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

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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.


Diagnosis
**Serum uric acid
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


Diagnosis
**Serum uric acid
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


Diagnosis
**Serum uric acid
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


Diagnosis
**Serum uric acid
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


Diagnosis
**Serum uric acid
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


Diagnosis
**Serum uric acid
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


Diagnosis
**Serum uric acid
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


Diagnosis
**Serum uric acid
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.


Diagnosis
**Serum uric acid
-- 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.


Diagnosis
**Serum uric acid
-- 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)


Prevention
**Medication
-- 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


Prevention
**Medication
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.


Prevention
**Medication
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.


Prevention
**Medication
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


Prevention
**Medication
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.


Prevention
**Medication
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.


Prevention
**Medication
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


Prevention
**Medication
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


Prevention
**Medication
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


Prevention
**Medication
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


Prevention
**Medication
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


Prevention
**Medication
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


Prevention
**Medication
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:


Prevention
**Medication
-- indigestion
-- headache
-- diarrhoea
If you are currently being treating with
immunosuppressant
medications (often used to prevent your body
rejecting a donated organ)


Prevention
**Medication
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.


Prevention
**Medication
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


Prevention
**Medication
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


Prevention
**Medication
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


Prevention
**Medication
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


Prevention
**Medication
(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)


Prevention
**Medication
-- diarrhoea
-- headache
-- feeling sick
-- skin rash
If you experience more serious symptoms such as
breathing


Prevention
**Medication
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


Prevention
**Medication
disease.
Less commonly used ULT medications
Less commonly used ULT medications include:
-- benzbromarone
-- sulphinpyrazone


Prevention
**Medication
-- 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


Prevention
**Medication
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


Prevention
**Medication
supervision of a specialist.


Gout

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