What Is Gout?
Gout is a form of inflammatory arthritis which is characterized by sudden, intense attacks of the affected joint with extreme pain, redness, warmth and swelling. Initially, it attacks only one joint which is mostly the joint of the big toe. However, many other joints and the tissues around the joints can be affected as well.
Gout most often causes symptoms in the big toe, but it can affect:
Gout is the most painful form of arthritis which is caused by the disorder of uric acid metabolism, where excessive uric acid builds up in the joint. Eventually, it results in the formation of uric acid crystals in the synovial fluid of the affected joint, tophus (deposit of sodium urate crystals) and kidney stones. Generally, it occurs due to a stressful lifestyle, after an illness or surgery, or heavy intake of red meat and alcohol.
Who Are Affected By Gout?
It is estimated that more than 6 million adults aged 20 years and above have been diagnosed to be suffering from gout. Men, particularly those between the ages of 40 and 50, are 3 time more likely to develop gout than women. Gout usually attack women in their late 40s or early 50s after their menopause period (end of the fertile phase). However, it is rare in children and young adults.
Causes Of Gout
Gout occurs in people who have a higher-than normal level of uric acid (Hyperuricemia) in the blood. Uric acid is a type of chemical results from the breakdown of purines which is found in the food we eat such as peas, liver, mackerel, mussels, sardines and yeast. Generally, it is perfectly normal for uric acid to form in the body as it helps to prevent the blood vessels from damages.
Normally, the body would get rid of the excess uric acid through the kidneys in the urine. However, the level of uric acid will start to build up when there is a disorder of uric acid metabolism as below:
- The body is making too much uric acid due to excessive breakdown of purines normally present in the cells of the body or due to a diet rich in purines.
- The kidneys are unable to excrete the uric acid effectively due to an inherited defect or acquired disease.
- Use of certain medications such as diuretics, which decrease the amount of uric acid passed in the urine
When the uric acid level goes above a certain point (the saturation point), it results in the formation of sodium urate crystals (hard, needled shape crystals) and accumulate in the synovial fluid and joint capsule, causing intense pain and rapid inflammation. The crystals may accumulate in the kidney to form kidney stones which leads to renal failure. Otherwise, they may accumulate under the skin which looks like white and chalky lumps, known as “tophi”.
12 Risk Factors For Gout Development
- Family History: Studies shows that up to 18% of the people have an inherited risk of developing gout.
- Weight: Being overweight increases the risk of developing hyperuricemia and gout because there is more tissue available for turnover or breakdown, which leads to excess uric acid production.
- Alcohol: Drinking too much alcohol can lead to hyperuricemia, because alcohol interferes with the removal of uric acid from the body.
- Diet: Eating foods rich in purines is a definite risk factor as the body has to remove the excess uric acid produced.
- Chemotherapy: An excess and rapid turnover of cells will results in an increase in the level of uric acid.
- Other health problems: Other medical problems that cause the development of gout such as psoriasis (Refer to right image), hemolytic anemia, diabetes, hypothyrodism, down sydrome or high blood pressure.
- Medications: Taking medications like diuretics, neoral, levodopa, niaspan and aspirin have an increase risk of developing gout.
- Occupational Exposure: This is the main cause of lead poisoning. Occupations like lead miners, smelters, plumbers, battery manufacturers, construction workers are at risk for lead exposure.
- Kidney Malfunction: Loss of kidney function such as chronic renal disease and polycystic kidney disease (Refer to right image).
- Joint injury: Have a higher risk of developing uric acid crystals in the joint.
- Organ transplant: Organ transplantation procedures such as the heart or liver may increase the risk for gout.
- Weather: Several studies revealed that the cause of dehydration in hot and humid climate correlate to an increase risk for gout attack.
Common Signs And Symptoms Of Gout
Typically, the symptoms of gout are characterized by crippling pain and swelling which usually ‘attack’ a single joint, most commonly the base of the big toe. However, it can also affect the ankles, knees, elbows or fingers. The skin over the affected joint appears shiny with peeling and is very painful to the touch.
Sudden onset of gout attack usually starts at night with intense, rapidly developing pain in the affected joint associated with redness, swelling, low-grade fever or chills. There will be limited joint movement, even in walking or moving the bed sheet. Typically, there are 4 stages of gout. As such, the symptoms are different for each stage of the disease.
Stage 1 – Asymptomatic hyperuricemia
This is the stage where the existence of gout is unknown, no signs and symptoms at all. However, there is hyperuricemia, an abnormal level of uric acid in the blood. No treatment is needed at all.
Stage 2 – Acute gout/ acute gouty arthritis
At this stage, there is accumulation of uric acid crystals in the joints. The first gout attack is characterized by sudden onset of severe pain, swelling in the joint. The inflamed joint is hot and tender to the touch. There is intense and rapidly developing pain over the next 8 to 12 hours in the affected joint, usually the big toe. Gout attacks usually start at night and may be triggered by alcoholic drinks, psychological stress or the presence of medical conditions. Symptoms may subside after a few days and the second attack may be months or years later. As the disease develop gradually, the frequency and duration of gout attack is higher and longer.
Stage 3 – Intercritical or interval gout
This is the time period between each gout attacks. As such, there are no symptoms or even pain. However, the presence of uric acid level in the blood remains high and more crystals continue to accumulate in the joint fluid causing further damages. In fact, this is the stage whereby treatment should be administered to reduce the chances of future attacks. If not, the condition will get worsen and progress into chronic gout.
