(Gouty Arthritis)
Definition
Gout is recurrent attacks of joint inflammation caused by a build-up of uric acid crystals. If the crystals accumulate in the kidneys, kidney stones may result.
Causes
Gout typically occurs in people with high levels of uric acid in their blood (hyperuricemia). However, most people with hyperuricemia do not develop gout. Conversely, people with normal blood uric acid levels can have gout.
Uric acid is derived from the breakdown of purines. Uric acid is metabolized in the liver and eliminated by the kidneys via the urine. Levels of uric acid build up when:
• The body produces too much uric acid
• The kidneys do not eliminate enough uric acid
Most patients with gout and hyperuricemia do not eliminate enough uric acid from their bodies.
Risk Factors
A risk factor is something that increases your chance of getting a disease or condition. All causes of hyperuricemia are risk factors for gout.
Risk factors include:
• Obesity or sudden weight gain or very rapid weight loss
• Age: over 40 years old
• Sex: Male
• Family members with gout
• Diuretics, such as hydrochlorothiazide
• Certain medications, such as aspirin
• A purine-rich diet including:
o Liver and other organ meats
o Dried beans and peas
o Anchovies
o Gravies
• Alcohol consumption, especially binge drinking
• Certain types of cancer or cancer treatments (eg, cytotoxic drugs)
• Medications (such as antiseizure, anti-rejection medications and others)
• Dehydration
• Hypercholesterolemia
• Kidney disease
Symptoms
Symptoms include:
Acute Gouty Arthritis
• Sudden onset of severe pain in an inflamed joint, usually starting in the big toe
• Joints that are red, hot, swollen, and very tender
• Increased pain 24-36 hours after the onset of symptoms
Gout of the Big Toe
Recurrent Gouty Arthritis
Most gout suffers will have a recurrent attack within two years, which can affect many different joints. Recurrent gout can lead to the development of tophi, which are chalky deposits of uric acid that most commonly occur in the elbows and earlobes.
Diagnosis
The doctor will ask about your symptoms and medical history, and perform a physical exam. In addition, the doctor may take a sample of fluid from the affected joint. This fluid will be tested for uric acid crystals.
Other tests may include:
• Blood and Urine Tests–to measure the level of uric acid in your blood and to assess kidney function and involvement
• X-rays–to check for joint destruction, which may complicate recurrent cases
Treatment
Treatment depends on whether the gout is acute or recurrent.
Acute Gouty Arthritis
In general, the sooner treatment begins for an acute attack, the more effective it is. Treatment depends on:
• Onset of symptoms
• Number of joints affected
• Previous responses to treatment
• Overall health
General Measures
Putting a warm pad or an ice pack on the joint may ease the pain. Keeping the weight of clothes or bed covers off the joint can also help.
Medications
• Nonsteroidal anti-inflammatory drugs (NSAIDs) may also help:
o Indomethacin
o Ibuprofen
o Naproxen
• Aspirin is not recommended because it can increase uric acid levels.
• Corticosteroids–may be used if NSAIDs are not effective or not recommended (taken orally, injected into a muscle, or injected into the affected joint)
• Colchicine–also used to prevent attacks of gout. Seldom it is used as a treatment for an acute attack. Note: This drug is associated with many adverse effects, so it is rarely used first.
Recurrent Gout
General measures
• Consume a low-purine diet.
• Avoid alcohol.
• Lose weight if overweight. But do not lose weight rapidly and without the advice of your doctor since rapid weight loss can precipitate a gout attack.
• Discontinue or avoid medications that increase uric acid levels.
• Stay well-hydrated.
Medications
• For recurrent gouty arthritis, or an initial attack with persistent hyperuricemia, you may be given medication to either:
o Lower the production of uric acid (allopurinol); or
o Increase the excretion of uric acid by the kidneys (probenecid or sulfinpyrazone)
• Under some circumstances, low dose colchicine may also be used to prevent recurrent attacks.
Prevention
To reduce your chance of getting gout:
• Consume a diet low in purines if you have hyperuricemia or family members with gout.
• Limit your intake of alcohol, especially binge drinking.
• Avoid dehydration.
• Lose weight if you are overweight. But do not lose weight rapidly and without the advice of your doctor since rapid weight loss can precipitate a gout attack.
• Gout is also associated with high blood pressure and heart attacks. Speak to your doctor about reducing your risk factors for these complications.
