory arthritis. Gout usually develops in adults. It is rarely seen in children. Gout affects approximately 4 percent of U.S. adults or more than 8 million people.

Typically, gout develops earlier in men than in women. For men, the usual age of onset is between 30 and 45 years old. Women usually develop gout after they are 55 years old.

Gout is most common in people over 65 years old, irrespective of gender.

Take a look at a visual of gout in the foot.

Cause of Gout

Gout develops when an accumulation of excess uric acid in the body causes uric acid crystals to form and be deposited in an affected joint. Excess uric acid can result from increased uric acid production or decreased elimination of uric acid from the body.

Certain purine-rich foods can cause an increase in uric acid levels.

Some medications also can cause increased uric acid levels. About 10 percent of people with hyperuricemia produce too much uric acid. More than 90 percent of people who have gout do not excrete enough uric acid in their urine.

Not everyone with an elevated serum uric acid (hyperuricemia) develops gout. Actually, up to two-thirds of those with hyperuricemia never develop symptoms. While it is not clear why some people with hyperuricemia develop gout and why others do not (asymptomatic hyperuricemia), gout symptoms do develop when the body reacts to the deposition of uric acid crystals in the tissues.

Symptoms of Gout

Gout is characterized by the sudden onset of severe pain in the affected joint, along with tenderness, warmth, redness, and swelling from inflammation. Gout usually affects a single joint (monoarthritis) and most often the big toe is involved (i.e. podagra). The knee, ankle, foot, hand, wrist, and elbow may also be affected. Shoulders, hips, and spine may later become involved, but rarely. While typically one joint is affected at a time, it is possible for more than one to be affected at the same time.

Other conditions which mimic gout include:

During an acute episode of gout, especially the first time it occurs, you may be startled by the suddenness and intensity of joint pain. Often, the first gout attack occurs at night. The affected joint may appear red or purplish. The skin may be taut due to swelling, Typically, the gout attack goes away after five to 10 days. Without treatment, gout attacks may occur with more frequency and may last longer.

Frequent gout attacks can damage the affected joint.

There are three phases of gout:

  • Acute gouty arthritis - the initial gout attack that usually affects a single joint
  • Intercritical period - the period of time between gout attacks
  • Chronic tophaceous gout - in people who have repeated gout attacks or who have persistent hyperuricemia, urate crystals accumulate and form masses, known as tophi (the tophi can develop in joints, bursae, bones, cartilage, or under skin)

Diagnosis of Gout

A diagnosis of gout is based on a physical examination and diagnostic tests. Synovial fluid is withdrawn from an affected joint using a needle and syringe. Then a microscopic examination (using a compensated polarized light microscope) is performed to identify the presence of monosodium urate crystals.

Tophi underneath the skin can be accessed using a needle to also help diagnose gout. The skin itself can also be accessed using a needle. The presence and identification of the urate crystals are what provide the definitive diagnosis of gout.

 

Elevated serum uric acid levels are less useful or definitive. While it certainly provides a clue, as does sudden pain and inflammation in one joint that resolves between attacks, none are as telling as the identification of the crystals. It is also noteworthy that the blood uric acid level can be normal or low during an attack or can be elevated in people who have never had a gout attack.

Blood tests also may reveal an elevated white blood cell count with mostly neutrophils (a type of white blood cell), an elevated sedimentation rate, and an elevated CRP during a gout attack. Since other types of arthritis are also associated with an elevated sedimentation rate and CRP, the diagnostic usefulness is limited. Imaging studies may be used to support the diagnosis and estimate tophi size.

Treatment of Gout

The treatment of gout involves medications, dietary changes, and lifestyle modifications.

Medication options include:

  • Corticosteroids - decreases inflammation quickly and may be used by people who cannot take NSAIDs
  • Probenecid and sulfinpyrazone - helps the kidneys eliminate uric acid (sulfinpyrazone is not currently available in the US)
  • Allopurinol - blocks production of uric acid and helps prevent gout attacks
  • Colchicine - for acute gout attacks or as a prophylactic
  • Krystexxa (pegloticase) - a biologic drug that works by breaking down uric acid
  • Uloric (febuxostat) - lowers serum uric acid levels by blocking the enzyme xanthine oxidase

Lifestyle and dietary modifications are also important for managing gout. Weight management, abstaining from alcohol, and avoiding purine-rich food is necessary to prevent recurrent gout attacks.

Risk Factors

Certain medical conditions, medication use, dietary preferences, and lifestyle choices are linked to an increased risk of developing gout. The risk factors for gout include obesity, hypertension, chronic kidney disease, regular consumption of excessive amounts of alcohol, overeating, and consuming large amounts of meat, specific kinds of seafood, and sugary drinks. Also, medications that can affect blood levels of urate may increase your risk of gout. 

In people who have already been diagnosed with gout, certain factors increase the risk of recurrent gout attacks, including injury, recent surgery, fasting, dehydration, excessive alcohol intake, overeating, and taking medications that can affect blood levels of urate: 

  • Loop and thiazide diuretics can affect kidney function
  • Low dose aspirin can raise blood urate levels
  • Allopurinol and probenecid can actually cause a sharp fall in uric acid which triggers gout attacks when the medication is first started

Complications Associated With Gout

There are complications associated with chronic hyperuricemia. Nephrolithiasis and chronic urate nephropathy are renal (kidney) complications that can develop in people with inadequately treated or untreated gout.

Nephrolithiasis refers to the formation of kidney stones. In people with gout, the kidney stones may be entirely composed of uric acid, calcium oxalate, or calcium phosphate around a core of uric acid. Chronic urate nephropathy usually occurs in gout patients with comorbid conditions, such as hypertension, diabetes mellitus, obesity, atherosclerosis, and lead intoxication.

Also, urate crystals can deposit in the renal medullary interstitium and cause damage. 

Points of Interest About Gout

  • Gout is actually a disease with a long history. Benjamin Franklin reportedly suffered terribly from gouty arthritis.
  • Gout was once referred to as "the disease of kings" because it was thought to be rooted in overindulgence in the food and drink that only the rich could afford.
  • Gout is strongly associated with obesity, hypertension, diabetes, and hyperlipidemia.
  • Gout seems to run in families, indicating a genetic aspect.

A Word From Verywell

There are four goals of gout treatment:

  1. To stop acute gout attacks 
  2. To relieve pain and inflammation quickly 
  3. To prevent future attacks 
  4. To prevent tophi formation, kidney stones, and kidney disease

By managing gout, you will attempt to maintain your quality of life.

Recurrent gout attacks intrude on normal life. As an example, one published study concluded that gout had a significant impact on work absence and work productivity. In the study, employees with gout had 4.56 more annual absence days than people without gout.

It's important to know what you need to do to keep gout under control and as minimally intrusive as possible. It will require you to be committed and compliant—and it's doable.

Sources:

Gout. American College of Rheumatology. H. Ralph Schumacher, MD. April 2015.

Clinical Manifestations and Diagnosis of Gout. Michael A. Becker MD. UpToDate. Reviewed June 2016.

Patient Information: Gout (Beyond the Basics). Michael A. Becker MD. UpToDate. Reviewed June 2016.

The Impact of Gout on Work Absence and Productivity. Value in Health. July/Aug 2007.

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