In this Q&A session, Dr Helen Keen answers questions on Gout, a common and painful condition that affects the joints. The session covers questions such as the prevelance of gout; signs and symptoms; when to see a Rheumatologist; and how is gout medically managed.
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.
Request your free resources!
– Watch our Gout Q&A video here
– Download your free Gout Fact Sheet here
– Request your free ‘Taking Control of your Gout’ booklet which offers practical advice to help manage your symptoms by calling us on 1800 011 041 or complete our online form here
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.
I work in the electorate office of a senior member of the WA Government. Being a desk job it is quite sedentary and weight has often been a problem over the years. I was very fit as a young man but for various reasons have not been sufficiently so for many years. Before this I was (respectively) a press photographer and journalist (20 years), private secretary, computer systems engineer, newspaper managing editor, sub-editor, and speech writer.
When I first suffered from gout I thought I’d twisted an ankle or foot. Soon, however, the pain was too great and the swelling lasted too long for that to be the case. I visited my Doctor and to my shock I was diagnosed with gout. I believed, like many do, that it was a disease of massive overindulgence and risky high living.
On the occasions I have had bouts, it has had a severe effect. When one can hardly move a foot, one isn’t much good at walking to work or, in fact doing anything. In fact, without treatment, the pain is so all-consuming that the sufferer cannot think of anything else but the pain and possible ways to relieve it.
I try not to consume some of the things I think contribute to gout and I try to drink lots of water and other liquids during the day. These days I am more sensitive to the onset of a possible bout and there is usually a prolonged period of days of feeling unwell for no particular reason, and one comes to recognise this is subtly different from other illness or weariness.
In my spare time I design paperback books and dust jackets, and edit and assess manuscripts for emerging writers. I used to play a lot of sport, particularly swimming, squash and cricket. However, an improperly-diagnosed Achilles injury failed to repair properly, largely curtailing the sporting activity. I write fiction (having completed 2 novels) and help other writers where I can. I’m also a committee member of the Fremantle International Portrait Prize, which runs portrait photography competitions to help raise funds for AOWA.
Watch our Gout Q&A with Rheumatologist Dr Helen Keen by clicking here
To say that 2020 was a challenging, unusual, and different year is an understatement. Unfortunately, we had to cancel Camp Stretch in April and the inaugural Family Weekender in May due to the COVID-19 virus. We were all very saddened at AOWA to make the decision; however, a silver lining was in sight as we determined to run Camp Freedom and Camp Stretch as a combined event later in the year.
A record number of 68 participants, aged between 7-16 years old, attended the Kerem Adventure Camp ground from Sunday 27th September until Friday 1st October. The camp was supported by 12 AOWA Leaders who gifted their time and talents towards ensuring that everyone had a fun and safe time. The Leaders included some AOWA regulars, including Nurse Debbie, Gloria, Tim, Rachel, Joe, Ethan, and Nurse Jay. We were also supported by five new leaders: Nicole a past camper; and from Curtin and Notre Dame University, there was Erin, Madison, Hannah, and Lachie. I am happy to state that they all enjoyed their first camp so much that they would like to return to support us again next year.
The week commenced with us getting to know one another. There were many new friendships formed, as well as old friendships rekindled. We then went on to engage in some fun and inspiring activities which included the following:
- Theatre Sports for our first night’s activity
- Daily wake-up with Morning Fitness
- Low & High Ropes
- Laser Tag
- Tie Dying
- Wall Climbing Archery
- Team Games
- And a visit to Outback Splash for some water fun.
The fun and activities did not stop at sunset as our evenings were filled with: a Movie Night; Campfire; the eagerly awaited Camp Has Talent Show (wow do we have some talent in our campers); and of course, the ever-popular Disco, which had a theme of the Wild, Wild, West.
Along with AOWA, I would like to thank Lotterywest for their generous contribution enabling us to run camps to support children and young people with chronic musculoskeletal conditions. We also appreciate the understanding that Lotterywest has demonstrated whilst we implemented an abundance of changes in response to the pandemic outbreak.
We would also like to thank all the Leaders who attended camp during these difficult times with the extra measures we needed to put in place, and the parents who trust us to deliver a fun and safe camp yearly.
