More than 9.2 million Americans suffer from gout. In fact, gout is the most common form of inflammatory arthritis. Gout, or gouty arthritis, was long ago known as the “Disease of Kings” due to the thought that it is caused by overindulgence, but this is incorrect. In all reality, gout is a common disease most often caused by genetic predisposition, comorbid medical conditions such as diabetes and obesity, and more uric acid in the body than tolerated.
Despite being around for thousands of years, gout is still misunderstood—creating a gap in the medically correct information. The mission of the Gout Education Society is to raise awareness about the condition, clearing up misconceptions about gouty arthritis. Anyone with gout should not only review our resources but also reach out to a medical professional to get started on treatment and management plans today.
Causes of Gout
Gout, or gouty arthritis, is a disease that impacts a person’s joints, most commonly the foot or big toe. But what causes these parts of the body to be impacted? The root cause of gout ultimately comes down to a substance called uric acid, which is naturally produced by the human body.
The Uric Acid Connection
Uric acid is created in the liver while processing purines. A common component of many foods, purines are processed and filtered out through the body. Some people have trouble filtering purines, causing excess uric acid to remain in the body.
While everyone has uric acid in their blood, people who have trouble getting rid of it find themselves with elevated amounts in their system. This is problematic and is the main factor for developing gout. Over time, uric acid can crystalize in the body, especially around the joints.
Uric acid levels can be measured via a blood test by medical professionals. A normal serum urate acid level in someone’s body is 7.0 mg/dL or below. A level of uric acid above 6.8 mg/dL designates someone as having hyperuricemia, a necessary condition for the development of gout.
Risk Factors
While high uric acid is the most prevalent risk factor to develop gout, there are others important to note. Below, find a list that outlines some of the more common conditions that can leave someone predisposed to gout.
Hyperuricemia
Hyperuricemia can be briefly summarized as having too much uric acid in the body. As mentioned above, having hyperuricemia makes the risk of gout much higher. Furthermore, gout flares can happen much more frequently, in someone with uncontrolled hyperuricemia.
During extended periods of time with hyperuricemia, more uric acid crystals can begin to form around joints. With that in mind, this risk factor is one of the most important to keep in mind.
Genetics
Research has shown that genetic factors are very important in how efficiently a person can eliminate uric acid from the body. One in four people with gout also have a direct family member with the disease. This is an often-overlooked statistic by the general public and should be a matter of discussion between the afflicted and their families.
Obesity
Obesity is one of the biggest risk factors for gout. Higher amounts of body fat impact the uric acid excretion ability of the kidneys. Obesity is usually considered a body mass index (BMI) of 30 or higher.
Kidney Function and Diabetes
Kidney function and gout go hand-in-hand as this is the part of the body involved with filtering uric acid from a body. If the kidneys cannot filter enough uric acid from the body, the risk of gout developing is heightened. Often, underlying kidney disease or kidney stones can impact the kidney’s ability to function.
Related to the kidneys, diabetes is another comorbid medical condition that can impair the organ’s ability to function correctly.
Gender
While gout can affect anyone, there are some disparities between genders. Overall, men are more likely to develop gout than women and gout is very rare in pre-menopausal women. However, after menopause the incidence of gout rises in women and can be almost as common as is seen in men.
Developing Gout
As highlighted through the risk factors and underlying causes, gout occurs after years of untreated hyperuricemia. Left untreated, gout can present itself in a variety of ways depending on the person affected.
Presentation of Gout
The first symptoms of gout usually present in a dramatic fashion with joint-swelling and excruciating pain described by most gout sufferers as the worst pain in their lives. However, these dramatic symptoms follow years or even decades of asymptomatic accumulation of uric acid crystals caused by elevated levels of uric acid in the blood.
What Joints Gout Affects
There is a common misconception that gout will only affect the big toe—this is false as gout can impact many different joints. The big toe is the most common places for it to appear first. In fact, gout affects the big toe in 50 percent of all first flares. Other joints frequently affected by gout include the mid-foot, ankles, knees, wrists, elbows, and small joints of the hands.