Stage 4 – Chronic tophaceous gout or polyarticluar gout
This is the final stage of disabling gout which has developed over a long period of time. There may be permanent damage to the affected joint and results in loss of mobility. In severe cases, it may leads to kidney failure, resulting death eventually. The pain is sustained throughout the joints and tophi (deposit of sodium uric crystals) may appear at the elbows, ears, knees, cartilage and other tissues or organs in the body.
Complications Of Gout
- Involvement of new joints: As the disease progress after a period of time, the frequency of gout attacks tends to increase and new joints are affected.
- Kidney stones: Also known as renal calculus results when the uric acid stones collect in the urinary tract.
- Joint damages: A build-up of urate crystals can damage the cartilage and bone in the joints, leading to chronic arthritis.
- Formation of tophi: A build-up of crystals can also lead to the formation of tophi in and around the joints. Tophi can grow and cause pressure damage to the joint cartilage and bone.
- Skin and ear involvement: Urate crystals form small, firm white lumps called tophi under the skin and rim of the external ear, which sometimes break down and discharge pus-like fluid containing gritty white material, the urate crystals themselves.
Diagnosis Of Gout
To confirm a diagnosis of gout just by screening at the symptoms of gout or medical history is inadequate as most of other medical conditions have similar symptoms. For example, the symptoms of gout (sudden pain, swelling and immobility) are rather similar to other arthritis-related conditions such as pseudogout, an inflammatory arthritis of the joints which is caused by the deposits of calcium pyrophosphate crystals in and around the structural parts of the joints.
Unlike gout, it particularly affects the larger joints such as the knees or ankle and rarely the big toe. Therefore, further clinical test may be conducted to either confirm the diagnosis of gout or rule out other conditions with similar symptoms. The following tests would help confirm the diagnosis.
Blood test – To measure the amount of uric acid in the blood. A high level of uric acid indicates the possibility of gout but not always. However, this test is not reliable as some patients who have gout, have normal level of uric acid in their blood. As for others who have abnormal levels of uric acid, they do not experience any symptoms of gout at all.
Joint aspiration – Most reliable test for gout which examines the synovial fluid under the microscope for sodium urate crystals. A procedure that utilize a syringe and needle to draw the fluid from the affected joint under local anesthesia.
X-rays – Use primarily in the phase of chronic gout to assess the extent of joint damages and signs of tophi development. Other imaging techniques used may include magnetic resonance imaging (MRI) and computed tomography (CT).
Treatment For Gout
Generally, there are 2 phases in the treatment for gout:
Phase 1: Medications To Relieve the Symptoms of Acute Gout
The aim of this phase is to relieve joint pain, swelling and inflammation of the affected joint through medications which are usually prescribed as below:
- Non-steroidal anti-inflammatory drugs (NSAIDs): They should be taken at the beginning of an attack along with a proton pump inhibitor (PPI) to help protect the stomach.
- Colchicine: It is very effective at damping down inflammation caused by the crystals interacting with the joint lining. The recommended dose is 0.5 mg 2–4 times per day, depending on your weight, age and health.
- Corticosteroids: If an acute attack doesn’t improve with NSAIDs or colchicine, the doctor may prescribe a steroid injection into the joint or muscle, or a short course of steroid tablets.
Phase 2 – Prevention Of Recurrent Gout Attack
The aim of this phase is to prevent future gout attacks or any complications which may leads to severe joint or kidney damages. The medications below are used to reduce the amount of uric acid in the body:
- Allopurinol: It is the most commonly used urate-lowering drug. It works by reducing the body’s urate production. The starting dose is usually 100 mg a day. If side-effects such as a rash, headache or nausea occur, the drug should be stopped and to be advised by the doctor consulted.
- Febuxostat: The drug is broken down by the liver, so is particularly useful for people with kidney problems who can’t take allopurinol. The starting dose of febuxostat is 80 mg.
- Uricosuric drugs: Uricosuric drugs, which include sulfinpyrazone, benzbromarone and probenecid, works by flushing out more urate than normal through the kidneys.
10 Tips On The Prevention Of Gout Attacks
- Drink plenty of fluids, which helps in removing the excess uric acid from the body and avoid dehydration. Also recommended to consume at least 3 oz. of cranberry juice to relieve the symptoms of gout.
- Alcoholic drinks should be avoided as it can raise the levels of uric acid in the blood.
- People with gout should exercise regularly and maintain a normal body weight.
- Avoid foods that are rich in purines, such as anchovies, asparagus brains, dried beans and peas, gravy, herring, liver, mackerel, sweetbreads, seafood (scallops, sardines, lobster, mussels), yeast and red meat (beef, lamb and pork).
- A knock or injury to the joint can encourage urate crystals to shake loose from the cartilage and trigger an acute attack. Hence, it is recommended to use a splint or sling to immobilize the joint which can helps to relieve pain and protect the affected joint.
- Use ice packs to relieve pain and reduce swelling. Ice pack should wrap within a light towel and application on the joint should not be more than 20 minutes.
- During periods of gout attack, it is vital to rest and elevate the affected joint.
- Should not wear a tight-fitting shoe as it may trigger gout attack in your big toe. Only wear shoes that allow your feet and toes to move freely.
- Adopt a healthy diet and eat food which provide nutrients to your body and eat more low-dairy products. Cut down on foods that are high in calories and fats.
- Take medications as prescribed by the doctor and inform the doctor if you are taking other herbal supplements, vitamins or other forms of complimentary treatments.
Future of Gout
Learning as much as possible about “what is gout” enables you to gain control over the condition with confidence and a positive outlook. Just like many other forms of arthritis, gout is a progressive condition which will worsen if not treated in the initial stage. Therefore, by getting proactive in your own care and working closely with your rheumatologist in the treatment, it is possible to slim down the chances of repeat gout attacks and even chronic gout in the later stage.