GOUT – Treatment and Prevention*
Gout is a painful inflammation of a joint, a complex form of arthritis, and is characterised by sudden, severe attacks of pain, redness and tenderness in joints, often the first joint at the base of the big toe (first metatarsophalangeal joint), although it can affect the hands, wrists, knees, ankles, elbows or any other joints.
History of Gout
The word "gout" was initially used by Randolphus of Bocking, around 1200 AD.
The Oxford English Dictionary defines gout as
- a disease in which defective metabolism of uric acid causes arthritis…
- a drop or spot of something…,
and gives the origin of the word as Old French goute and Medieval Latin gutta, literally 'drop' (because gout was believed to be caused by the dropping of diseased matter from the blood into the joints).
Gout has been known since antiquity. Historically it has been referred to as "the king of diseases and the disease of kings" or "rich man's disease".
The first known documentation of the disease is from Egypt in 2,600 BC, in a description of arthritis of the big toe. It is referred to by Hippocrates around 400 BC. Aulus Cornelius Celsus described the linkage to alcohol in 30 AD. A full description was recorded by the English physician Thomas Sydenham in 1683. The Dutch scientist Antonie van Leeuwenhoek first described the microscopic appearance of urate crystals in 1679, and in 1848 the English physician Alfred Baring Garrod realised that this excess of uric acid in the blood was the cause of gout.
Facts and Figures on Gout
- Gout is the most common form of arthritis in men over the age of 30 years.
- Gout is rare in women before the menopause.
- Gout affects men 20 times more often than women (only 5% of people with gout are women).
- Gout can easily be treated and can be prevented in some people.
- Long term effects of gout mean that medical advice for treatment and prevention should be sought immediately gout is suspected.
What is Gout?
Gout is a form of arthritis (inflammation of the joint). Small crystals form in and around the joints, causing irritation that leads to inflammation, and hence redness, swelling and pain. These crystals are uric acid, one of the body’s normal waste products. Normally the body rids itself of excess uric acid through the kidneys into the urine. However this does not happen fast enough in people with gout. This causes uric acid levels in the blood to build up, and the uric acid precipitates out as small crystals into the joints, causing the irritation that gives the symptoms of gout.
Symptoms of Gout
The symptoms usually come on rapidly and can last for one to two weeks. These are:
- Pain in a joint, which can be quite severe
- Swelling in and around the joint, which can be very tender to touch, even the touch of clothing
- Warmth and redness of the skin over the affected joint
- Restricted movement of the joint.
These are the classical signs of inflammation.
The big toe is the joint most commonly affected, although the hands, wrists, knees, ankles, elbows or any other joint can be affected.
Frequent attacks of gout can cause irreversible damage to the joint and adjacent bone. Over the long term, recurrent attacks can also cause kidney stones, kidney damage and tophi - solid lumps of urate crystals, especially on the ears, fingers, hands, forearms, knees and elbows.
Diagnosis of Gout
The diagnosis may be obvious: a red, hot, painful swollen big toe in a man over 40 years is usually gout. If a diagnosis has been made in the past, a recurrence is easily diagnosed.
The diagnosis is confirmed by:
- A blood test showing elevated blood levels of uric acid. The normal range for males is 2.5-8 mg/dL (some say 7mg/dL is the upper limit) and the normal range for females is 1.9-7.5mg/dL (some say 6 mg/dL is the upper limit)
- Synovial fluid analysis - a sample of fluid is taken from the joint with a thin needle, and urate crystals can be seen under the microscope
- In recurrent gout, X-rays may show damage to the joint
- Kidney function should be monitored in recurring gout.
The only way to have a positive diagnosis of gout is to identify uric acid crystals in the synovial fluid, since not everyone with an elevated blood uric acid may have clinical gout, and it is possible to have normal or low blood levels of uric acid in the presence of gout.
This term refers to looking at conditions with similar symptom expressions.
- The most important differential diagnosis is septic arthritis. This is diagnosed by culture for bacteria in the synovial fluid.
- Pseudogout (chondrocalcinosis where crystals of calcium pyrophosphate are deposited in the joint, mainly the knee).
- Rheumatoid arthritis.
Predisposing Factors of Gout
As mentioned above, gout is more common in men than in women, and is more common in older people than in younger people.
Apart from sex and age, gout is most common when the following are present:
- Overweight or obese
- Raised cholesterol levels in the blood
- Glucose intolerance
- Metabolic syndrome
- Kidney disease
- Diuretic drugs
- Low dose aspirin medication
- Excess alcohol
- Positive family history (although not all family members may be affected)
- Maori and Pacific Islanders.
Experiencing recent surgery or trauma has been associated with an increased risk of developing gout.
Foods that are high in purines should be avoided or at least limited. Most uric acid comes from purines made naturally by the body. The rest comes from purines in the diet:
- Organ meats: liver, kidneys, sweetbreads and brains
- Meats: bacon, red meats ... beef, pork and lamb
- Game meats
- Excessive fructose ingestion
- Anchovies, sardines, herring, mackerel and scallops
- Fish and other sea foods
- Oatmeal, wheat bran and wheat germ.
Treatment of Gout
The initial aim of treatment is to settle the symptoms of the acute attack. It should be treated straight away because it is very painful, and it can cause damage to the joint if not treated.
It is important to rest the joint. Putting ice on the joint and elevating it can help ease the pain.
The following drugs are used to treat acute attacks of gout:
- Non-steroidal anti-inflammatory drugs such as ibuprofen, naproxen, indomethacin
- Colchicine (tends to cause diarrhoea)
Diet and Lifestyle Approaches to Prevent Gout and its Complications
- Given the predisposing factors listed above, these include limiting alcohol, reducing fructose intake, adequate intake of water, limiting foods with high purine content, losing weight and regular exercise.
- Foods that have been shown to have the potential to lower uric acid levels include coffee and cherries.
- Supplement of vitamin C can reduce levels of uric acid (and hence the severity of attacks) but may not reduce the frequency of attacks.
Medications to Prevent Gout and its Complications
- Medications that block uric acid production. These are called xanthine oxidase inhibitors and include allopurinol and febuxostat, they limit the amount of uric acid that the body makes.
- Medications to improve uric acid removal. Probenecid improves the kidneys' ability to remove uric acid from the body.
Without treatment, an acute attack of gout usually resolves in about a week, but possibly two weeks.
60% of people have a second attack within one year unless lifestyle changes take place with possible appropriate medication.
Without treatment, episodes of acute gout may develop into chronic gout with destruction of joint surfaces, joint deformity and painless tophi. These tophi occur in 30% of those who are untreated for five years, often in the helix of the ear, elbow and Achilles' tendon.
Kidney stones are a frequent complication of gout, and other forms of renal dysfunction may occur.
Gout is treatable, and there are ways to reduce the risk that gout will recur.
*Copyright 2015: The Huntly Centre.
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