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Gout

What is gout?

Gout is a common type of arthritis (joint inflammation). It causes sudden bouts of pain and swelling, usually in just one or two joints. Commonly, the ball of the foot is involved. If left untreated, bouts of acute gouty arthritis – also called gout attacks – can last from days to weeks.

Gout affects men (middle-aged generally) much more often than women. In New Zealand, high rates of gout are seen in Maori and Pacific Island people (especially men). Gout is closely linked with the body's level of uric acid (see below). Your doctor can treat high uric acid levels and gout attacks.

Uric acid

Uric acid is a natural byproduct of the body's metabolism of foods rich in chemicals called purines. Normally, excess uric acid in the blood is transferred by the kidneys into the urine and removed from the body. However, people with gout either produce too much uric acid or their kidneys are unable to dispose of it sufficiently, so it accumulates in the body. When uric acid accumulates it can form tiny needle-shaped crystals in the joints – this causes inflammation and pain.

Sometimes people can have high levels of uric acid in the blood (hyperuricaemia) but have no joint pain, and other people who have gout attacks can have near-normal uric acid levels. Accumulation of uric acid may also cause kidney problems – this is another important reason for controlling uric acid levels with medications.

Acute gouty arthritis (gout attacks)

When uric acid crystals form in a joint they cause a painful arthritis called a gout attack. This often occurs overnight. Within 12 to 24 hours there is severe pain, which usually lasts five to 10 days, but can continue for weeks. The pain is accompanied by joint inflammation (it appears red and swollen, and feels hot and extremely sensitive even to light touch).

Gout commonly strikes the big toe where it joins the ball of the foot, but other joints can be affected; including, the instep, ankle, knee, kneecap, wrist, tip of the elbow and fingers. It can also cause inflammation of the tendons and the fat pads of the feet.

How can I avoid a gout attack?

If you are predisposed to high uric acid levels, or have had a gout attack before, there are changes you can make to reduce the risk of an attack:

  • avoid or restrict foods high in purines (eg, liver, kidneys, tongue, sardines, anchovies, shellfish, fish roe, peas, lentils, beans and food extracts like marmite and vegemite)
  • avoid eating large amounts of red meat
  • reduce alcohol intake and drink alcohol only in moderation (one to two drinks per day for men) 
  • drink plenty of water and non-alcoholic fluids (at least five glasses a day) - dehydration can be a trigger for an attack of gout
  • avoid or limit sugary drinks such as fruit juices and soft drinks
  • do not overeat or starve (aim for regular meals)
  • aim to have low-fat dairy products each day 
  • keep to a healthy body weight (talk to your doctor if you are overweight because unsupervised weight loss may also cause gout)
  • ask your doctor whether you need to change any medications you take for other health problems.

Chronic (long term) gout

After a gout attack you may not have another for months or years. However, if your uric acid levels remain high the risk increases, and chronic gout is also more likely. In chronic gout the affected joints are persistently painful and the uric acid crystal deposits result in joint damage, which can stiffen and limit joint motion. The larger deposits can form tophi (which appear as yellow-white nodules under the skin covering the joints and, sometimes, around the outer ear).

Am I at risk of developing gout?

The strongest predictor for gout is a high uric acid level. Heredity can influence the body's handling of uric acid. This means being predisposed to high uric acid levels and gout tends to run in some families. In about 90% of cases, gout affects men aged over 40 years and women after the menopause.

Gout is also strongly associated with being overweight and having high blood pressure. Certain medications (eg, 'water tablets' or diuretics, for high blood pressure or heart failure), existing kidney problems and some other diseases, high alcohol intake and a diet too rich in purines can also raise uric acid levels, and trigger gout.

Testing
Your doctor can diagnose gout based on your symptoms, blood tests showing high levels of uric acid and, most reliably, the presence of urate crystals in any joint fluid or the overlying bursa (cushions) if this has been obtained. In the early stages of gout, x-rays are not usually helpful in diagnosis, but in chronic (long term) gout, x-rays can show damage to cartilage and bones caused by tophi.

Treating a gout attack

You may not always be able to avoid gout attacks, but medications and self-care can help reduce your symptoms. A non-steroidal anti-inflammatory drug (NSAID) can be very effective as a pain reliever. To gain the best results, the dose should be adequate and the drug taken at the first sign of an attack. Hence, medical advice must be sought early. With effective treatment the pain and inflammation can be controlled within 12 to 24 hours and treatment discontinued after a few days. NSAIDs are not suitable for some people. Your doctor will take into account individual factors, such as whether you have other medical conditions or take other medicines.

Other drugs such as colchicine, or corticosteroids (given as tablets or by injection into the joint), can also be used for a short period to control gout. People with gout pain should avoid medications containing aspirin as these can make gout worse. Drugs used for gout attacks have no effect on reducing uric acid levels.

Medications to lower uric acid levels

If your uric acid level remains high and attacks continue or become more frequent, your doctor will usually recommend long-term use of the drugs allopurinol (this lowers uric acid production) or probenecid (this helps the kidneys remove uric acid).

These drugs will not relieve your pain immediately but it is important to keep taking them as advised (even when feeling well) because the benefits of controlling your uric acid levels will occur over years. Drugs for reducing uric acid levels must be taken as advised by your doctor as side effects may occur – your doctor will explain all of this to you.

High uric acid levels and recurrent gout are often associated with high blood pressure, which also needs to be checked and treated as required. This combination of health problems can cause kidney damage if they are not controlled with supervision from your doctor. Also see: Blood pressure and kidney disease

Self-care during gout attacks

  • seek help from your doctor as early as possible, take any medications prescribed by your doctor and continue taking them for as long as advised
  • rest and try to keep the weight of any bedclothes off the painful joint
  • try using ice or a heat pack on the joint (stop if the pain worsens)
  • maintain an adequate fluid intake (at least five glasses per day), and avoid alcohol.

Further information and support

Talk to your doctor, and a dietitian can give further help with your diet. Arthritis New Zealand also offers support and advice (contact details further below).

Original material provided by everybody, 2013. Latest update by Health Navigator NZ, August 2014.

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