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Gout Information

What is Gout?

Gout is one of the most common forms of arthritis (joint inflammation).  Known as the disease of kings and the king of diseases, gout has caused suffering in countless humans since the days of Hippocrates.  Gout occurs when needle-like crystals of uric acid form in the joint causing swelling, redness, heat, pain, and stiffness in the joints.

For many people, gout initially affects the joints in the big toe.  Sometime during the course of the disease, gout will affect the big toe in about 75 percent of patients.  It can also affect the instep (mid-foot), ankles, heels, knees, wrists, fingers, and elbows.  The disease may progress through four stages:

I.  Asymptomatic (without symptoms) hyperuricemia -- In this stage, a person has elevated levels of uric acid in the blood but no other symptoms.  A person in this stage does not usually require treatment. 

II.  Acute gout, or acute gouty arthritis -- In this stage, hyperuricemia has caused the deposit of uric acid crystals in joint spaces.  This leads to a sudden onset of intense pain and swelling in the joints, which also may be warm and very tender.  An acute attack commonly occurs at night and can be triggered by stressful events, alcohol or drugs, or the presence of another illness.  Attacks early in the disease usually subside within 3 to 10 days, even without treatment, and the next attack may not occur for months or even years.  Over time, however, attacks can last longer and occur more frequently. 

III.  Interval or intercritical gout -- This is the period between acute attacks.  In this stage, a person does not have any symptoms and has normal joint function.

IV.  Chronic tophaceous gout -- This is the most disabling stage of gout and usually develops over a long period, such as 10 years.  In this stage, the disease has caused permanent damage to the affected joints and sometimes to the kidneys.  With proper treatment, most people with gout do not progress to this advanced stage.

What causes Gout?

Gout is caused by an excess of uric acid in the body.  Uric acid is a chemical which is a natural part of the normal breaking down and building up of food and body tissues.  Normally, uric acid is dissolved in the blood and passed through the kidneys into the urine, where it is eliminated.  The level in the blood can be measured to show how much there is in the body overall. 

The condition of raised blood uric acid is called hyperuricaemia.  Hyperuricemia is not a disease and by itself is not dangerous.

Excess uric acid can be caused by an increase in production by the body, by under-elimination of uric acid by the kidneys or by increased intake of foods containing purines that are metabolized to uric acid in the body.

Eventually, the uric acid may form needle-like crystals in joints, leading to acute gout attacks.  Uric acid may also collect under the skin as tophi or in the urinary tract as kidney stones.

A number of risk factors are related to the development of hyperuricemia and gout:

  • Genetics: Up to 18 percent of people with gout have a family history of the disease. 
  • Gender and Age: Gout is more common in men than women and rare in children. 
  • Being overweight: There is more tissue available for turnover or breakdown, which leads to excess uric acid production. 
  • Alcohol: Drinking too much alcohol can lead to hyperuricemia because it interferes with the removal of uric acid from the body. 
  • A Purine-rich Diet: Eating too many foods rich in purines (see a table of foods) can cause or aggravate gout in some people. 
  • An enzyme defect that interferes with the way the body breaks down purines causes gout in a small number of people, many of whom have a family history of gout. 
  • Exposure to lead in the environment can cause gout.

Some people who take certain medicines or have certain conditions are at risk for having high levels of uric acid in their body fluids.  Hyperuricemia is strongly associated with obesity, hypertension, hyperlipidemia and diabetes.  Also longstanding kidney disease and organ transplant recipients are more likely to have higher levels of uric acid.  The following types of medicines can also lead to hyperuricemia because they reduce the body's ability to remove uric acid:

  • Diuretics, which are taken to eliminate excess fluid from the body in conditions like hypertension, edema, and heart disease, and which decrease the amount of uric acid passed in the urine;
  • Salicylates, or anti-inflammatory medicines made from salicylic acid, such as aspirin;
  • The vitamin niacin, also called nicotinic acid;
  • Cyclosporine, a medicine used to suppress the body's immune system (the system that protects the body from infection and disease) and control the body's rejection of transplanted organs; and
  • Levodopa, a medicine used to support communication along nerve pathways in the treatment of Parkinson's disease. 

Who Is Likely To Develop Gout?

Gout occurs in approximately 840 out of every 100,000 people.  It is rare in children and young adults.  Adult men, particularly those between the ages of 40 and 50, are more likely to develop gout than women, who rarely develop the disorder before menopause.

How Is Gout Diagnosed?

Since several other kinds of arthritis can mimic a gout attack, and since treatment is specific to gout, proper diagnosis is essential.  Gout may be difficult for doctors to diagnose because the symptoms may be vague, and they often mimic other conditions.  Although most people with gout have hyperuricemia at some time during the course of their disease, it may not be present during an acute attack.  In addition, having hyperuricemia alone does not mean that a person will get gout.  In fact, most people with hyperuricemia do not develop the disease.

