What Is Gout?
Gout is the most common form of inflammatory arthritis. It is a serious, lifelong disease that needs ongoing medical treatment and requires some changes to lifestyle habits to achieve control. If left untreated, advanced gout can lead to the same level of work loss, physical disability, and diminished quality of life as is seen in advanced rheumatoid arthritis.![]()
Overview
Gout is one of the oldest conditions in the medical literature and, in the past, was called the “disease of kings.” It is historically associated with eating rich foods and consuming a lot of alcohol, particularly beer, but our understanding about what actually caused gout has greatly changed in recent years.Many people have a lot of guilt associated with their disease – stemming from the myth that gouty arthritis is self-inflicted by poor dietary and lifestyle habits.Over the past 30 years, the percentage of people developing gout has been steadily rising. People in industrial societies now have access to rich food, live longer, and are not as physically active as in the past.Understanding what gout is and following treatment advice from a medical professional is important.Gout Symptoms
The signs and symptoms of gout almost always occur suddenly, and often at night.Signs and symptoms of gout include:- Intense pain and swelling — usually in one or two joints in the feet or legs, most commonly the big toe. During a gout flare (sometimes called a gout attack), the intensity of the pain in the affected joint is usually described as excruciating (8 to 10 out of 10).
- Limited joint function — During a gout flare, virtually all motion or use of the involved joint is greatly limited. After five or more years of recurrent gout attacks, people with gout may develop tophi crystals under the skin and around joints. While generally not painful, tophi can be disfiguring and interfere with normal joint function. The presence of tophi close to bones can lead to bone and cartilage destruction creating further deformities in the affected joint.
- Chronic persistent arthritis — During the early stages of gout, the inflammatory arthritis is intermittent and during the periods between gout attacks, the affected joint may feel and function normally. Years to decades after the initial flare (gout attack), flares may continue to be a recurrent problem but the intervals between gout attacks become painful daily.
The severity of gout can be classified into three manifestations.
- Gout Flares
- Chronic Persistent Arthritis
- Tophus Formation and Bony Erosions
Uric Acid Crystals and Gout Attacks
Gout is a painful condition that can be caused by uric acid crystals building up in the body. These uric acid crystals form when there is too much uric acid in the blood, and they can cause intense gout attacks that are characterized by throbbing pain, inflammation, and swelling in the joints.Since symptoms of gout include red, hot, and swollen joints, as well as joint stiffness and intense pain, it’s important to see a medical professional. These gout flares can last for days or weeks at a time, and they can be extremely debilitating and interfere with your ability to move or perform everyday tasks.
Gout Causes
Uric acid is naturally produced in everyone’s body. Too much uric acid can put people at risk for gout. As cells die, they release substances called purines, which are also found in some foods. When your body breaks down purines, they are converted into uric acid; from there, uric acid is then primarily processed by the kidneys.If the body has high levels of uric acid (greater than 6.8 mg/dL), hyperuricemia develops. Hyperuricemia is what causes gout, so lowering excess uric acid to a healthy range – 6.0 mg/dL or below – is the most important step to successfully managing gout.Prevent Gout Attacks
Not everyone with hyperuricemia will get gout, but once it develops, it is likely to return unless treated by medicine to lower uric acid. Medication to lower your uric acid level and some changes to your diet and exercise habits can reduce uric acid buildup and prevent further accumulation.After years with hyperuricemia, the extra uric acid in the body can turn into tophi crystals in your joints and other tissues. This crystal formation can cause the inflammation associated with gout flares and lead to the commonly seen pain.Gout Treatment
Getting a physical examination immediately upon the first signs of gout will help your doctor in diagnosing gout. Getting gout diagnosed sooner rather than later will help you prevent gout attacks and avoid long-term gout pain.Acute Gout
Once diagnosed with gout, a new patient will likely be given medications to treat his or her disease. Like many other medications for chronic conditions, such as high blood pressure or high cholesterol, uric acid medications are meant to be taken daily for life. They should not be discontinued—even when a gout flare is over as they will help reduce gout attacks in the future.Certain medications for pain and inflammation can be stopped, such as NSAIDs, steroids, or colchicine, as directed after pain and inflammation have subsided. However, urate-lowering therapy must be continued for life.Standard urate-lowering medicines are:
- Allopurinol – This is an oral prescription that helps lower serum uric acid levels. This medicine is also known by brand names Lopurin® and Zyloprim®. When started on this drug, your doctor will likely gradually increase the dosage to a dose that achieves the target uric acid level.
