gout

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Gout


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Overview

Gout is a common, painful form of arthritis.

It causes swollen, red, hot and stiff joints. Gout occurs when uric acid builds

up in your blood. This happens if your body produces extra acid or does not



Overview

eliminate enough, or if you eat too many foods with purines, such as liver and

dried beans. Pseudogout has similar symptoms and is sometimes confused with

gout. However, it is caused by calcium phosphate, not uric acid.

Often, gout first attacks your big toe. It



Overview

can also attack ankles, heels, knees, wrists, fingers and elbows.

You are more likely to get gout if you:

Are a man

Have family

member with gout



Overview

Drink

alcohol

At first, gout attacks usually get better in

days. Eventually, attacks last longer and occur more often. Uric acid buildup

can lead to kidney stones.



Overview

Untreated gout can cause permanent joint and kidney damage. You can treat gout

with medicines.



Symptoms

The most common symptom of gout is sudden and severe pain in

one or more joints; typically your big toe. Gout is extremely painful;

some people feel it's as painful as childbirth.



Symptoms

Symptoms often develop at night, although they can occur at any time. Other symptoms include:

-- swelling (inflammation) in and around the affected joint

-- red, shiny skin over the affected joint



Symptoms

-- peeling, itchy and flaky skin over the affected joint as the inflammation subsides

The intense pain that gout causes can make walking and getting around

difficult. Even the light pressure of a bed cover or blanket can be

painful.



Symptoms

What joints are affected?

Seventy per cent of people with gout experience their first attack in

the big toe, and most people with gout will experience pain in this

joint at some point.



Symptoms

However, while gout is most common in the big toe, it can affect any

peripheral limb joint and can occur in two or more joints at the same

time.

Affected joints may include:

-- midfoot



Symptoms

-- ankles

-- knees

-- fingers

-- wrists

-- elbows



Symptoms

If gout is left untreated, it is more likely to affect more than one joint as it progresses.

Pattern of symptoms

It is difficult to predict when an attack will occur. Symptoms can

develop rapidly over a few hours and usually last for 3-10 days. After



Symptoms

this time, the joint will start to feel normal again and any pain or

discomfort should eventually disappear completely.

Just over half of all people with gout (62%) experience a repeat

attack within a year. You may experience symptoms every few weeks,



Symptoms

months or years, but it is impossible to predict when the condition will

recur. Some only experience a few attacks in their lifetime.



Diagnosis

The most accurate way to diagnosis gout is to check your

joints for the presence of crystals. However, this test is often not

practical to carry out at your local GP.



Diagnosis

Instead, usually your GP will look at your symptoms and medical history to make a diagnosis.

Many conditions can cause joint pain, inflammation and swelling. Gout

is just one of over 200 different forms of arthritis (any condition



Diagnosis

that causes pain and problems with the joints).

Therefore, your GP may be unable to make a firm diagnosis straight

away and you may be referred for further tests. These will either

confirm the diagnosis of gout or rule out other conditions.



Diagnosis**Serum uric acid

A serum uric acid test is usually carried out four-to-six weeks after

an attack of gout, as the serum uric acid level is often not raised at

the time of the attack.




The test involves analysing a sample of blood taken from a vein in your arm to measure the amount of uric acid in your blood.

A raised uric acid level is often an indication you may have

developed gout. However, a serum uric acid test is not definitive. Some




healthy people without gout have high uric acid levels in their blood,

while others who experience an attack of gout have a normal level.

Synovial fluid

If there is any doubt about what is causing your joint pain, you may




have a sample of synovial fluid taken from the affected joint. Synovial

fluid helps to keep the joint lubricated and stops the bones and

cartilage from rubbing against each other.

The fluid sample is taken using a needle and syringe. It is then




examined under a microscope. If you have gout, there will nearly always

be crystals of sodium urate in the sample. This sort of test will also

help to rule out other crystals (calcium pyrophosphate) that can cause




similar attacks of inflammation, as well as an infection in the

joint such as septic arthritis (when a joint becomes infected with bacteria).

X-ray

An X-ray




is rarely used to diagnose gout because inflammation caused by gout is

not usually detectable using this method. However, an X-ray is sometimes

used to help rule out other conditions that affect the joints, such as




chondrocalcinosis (a build-up of calcium crystals in the joints).

Confirming the diagnosis

As checking the joints for crystals is not always practical in

general practice, a checklist is often used. This is based on the known




pattern of symptoms associated with the condition.

The checklist used is as follows:

-- You have had more than one attack with symptoms of pain, swelling and inflammation.

-- You have experienced high levels of inflammation within just one day of the onset of symptoms.