At this stage, we have not locked in planning for Camp 2021 and will be waiting to see what unfolds in the next couple of months regarding the pandemic before progressing forward. So, watch this space – we will let you know as soon as we have more information and can make a decision.
By Kerry Mace, Camp Coordinator AOWA
Arthritis and Osteoporosis WA (AOWA) provides self-management programs for consumers living with arthritis. The programs consist of six classes held over six weeks. Facilitators lead the classes and help participants to identify high-value care options and empower them with “how-to” skills, based on scientifically evidenced ways to manage their Osteoarthritis (OA), Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) or Ankylosing Spondylitis (AS). These programs encourage interaction with others facing similar health-related challenges and enable health goal setting in a friendly, small group environment.
Keeping current with arthritis evidence
AOWA’s programs were originally created over fifteen years ago and have successfully helped people better manage their arthritis. However, as new evidence has emerged over the years, it was time to update the programs. AOWA knew that this would be a significant program of work to take on, so they employed a health professional with project management skills in June 2019 to lead the work.
Guided by a Steering Committee and supported by existing AOWA staff and a volunteer working group, the project commenced with the key objective of overhauling the programs. Through the team’s tireless efforts, the program materials were reviewed, updated, and polished. This was an extensive exercise as over 350’s relevant scientific paper references were embedded.
In addition, the OA knee program was reconfigured and expanded to include OA of any joint. This expansion has improved access to AOWA services for people living with OA – regardless of which joint/s is affected. The programs were renamed to ‘Arthritis KEYS program’, an acronym derived from the program’s objective: Knowledge Enhances Your Skills. The affordable KEYS programs are delivered as small group classes, either online or in-person at various locations.
Investing in service quality
Facilitators who lead the program are all currently registered health professionals or have a background as a trained health professional. To support the facilitators in their role and ensure a high-quality learning experience for consumers, AOWA embarked on a second project in July 2020. This project will design a training program that all facilitators will undertake before independently leading the KEYS programs. For this project, the training pathway will be redesigned to ensure that quality standards are achieved and upheld, and that training is efficient and utilises modern online learning modalities.
It has been a pleasure working in the Project Manager role. Despite several challenges along the way, including the emergence of the COVID-19 pandemic mid-project, the AOWA team and their support networks have a great “can-do” attitude and spirit.
In recognising the enormous value that AOWA volunteers bring to the organisation, a volunteer stream has opened for people to assist facilitators in delivering the KEYS programs with activities such as: distributing AOWA resources, sharing lived experience of arthritis, helping with group dynamics, and interacting with participants with empathy and understanding.
If you are interested in becoming a participant volunteer or new facilitator, express your interest today.
Call AOWA on 1800 011 041.
By Sam Haebich, Project Manager AOWA’s Arthritis KEYS Program
What is Ankylosing Spondylitis?
Ankylosing Spondylitis (AS) is a disease involving inflammation, mainly of the joints of the spine and of the sacroiliac joints (where the bones of the spine meet the bones of the pelvis). This inflammation causes the affected joints to become swollen and tender, and reduces their range of motion.
Over time, this inflammation can lead to the fusing together of the bones of the spine and of the sacroiliac joints, causing stiffness and abnormal posture. However, current treatment options mean that this feared complication is fortunately becoming less frequent.
What is the cause?
The cause is not yet known. It is likely to be caused by several factors, including genetic and environmental influences, most of which have not yet been clearly identified.
However, the general view is that AS is an autoimmune disease. This means that it arises when the body’s own immune system mistakenly thinks that some of the body’s normal cells are intruders and tries to get rid of them by releasing certain substances that cause inflammation.
Research has found that this disease is more common in some families. The relatives of a person with AS – especially first and second-degree relatives – have an increased risk of developing the disease. It is particularly common in people who carry the gene known as HLA-B27. This suggests that there is a hereditary predisposition to developing the disease.
How common is it and who does it affect?
Ankylosing Spondylitis affects approximately half a percent to one percent of the adult population worldwide, spread approximately equally across mane and women. Symptoms usually begin to appear between the ages of fifteen and thirty-five.