- Febuxostat – This is another urate-lowering therapy that can be prescribed under the brand name Uloric®. This medication is taken orally and decreases the body’s production of uric acid. It can be taken by people with mild to moderate kidney or liver disease.
What is gout medication for pain and inflammation?
- Nonsteroidal anti-inflammatory drugs (NSAIDS) – Several—like Advil®, Aleve®, and Motrin®—are available in over-the-counter dosing. Your doctor may also give you a prescription dose. Other brand-name NSAIDs include Celebrex®, Indocin®, Naprosyn® and Tivorbex®.
- Glucocorticosteroids – Cortisone can be taken orally or injected, and quickly suppresses the inflammation of an acute gout flare. It may be prescribed under the brand names Deltasone® (prednisone), Kenalog®-40 or Medrol®.
- Colchicine – This is usually most effective when taken within the first 12 hours of an acute flare; however, other medications may still be needed for treating pain. A common dosing schedule is to take two, 0.6 mg tablets together at once, then a third tablet one hour later, followed by one tablet 2-3 times per day over the next week. Patients may have side effects such as nausea, vomiting, abdominal cramps, or diarrhea. Brand names include Colcrys® and Mitigare®.
Chronic Gout (Advanced Gout)
With severe tophi that limits a patient’s quality of life, physicians may choose to prescribe pegloticase, also known as Krystexxa®, given by intravenous infusion every two weeks to aggressively dissolve gout crystals.Medical specialists who are trained to treat gout, such as rheumatologists and nephrologists, give infusions at their offices, where patients are monitored throughout the treatment. These infusions take two to four hours, including pre-infusion medication and post-infusion monitoring.This more aggressive way to treat gout is used without other drug therapy and can reduce uric acid levels significantly and eliminate the tophi.Some side effects of pegloticase are muscle pain, nausea, vomiting, and upset stomach – which need to be addressed by a doctor if they persist or are bothersome.In some advanced cases, the combination of drugs is used: high doses of either allopurinol or febuxostat can be combined with probenecid, a drug that helps the kidneys eliminate uric acid. This approach will likely take longer to reduce the body’s uric acid pool size, and that will eliminate flares and dissolve tophi.Risk Factors
The following is a list of common risk factors that can lead to gout flares.
- Hyperuricemia – High levels of uric acid, above 6.8 mg/dL, can lead to gout attacks. The best uric acid level for a person with gout is below 6.0 mg/dL—regardless of age or gender.
- Family History/Genetics – One in four people with gout has a family history of the disease, yet less than half of people with the disease know that it can be hereditary.
- Age – Gout can occur in men during their 30s through 50s and in women in their 60s through 80s.
- Gender – Gout affects men more often than women—although, once women are post-menopausal, their rates of gout increase nearly to the same level as men.
- Ethnicity – Some ethnic groups are more likely to get gout than others. This is genetic and varies by ethnicity and other health risks. For example, Hispanics and African Americans are more likely to suffer from obesity, which has been linked to gout.
- Obesity – Only one in 10 Americans knows that obesity can contribute to an increased risk of gout. Someone with a Body Mass Index (BMI) of 30 or higher is considered obese.
- Other Health Issues – Gout is associated with other health issues, including high blood pressure, heart disease, diabetes, and kidney disease. It is important to receive a prompt diagnosis and ongoing treatment to manage these conditions.
- Joint Injury – People with previously damaged joints are more likely to be the sites of gout flares.
- Diet – Many foods can raise the level of uric acid in the blood. Chief among these are beer, beef, pork, shellfish, and foods or beverages sweetened with high-fructose corn syrup (which causes uric acid to go up). High-fructose corn syrup is also found in sweetened soft drinks and juices; certain cereals and pastries; ice cream and candy; and processed foods at fast food restaurants. In some people with gout, eating these foods can trigger gouty flares.
- Medications – The use of certain medications—especially diuretics or water pills and certain anti-rejection medications used in transplant patients—can increase uric acid levels in the blood.