-- Symptoms only affect one joint at a time.

-- The joint in your big toe or other foot joints have been affected.

-- Results of the serum acid test show raised levels of uric acid in your blood.

-- Physical examination or X-rays have detected swelling within a joint.




-- There is no evidence that your joint has been infected by bacteria.

You will usually be diagnosed with gout if at least six of the statements above apply to you.



Treatment

If you are diagnosed with gout, your treatment plan will have two goals:

-- relieving the symptoms of a gout attack

-- preventing further attacks

Relieving Symptoms: Self-care techniques



Treatment

During a gout attack, it is important to rest, elevate (raise) your

limb and avoid accidentally knocking or damaging the affected joint.

Keeping the affected joint cool should also help. Remove surrounding



Treatment

clothing and apply an ice pack to it, such as a bag of frozen peas or

some ice wrapped inside a towel.

Apply the ice pack to your joint for approximately 20 minutes. Do not

apply ice directly to your skin and do not apply it for more than 20



Treatment

minutes at a time because this could damage the skin.

Medication

Non-steroidal anti-inflammatory drugs (NSAIDs)

are a type of painkiller usually recommended as an initial treatment



Treatment

for gout. They work by reducing the levels of pain and inflammation.

NSAIDs often used to treat gout include:

-- diclofenac

-- indometacin

-- naproxen



Treatment

If you have been prescribed NSAIDs for gout, it is best to keep them

near you at all times so you can use them at the first sign of a gout

attack. Continue to take your medication throughout the attack and for



Treatment

48 hours after the attack has finished. NSAIDs should be prescribed

together with a medication called a proton pump inhibitor (PPI) that

reduces the risk of the NSAID causing indigestion, stomach ulcers and bleeding from the stomach.



Treatment

People with reduced kidney function or those with conditions such as stomach ulcers or bleeding should avoid using NSAIDs.

Colchicine

If you are unable or do not want to take NSAIDs, or if NSAIDs are

ineffective, colchicine can be used instead. Colchicine is derived from



Treatment

the Autumn crocus plant. It is not a painkiller, but works by reducing

the ability of the urate crystals to inflame the joint lining

(synovium), which reduces some of the inflammation and pain associated

with a gout attack.



Treatment

Colchicine can be an effective treatment for gout. However, it should be used at low doses since it can cause upsets, including:

-- nausea

-- abdominal pain

-- diarrhoea



Treatment

Colchicine can cause major gut problems if taken in too high a dose.

It is important to follow the recommended dose. For most people, this

means taking no more than two to four tablets a day.

Corticosteroids



Treatment

Corticosteroids are a type of steroid sometimes used to treat severe cases of gout that do not respond to other treatment (above).

A short course of steroid tablets often provides relief, but can't be used long-term as they cause side effects including:

-- weight gain



Treatment

-- thinning of the bones (osteoporosis)

-- bruising

-- muscle weakness

-- thinning of the skin

-- increased vulnerability to infection



Treatment

Corticosteroids can also exacerbate diabetes and glaucoma (an eye condition which can cause blindness if untreated).

Corticosteroids may not be suitable for you if you have:

-- bone marrow disease

-- impaired kidney function



Treatment

-- impaired liver function

-- heart failure

Corticosteroids can also be given by injection, either into muscle or

directly into the affected joint, which can provide rapid pain relief.



Treatment

Lifestyle changes: Food

Some foods are high in purines. Avoiding eating the foods below

frequently or in large quantities can help reduce the risk of a gout

attack:



Treatment

-- meat, particularly kidney, liver, veal, turkey and venison

-- seafood, particularly anchovies, herring, mackerel, sardines, fish roe, mussels and scallops

-- certain types of vegetables, such as asparagus, kidney beans, lima beans, lentils and spinach



Treatment

-- foods or supplements that contain yeast extract, such as Marmite and Quorn

Weight

If you are overweight, the levels of uric acid in your blood often

rise. Losing weight will help reduce your uric acid levels



Treatment

significantly.

If you need to lose weight, it is important to follow a balanced,

calorie-controlled diet. Do not crash diet. A high-protein,

low-carbohydrate diet should be avoided because high-protein foods often



Treatment

contain high levels of purines.

Ensure you get plenty of regular exercise. Not only will this reduce

your urate levels and decrease your risk of developing gout, it will

also make you feel more energised and healthier.



Treatment

If you have a gout attack, keep the joint rested and elevated

(raised). Avoid exercise that puts strain on the affected muscles or

joints. Swimming is a good way to stay fit without putting pressure on

your joints as the water supports your weight.



