Gout is a form of arthritis that occurs when uric acid levels in the blood rise above that which can remain soluble, and the uric acid crystallises. These crystals are deposited in soft tissues and joints, causing gout.
Gout is the most common form of arthritis in men but is rare in pre-menopausal women. The incidence of gout is increasing, particularly as the population ages. It is a disease associated with significant disability and illness and can affect more than just the joints.
Gout is best diagnosed by having a doctor take fluid from a joint and demonstrating the crystals in the fluid. Sometimes this is not possible, and a rheumatologist or other doctor may be reasonably comfortable in making the diagnosis of gout based on the symptoms. Sometimes the level of uric acid in the blood, and x-rays or a CT scan may assist in the diagnosis.
Gout usually affects people by causing arthritis, which is inflammation of the joints. Inflammation is associated with pain, swelling, heat and redness. The arthritis in gout usually affects peripheral small joints, and indeed the most typical presentation is an acutely inflamed big toe (sometimes termed podagra). But any joint can be involved, and it is common for gout to involve other joints of the feet, the ankles, knees, hands and wrists. Occasionally gout can affect joints of the spine, and sometimes gout can affect several joints at one time.
Acute gout usually comes on very suddenly, often overnight, with some people reporting tingling being the first symptom, followed by increasing pain which reaches a peak within about 12 hours. The acute attacks of gout usually settle over some days to weeks but can settle more quickly with treatment.
Acute attacks may be precipitated by many factors in people prone to gout. These include an excess of protein or alcohol in the diet, dehydration, infection, trauma and changes in medications, such as blood pressure medications.
If the high uric acid levels in the blood are not treated, then gout may progress, with ongoing pain, and the deposition of the crystals in soft tissue, including the skin. These deposits are called tophi, and often appear to be chalky lumps, often on the fingers or ears. Tophi can disappear with long term treatment.
Untreated gout can result in irreversible damage to the joint, and untreated high levels of uric acid are associated with cardiovascular and kidney disease.
There are good therapies for gout; however international guidelines state that the management of gout should not rely solely on medications. It is important for people with gout to be educated so they can understand their disease, and what factors may precipitate an acute flare. People with gout should undertake regular physical activity, and try to maintain a healthy body weight in order to reduce the risks. Dietary changes, decreasing the intake of meat, shellfish, fruit juices and other sugary drinks, alcohol (especially beer) as well as increasing the intake of water and dairy products may assist in preventing attacks of gout.
Additionally, people with gout should be screened for cardiovascular risk factors, such as high blood pressure, high cholesterol, and counselled about the risks of smoking.
The levels of uric acid in the blood can be lowered to prevent the development of acute attacks with drugs. The commonly used urate-lowering drugs include allopurinol, febuxostat and probenecid.
If an acute attack occurs, then the inflammation can be treated in the short term to resolve the attack with drugs such as non-steroidal anti-inflammatories, colchicine, and sometimes steroids.
These are often co-prescribed when you begin urate lowering drugs to manage any inflammation that may occur.
New drug therapies for gout have been developed, but these drugs are expensive, and can cause side effects, so they are usually reserved for people whose gout cannot be controlled in the usual way. These drugs include synthetic uricase enzymes that prevent the production of uric acid.
Maintaining healthy body weight, regular exercise, a healthy diet low in protein and sugar, and increasing fluid and dietary dairy intake may aid the self-management of gout.
Additionally, understanding your disease combined with taking your long term medication correctly, may mean you can better control your disease. Your Rheumatologist will be able to assist you with education regarding lifestyle and medications and assist you in developing a self-management plan to reduce the impact of gout in your life.
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Article written by Dr Helen Keen, AdjunctProfessor (Rheumatology) MBBS FRACP PhD
Dr Keen consultants at Royal Perth and Fiona Stanley Hospitals, privately in Subiaco, and undertakes teaching and research at UWA.