Complications (Health Conditions)
- Heart disease — Too much uric acid is a known risk factor for both hypertension and heart disease. Many epidemiological studies show a link between uric acid and coronary disease, including stroke and heart attack. Left untreated, gout can be very dangerous, with new research showing that having gout doubles a person’s risk for heart attack or stroke.
- Kidney disease — those who have gout are more likely to get kidney disease. Likewise, those who have kidney disease are more likely to suffer from gout and high levels of uric acid.
- Ongoing deposits of uric acid crystals — When a patient with gout is between flares and is having no symptoms and the joints are functioning normally, but whose blood uric acid level is still elevated (greater than 6.0 mg/dL), uric acid crystals are continuing to accumulate and the disease is quietly worsening.
- Chronic, persistent joint complaints and deformities — After years of untreated or undertreated early gout, the disease can progress to a stage with chronic, persistent joint complaints and deformities as well as the appearance of tophi, or masses of uric acid crystals under the skin and around joints. Tophi break through the skin and appear as white or yellowish-white, chalky nodules.
- Finger or toe amputations — In 10-15 percent of patients, tophi are severe and disfiguring. Some patients need specialized shoes. Prior to pegloticase, finger and toe amputations were not uncommon.
- Decline in quality of life — There is a reported decline in quality of life when gout is uncontrolled. Gout not only takes a physical toll on the body, but it also takes a mental toll.
Diagnosis
Upon examination, the doctor might suspect gout. A CT scan, ultrasound, MRI, and or a synovial joint fluid aspiration will be done to assess for crystals that are proof-positive of a gout diagnosis. A blood test will likely be done to check serum uric acid (sUA) levels.While a blood test doesn’t provide a definitive diagnosis of gout, it helps the physician understand whether this is a potential diagnosis.Patients should provide the doctor with a thorough health history, answering these and other questions:- Have you had an experience like this before?
- Have you been diagnosed with hyperuricemia (uric acid levels above 6.8 mg/dL)?
- Has anyone in your family been diagnosed with gout or hyperuricemia?
- Do you have diabetes, kidney disease, hypertension, or heart disease?
- Have you had a recent joint injury?
- Do you consume a lot of sugar in your diet?
- If female, have you been through menopause?
Prevention and Diet
Preventing gout requires the reduction of the urate burden on your blood. By reducing the level of uric acid in your body, you can curb crystal buildup around your joints thus managing painful flares.While the most successful way to achieve this is through uric acid-lowering medications, dietary and lifestyle modifications can be helpful by reducing obesity and are helpful for other medical conditions associated with gout.Diet
At best, a healthy diet can reduce uric acid by 1.0 mg/dL; however, a healthy diet can help obesity – a risk factor that leaves someone three times more likely to develop gout.Dietary changes can also help you recognize foods that cause flares and avoid them. As such, maintaining a healthy weight and keeping up with good eating habits should be a goal alongside uric acid-lowering therapy.No food and drinks “cause” gout, but overindulgence in foods rich in purines can bring on painful flares. This includes foods such as:- Red meat
- Organ meats
- Alcohol (especially beer)
- Shellfish
- Processed foods
- Lean proteins like fish and chicken are fine in moderation (around 4 to 6 ounces per day).
- Low-fat and nondairy products
- Fresh fruits
- Nuts, nut butter, and healthy grains
- Vegetables: luckily there is a wide variety of vegetables to choose from for your healthy diet.
Lifestyle
Lifestyle changes can also reduce the impact of gout on your body. Regular exercise is a helpful method to keep your body in good shape. The CDC recommends moderate-intensity physical activities for at least 30 minutes most days of the week for adults. Maintaining a healthy body weight is also important; crash diets and other quick solutions for rapid weight loss can increase uric acid levels in the body. Staying hydrated is vital as well. Research shows that drinking adequate water might guard against kidney stones and constipation – two conditions that can be impacted by gout.Other healthy benchmarks to keep track of:- LDL Cholesterol
- 130 mg/dL or below
- Heart Rate
- 60-100 beats/minute
- HDL Cholesterol
- 40-60 mg/dL
- Cholesterol
- 200 mg/dL or below
- Blood Sugar
- 100 mg/dL or below if fasting
- Blood Pressure
- 130-80 or less