Treatment

Read more about losing weight safely and getting fit with exercise.

Water

It is important to drink plenty of water. Aim to drink about 1.2

litres (six-to-eight glasses) a day, or more if you are exercising or



Treatment

when it is hot. Keeping yourself well hydrated will reduce the risk of

crystals forming in your joints.

Alcohol

Some types of alcoholic drinks are associated with a greater risk of developing gout than others.



Treatment

Beer and stout, which contain significant quantities of purines,

carry a greater risk for the development of gout than equivalent units

of spirits, such as vodka and whiskey.



Treatment

A survey has shown that daily consumption of a small glass of wine is not associated with an increased risk of developing gout.

However, binge drinking of any kind of alcohol can bring on an attack

in people who have previously suffered with gout. Men should not drink



Treatment

more than three-to-four units of alcohol a day and women no more than

two-to-three units a day.



Causes

Gout is caused by a build-up of uric acid in the blood. Uric

acid is a waste product that forms when the body breaks down chemicals

in the cells known as purines.



Causes

Most uric acid is removed from the body through the kidneys. A small amount is removed through the digestive system.

Uric acid

Uric acid usually remains dissolved in your blood and passes through

your kidneys into your urine so it can be passed out of your body.



Causes

If you produce too much uric acid or excrete too little when you

urinate, the uric acid will build up and may cause microscopic crystals

to form, usually in a joint or surrounding tissue.

The crystals may spill over from the joint cartilage into the joint



Causes

space where they trigger a reaction from the soft lining (synovium),

which produces the intense pain and inflammation associated with gout.



Risks

Some things can increase the amount of uric acid in your blood,

making you more likely to develop gout. These risk factors fall into one

of two categories:



Risks

-- medical conditions known to increase levels of uric acid, such

as obesity, high blood pressure (hypertension), high lipid levels and

long-standing impairment of kidney function

-- lifestyle factors, such as diet or certain types of medication that you may be taking



Risks

These risk factors are discussed in more detail below.

Medication

Certain types of medication can increase your uric acid levels and your risk of developing gout. These include:



Risks

-- diuretics, used to treat high blood pressure (hypertension) or an abnormal build-up of fluid in your body

-- niacin, used to treat high cholesterol

Sex

Men are more likely to develop gout than women because their uric



Risks

acid levels rise during puberty. During the menopause, women experience a

similar, albeit smaller, rise in their uric acid levels. This explains

why symptoms start later in women than in men.

Diet



Risks

Foods naturally high in purines include:

-- beef

-- pork

-- bacon

-- lamb

-- seafood



Risks

-- liver

-- kidneys

Alcohol

Alcoholic drinks raise the level of uric acid in the blood by

increasing its production in the liver and by reducing how much is



Risks

passed out in urine.

Beer and spirits do so more than wine, and beer also contains

significant quantities of purines. (Moderate consumption of wine – one

or two glasses a day – should not significantly increase your risk of



Risks

gout).

Family history

Studies have shown that gout often runs in families.

Around one-in-five people with gout have a close family member who also

has the condition.



Risks

Medical conditions

Medical conditions that can increase your risk of developing gout include:

-- high blood pressure (hypertension)

-- diabetes, both type 1 diabetes and type 2 diabetes



Risks

-- kidney disease

-- having high levels of fat and cholesterol levels in your blood

Susceptibility

Gout attacks occur most frequently in the joints of the feet and



Risks

hands, possibly because the temperature in these joints is often lower

than the rest of the body, which increases the likelihood of crystals

forming.

It is still uncertain why some people are more susceptible to crystal



Risks

formation and gout than others with equally high blood levels of uric

acid. Many people with a high level of uric acid in their blood and

tissues never develop gout.

One theory is that certain genes you inherit from your parents may



Risks

make you more likely to develop gout by causing your kidneys that are

otherwise healthy to be relatively inefficient at excreting uric

acid. Several genes have recently been identified that are associated

with high uric acid levels and gout and which influence uric acid



Risks

elimination by the kidney.



Prevention

Two methods used to try to prevent further attacks of gout are:

-- medication to reduce uric acid levels

-- making lifestyle changes to reduce uric acid levels



Prevention**Medication

Usually recommended on a long-term basis for:

-- frequent attacks of gout and signs of tophi under the skin (tophi are small white lumps that can form under the skin)




-- evidence of joint damage; either in terms of associated symptoms or damage detected by X-ray

-- a history of kidney stones

The main treatment for gout is known as urate-lowering therapy or

ULT. The goal of ULT is to lower uric acid levels below the




levels required for crystals to form (the saturation point).