To confirm a diagnosis of gout, a doctor may insert a needle into an inflamed joint and draw a sample of synovial fluid, the substance that lubricates a joint.  This fluid is viewed under a microscope to look for crystals.  The definitive diagnosis of gout is dependent on finding uric acid crystals in the joint fluid during an acute attack.  The doctor may also examine deposits (tophi) around joints to diagnose gout.  Gout attacks may mimic joint infections, and a doctor who suspects a joint infection (rather than gout) may check for the presence of bacteria.

How Is Gout Treated?

With proper treatment, most people with gout are able to control their symptoms and live productive lives.  Gout can be treated with one or a combination of therapies.  The goals of treatment are to ease the pain associated with acute attacks, to prevent future attacks, and to avoid the formation of tophi and kidney stones.  Successful treatment can reduce both the discomfort caused by the symptoms of gout and long-term damage of the affected joints.  Treatment will help to prevent disability due to gout.

Treating the acute attack

The most common treatments for an acute attack of gout are high doses of nonsteroidal anti-inflammatory drugs (NSAIDs) taken orally (by mouth) or corticosteroids, which are taken orally or injected into the affected joint.  NSAIDs reduce the inflammation caused by deposits of uric acid crystals but have no effect on the amount of uric acid in the body.  Corticosteroids are strong anti-inflammatory hormones.  The most commonly prescribed corticosteroid is prednisone.  Patients often begin to improve within a few hours of treatment, and the attack usually goes away completely within a week or so.  To gain the best results the dose should be adequate and the drug taken as soon as possible at the first sign of an attack.  Hence medical advice should be sought early. 

When NSAIDs or corticosteroids do not control symptoms, the doctor may consider using colchicine.  This drug is most effective when taken within the first 12 hours of an acute attack.  While colchicine is very effective, it often causes side effects such as nausea, vomiting and diarrhea.

  • Rest and elevation of the joint involved, and increasing fluid intake are also important.
  • Aspirin and aspirin-containing products should be avoided during acute attacks.
  • For some patients, the doctor may prescribe either NSAIDs or oral colchicine in small daily doses to prevent future attacks. 

How to Lower Uric Acid Levels (Hyperuricaemia)

Therapy directed at lowering uric acid levels in the blood should be considered for patients who have had multiple gout attacks or have developed tophi or kidney stones.  Several drugs that help the kidneys eliminate uric acid are available, such as probenecid (Benemid), and a drug that blocks production of uric acid by the body, such as allopurinol (Zyloprim).  The choice between these two types of drugs depends on the amount of uric acid in the urine.  These drugs help to reduce the frequency of sudden attacks and the development of tophi. 

It must be understood that these drugs have no effect on the actual attacks of acute gout and they must be taken on a continuous and long-term basis.  The dose must be adjusted by repeated checks on the blood uric acid level before a permanent maintenance dose can be decided on.  It is also very important for patients beginning such drugs to realize that for the first few months of treatment, gout attacks can become more severe and frequent.  This is usually controlled by taking an NSAID for at least several months and if any acute attacks do appear they must be treated in the usual way and the long term medicines continued.

With correct treatment, gout can be controlled in almost all cases.

What Can People With Gout Do To Stay Healthy?

  • To help prevent recurrent attacks, take the medicines your doctor prescribes.  Carefully follow instructions about how much medicine to take and when to take it.  Acute gout is best treated when symptoms first occur;
  • Tell your doctor about all the medicines and vitamins you take.  He or she can tell you if any of them may increase your risk of hyperuricemia. 
  • Plan follow-up visits with your doctor to evaluate your progress;
  • Maintain a healthy, low-purine, balanced diet.  Purines are substances found in food, which, when broken down produce a lot of uric acid; Therefore the following foods which are high in purines should be restricted or avoided:
    • Offal foods such as liver, kidneys, tripe, sweetbreads and tongue
    • Excessive amounts of red meat
    • Shellfish, fish roe and scallops
    • Peas, lentils and beans
  • Drink plenty of fluids, especially water.  Fluids help remove uric acid from the body;
  • Alcohol intake should be reduced.  Two standard drinks a day or less is sensible;
  • Exercise regularly and maintain a healthy body weight.  Lose weight if you are overweight, but do not go on diets designed for quick or extreme loss of weight because they increase uric acid levels in the blood;

The pain caused by gout will go away.  If you are careful you can avoid having recurrent attacks of gout.

Where Can People Find More Information About Gout?

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
www.niams.nih.gov

American College of Rheumatology/Association of Rheumatology Health Professionals
www.rheumatology.org

Arthritis Foundation
www.arthritis.org

Table of Purine Content
PurineContent.aspx

This information is not a substitute for appropriate medical care.


Source for this article: http://www.niams.nih.gov/hi/topics/gout/gout.htm

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