What is the relationship between Ankylosing Spondylitis and Axial SpA?
Over the past ten years, the name axial spondyloarthritis (axial SpA) has become increasingly common. This is because an international group of experts in this field, known as the Assessment of SpondyloArthritis International Society (ASAS), now recommends that AS can be considered part of a broader and more widespread group of diseases called spondyloarthritis (SpA) and, more specifically, a type of axial SpA.
How is Ankylosing Spondylitis diagnosed?
Ankylosing Spondylitis is generally diagnosed by a Rheumatologist, as this is the specialist best able to recognise the early signs. While most people will experience episodes of lower back pain at some time in their life, these will generally be due to mechanical problems in or around the spine, such as muscle strain or disc prolapse. Only about five percent of adults under the age of forty who have lower back pain will have the specific chronic inflammatory back pain that is typical of ankylosing spondylitis.
What are the symptoms?
Early spinal symptoms
Ankylosing Spondylitis typically starts as lower back pain that begins gradually and is often described as dull. It is felt deep in the lower back or buttocks, and may radiate down the backs of the thighs. Frequently there is also back stiffness lasting half an hour or more after waking up, which usually get better with physical activity but returns after inactivity (such as sleep or prolonged sitting).
As the disease progresses, this initially intermittent back pain usually progresses to become more constant. Night-time back pain also becomes more common and troublesome, especially during the second half of the night, often making it necessary to get out of bed and move around.
Some people may also experience chest pain, due to the inflammation of the joints between the ribs and the backbone, which may lead to incorrect suspicion of heart or lung disease.
Later spinal symptoms
Over time, the chronic inflammation involved in AS results in the gradual formation of extra bone tissue. This leads to the development of bony ridges between spinal bones, eventually resulting in the fusing together of two or more spinal bones and/or of the sacroiliac joints.
When such fusing develops, it is usually obvious from the progressive stiffening and abnormal curvature of the spine, which can be easily seen on x-rays.
As the disease progresses, increasing stiffness of the spine is often accompanied by a reduction in back pain, which now becomes more mechanical in nature and is due to the resulting postural changes and limited range of motion rather than to the initial inflammation.
The fusing of bones usually takes several years to fully develop, but because it occurs at an unpredictable rate in different people, it is very difficult to give an accurate estimate of this risk in the early stages of the disease. This is an important aspect of the discussion about when to start targeted treatment, especially in people with longer-lasting AS, where a combination of spinal inflammation and fusing may be present at the same time.
- Peripheral Joints: Up to 25% of people with AS develop inflammation of peripheral joints (joints of the arms and legs).
- Anterior Uveitis: Around 30% – 40% of people with AS develop inflammation of the front part of the eye, known as anterior uveitis. It involves inflammation of the iris (the coloured part of the eye and sometimes the ciliary body (the part of the eye just behind the iris).
- Enthesitis: Inflammation of any site where a tendon attaches to the bone.
- Intestinal Symptoms: These include abdominal pain, ongoing loose stools and sometimes blood with the stool. The overlap between AS and inflammatory bowel disease occurs in 5% – 10% of people with AS.
- Skin: Around 10% of people with AS will develop Psoriasis, an autoimmune condition characterised by patches of red, dry, flaky, itchy skin.
- Osteoporosis and/or Fractures: Spinal osteoporosis is common in people with AS, where it is thought to be a result of spinal inflammation. The combination of spinal osteoporosis and spinal rigidity from the fusing of the spinal bones in people with AS results in a high risk of spinal fractures., which can occur with no or minimal trauma.
- Systemic Symptoms: Usually affects the whole body rather than a specific part of the body. Symptoms can include fatigue, anxiety and/or depression.
- Heart and/or Lung Disease: 15% (approx.) of people with AS are at risk of developing scarring of the upper parts of the lungs; 10% (approx.) of people with AS are at risk of developing scarring of the heart valve. These complications usually develop very late in the disease, are usually mild, do not cause significant symptoms or long-term problems unless other heart or lung conditions develop.
By Prof Hans Nossent MD, PhD, FRACP
Chair of Rheumatology & Musculoskeletal Medicine, UWA