This should also help to dissolve existing crystals leading to an

effective cure for gout. But to maintain the "cure" you would need to

continue with ULT on a daily basis.




Many people with gout begin ULT as soon as they are diagnosed to

reduce the frequency of attacks and the risk of developing joint damage.

This has to be balanced against possible side effects that can occur

with ULT, although these are rare.




Discuss the potential benefits and disadvantages of ULT with your GP

or the doctor in charge of your care. If you agree to start ULT, usually

the ULT medication to try first is called allopurinol.

Allopurinol




Allopurinol helps to lower uric acid levels by inhibiting the enzyme

(xanthine oxidase) responsible for converting purines into uric acid,

thus reducing the production of uric acid. However, allopurinol is not a

painkiller and will have no effect during an attack of gout.




Allopurinol is a tablet taken once a day and usually for up to a year

or two before all crystals have dissolved and no further attacks can

occur. The medication will then usually be taken for the rest of your

life.




It can take a while to assess the most effective dose for your

circumstances. You may need to have several blood tests to find the most

effective dose.

When you first start taking allopurinol it can sometimes cause a gout




attack, because rapid reduction of uric acid levels to below the

saturation point causes existing crystals in joint cartilage to

partially dissolve and become smaller.

The smaller crystals can escape more easily or “shed” from the




cartilage into the joint cavity and then inflame the joint lining

(synovium).

The risk of this happening is reduced by slowly increasing the dose

of allopurinol from a low starting dose (e.g. 100mg daily) to the




recommended dose.

You may continue to have gout attacks until all the existing crystals have dissolved, which is perfectly normal.

So if this does happen, don't lose confidence in the effectiveness of

ULT. It's important to persevere with treatment to achieve the maximum




benefit. If you do develop a flare-up of gout while taking

allopurinol, continue the medication while your doctor prescribes

additional treatment to settle the attack.

Although allopurinol is taken without any side effects in most




patients, around 10% do experience problems. A skin rash is the most

common side effect. In most cases, it’s mild and soon goes away.

However, in a small number of cases, it can be a sign of an allergic

reaction. If you develop a skin rash while taking allopurinol, stop




taking the medication immediately and contact your GP for advice. It may

be necessary to stop taking allopurinol and try an alternative ULT (see

below).

Other side effects of allopurinol include:




-- indigestion

-- headache

-- diarrhoea

If you are currently being treating with immunosuppressant

medications (often used to prevent your body rejecting a donated organ)




or a type of medication called cyclophosphamide (used in the treatment

of some cancers) then you will probably not be able to take allopurinol

for safety reasons.

Allopurinol may also not be suitable if you have severe kidney disease.




Patients with kidney problems may be started on a lower dose (50mg

daily) and have lower monthly increases (50mg) of allopurinol.

Those with severe kidney disease may not even be started on allopurinol, but prescribed an alternative ULT such as febuxostat.

Febuxostat




Febuxostat acts in the same way as allopurinol by inhibiting the

enzyme (xanthine oxidase) that produces uric acid, thus reducing the

body’s production of uric acid.

However, unlike allopurinol, it is broken down by the liver and not




the kidney, so can be used in patients with kidney disease

without concerns over side effects.

Also unlike allopurinol, it only comes in two doses (80mg or 120 mg

daily). Because even 80 mg daily may quickly reduce uric acid levels




below the saturation point, initiation of even the lowest dose of

febuxostat often triggers acute attacks.

To try to reduce the frequency and severity of this side effect your

doctor may prescribe you regular daily oral NSAID or colchicine




(one-to-two tablets daily) for up to six months following the start of

febuxostat as “prophylaxis” (preventative treatment).

Common side effects of febuxostat include:

-- an increased number of acute gout attacks (discussed above)




-- diarrhoea

-- headache

-- feeling sick

-- skin rash

If you experience more serious symptoms such as breathing




difficulties or facial swelling, stop taking febuxostat and contact your

GP for advice.

Currently, febuxostat is not considered suitable for people with

heart problems (especially heart failure), or with serious kidney




disease.

Less commonly used ULT medications

Less commonly used ULT medications include:

-- benzbromarone

-- sulphinpyrazone




-- probenecid

They work by helping the kidneys to remove uric acid from the body.

Sulphinpyrazone and probenecid are now rarely used as they are not as

effective as other types of ULT medications and are not suitable for




people with kidney disease.

Benzbromarone is more effective in removing uric acid and can be used in people with kidney disease.

These types of medication tend only to be used if people are unable

to take allopurinol or febuxostat. They need to be prescribed under the




supervision of a specialist.


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