An Overview of Gout

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Gout is a form of arthritis that affects over three million Americans each year. Also known as gouty arthritis, the disease is caused by the formation of uric acid crystals in a joint (most often the big toe), triggering severe pain, redness, and tenderness. While certain factors, like genetics or kidney disorders, may predispose you to gout, diet, alcohol, and obesity can also contribute.

Treatment can include over-the-counter (OTC) and prescription drugs to alleviate pain and reduce uric acid levels. You can further minimize the frequency of attacks by losing weight, exercising regularly, and avoiding trigger foods.

Symptoms

The symptoms of gout tend to be progressive and will worsen over time if left untreated. The severity and recurrence of symptoms are largely related to the stage of the disease.

Asymptomatic gout is the period prior to your first attack. It is during this time that the persistent elevation of uric acid in your blood will cause urate to form crystals. While you will not experience any symptoms at this stage, the gradual accumulation of crystals will almost inevitably lead to an attack.

Acute intermittent gout is the stage when you will start to experience attacks lasting anywhere from three to 10 days. The attacks (most commonly affecting the big toe but also the knee, ankle, heel, midfoot, elbow, wrist, and fingers) will cause sudden and extreme pain accompanied by swelling, stiffness, redness, fatigue, and occasionally mild fever.

Chronic tophaceous gout is an advanced stage of disease in which the urate crystals consolidate into hardened lumps called tophi. The formation of these mineralized masses can progressively erode bone and cartilage tissue and lead to chronic arthritis and joint deformity.

Complications of untreated gout include kidney stones and the deterioration of kidney function.

Causes

Certain medical conditions can increase your risk of gout, either because they impair kidney function (allowing uric acid to accumulate) or cause chronic inflammation (which some scientists believe promote uric acid production). Examples include chronic kidney disease (CKD)congestive heart failure (CHF)diabetes, and psoriatic arthritis.

Similarly, genetics can play a part. One such example is a genetic mutation of the SLC2A9 or SLC22A12 gene, which helps regulate how much uric acid is excreted by the body.

Certain lifestyle risk factors can influence both the development and progression of the disease. They include:

  • Obesity, which is associated with increased uric acid levels
  • Diets rich in purines, which the body converts to uric acid
  • High-fructose drinks and alcoholic beverages that impair uric acid excretion

Certain medications, most notably diuretics, can impair uric acid excretion in the kidneys, leading to increased concentration of uric acid in the blood.

Diagnosis

Gout is typically diagnosed on the basis of lab tests and a physical exam. Imaging tests can also be used to support the diagnosis and/or evaluate the characteristics of the joint damage.

The gold standard of diagnosis is the synovial fluid analysis in which the joint fluids are extracted with a needle and syringe and examined under a microscope for evidence of urate crystals. Other diagnostic tools include kidney function tests and a urinalysis to help assess your risk of kidney stones.

Different imaging tests can be used to assess how much a joint has been damaged. Among them:

Treatment

The approach to gout treatment is three-fold: to manage pain and inflammation when it occurs, to reduce uric acid levels in the blood, and to modify risk factors leading to high uric acid levels. 

Gout pain can often be treated with rest and an ice pack to reduce localized swelling. OTC nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil (ibuprofen) or Aleve (naproxen) can also help.

Severe or recurrent cases may benefit from the inflammation-reducing effect of corticosteroids (delivered either by pill or injection into a joint) or an oral drug called Colcyrs (colchicine), which can both treat and prevent attacks. 

If diet and other interventions fail to provide relief, uric-acid-reducing drugs like Uloric (febuxostat) or Zyloprim (allopurinol) may be prescribed. Side effects include stomach upset, nausea, joint pain, and muscle ache.

Krystexxa (pegloticase), a newer biologic drug delivered by intravenous infusion, is typically reserved for people in whom all other gout treatments have failed.

Coping

While gout can be controlled to a large extent with medications and rest, there are a number of self-care strategies you can try to treat or reduce the recurrence of acute attacks. They include:

  • Avoiding high-purine foods such as liver, veal, mussels, tuna, bacon, and beer
  • Increasing your intake of fruits, vegetables, whole grains, and low-fat dairy
  • Drinking plenty of water per day to help clear uric acid through urination and to dilute concentrations in the blood
  • Embarking on a structured weight loss plan if you are overweight or obese
  • Elevating your foot during an acute attack and icing it safely
  • Using a cane or mobility device to keep pressure off the foot
  • Using relaxation techniques to better manage pain

If your symptoms don't improve after 48 hours or last for more than a week, call your doctor to schedule an appointment. In some cases, medications may need to be changed or adjusted if they are failing to provide relief.

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