It is most common for gout to attack to one joint at a time, even if the uric acid crystals have developed in and around multiple joints.
Men often experience gout flares in their 40s through 70s and most frequently in the lower extremity joints. On the other hand, women are more likely to experience gout flares in their 60s and 70s and more often in their upper extremities.
What Gout Looks Like
As with any disease, the ability to see and diagnose an ailment is important. People will write off symptoms of gout until they can see it, which makes management difficult. The fact of the disease is that it looks different at each of the given stages that it can progress towards.
Uric Acid Crystals
As previously stated, the root cause of gout is the uric acid crystals and the affiliated buildup around a particular joint. These uric acid crystals are individually shaped like balls with microscopic needles pointed outwards. While it’s unlikely that a person with gout will ever see uric acid crystals, it is important to paint the picture of what causes the intense pain associated with a gout flare.
Incident gout or Early Stage gout
At its early stages, gout is not visible to the naked eye. Rather, the root cause of the disease sits silently under the skin around the affected joint. Minor buildup of uric acid may not cause disfigurement at this stage, however, there are still visual tells to look for.
Signs of joint inflammation to the body part suspected of gout is the first sign to look for. Light swelling is a noticeable enough sign, but this can often be written off as a minor injury to the joint. If someone with a genetic history of gout notices this inflammation, it should be further examined by a medical professional.
Recurrent gout or Intercritical Gout
If left untreated, gout can move into its second stage, often known as intercritical. At this point, the disease takes a much different appearance as years of high uric acid levels cause crystal buildup to increase during the periods of time between gout attacks.
The inflammation associated with a flare will begin to become much more apparent. Upon close examination, one can see the joint inflamed much more than before while also feeling somewhat hot to the touch. This inflammation will last longer than before, perhaps lasting upwards of one to two weeks.
Chronic gout
After years of recurrent gout and subsequent flares, one will move into the final stage, chronic gout. At this point, gout attacks are frequent due to the massive amount of buildup of uric acid around a joint. Between the buildup of uric acid crystals and the frequent flares, the affected joint will begin to deform.
This buildup can cause tophi, or larger deposits of crystals, to form around the joint. Tophi is extremely detrimental to one’s bone health. Prolonged periods of tophi around an affected joint can lead to bone erosion plus joint damage that will result in loss of normal use.
Gout Symptoms
Although the “gold standard” for the diagnosis of gout has been the demonstration of uric acid crystals in joint fluid obtained from an inflamed joint, most people diagnosed with gout have not undergone this procedure.
The alternative approach to diagnosing gout is the history of an abrupt onset of severe pain in one or more of the typical joints described above without any evidence of trauma or infection. The joint will be markedly swollen, red and extremely sensitive to even the lightest touch. A typical gout attack (flare) will last four to seven days. The presence of a blood uric acid greater than 7.0 mg/dL is also a required component of the diagnosis of gout.
A Note on Gout Flares or “Gout Attacks”
The gout flare, sometimes known as a gout attack, is the hallmark symptom of gout. Gout attacks are caused by the buildup of uric acid crystals in a joint and will often times lead to the sudden onset of severe pain, swelling and tenderness of the affected joint. Most gout sufferers rate their pain as an eight to ten out of ten. This severe pain can last for four to seven days if left untreated.
The buildup of uric acid crystals occurs slowly over years to decades before the first attack or flare. Many people with gout recognize that certain foods, drinks, physical activity or trauma may precede their attacks. The most common “triggers” that most people identify include the following:
Alcohol
One of the most commonly recognized triggers is alcohol, especially when an excessive amount is consumed. Beer or grain liquors (those made of corn, yeast, sugar and water) are the most frequent offenders, as purines are rich in these types of beverages.
Purine-Rich Foods
Overloading one’s system with purines is an easy way to trigger gout attacks. Uric acid is a byproduct of purines, and oftentimes, those with gout have an issue with uric acid production. An overindulgence of certain foods is another important trigger for gout flares.
Typical culprits of this triggering include organ meats, shellfish, and excessive amounts of red meat. While one should avoid these foods, it’s important to note that they don’t have to completely abstain from enjoying them. As with most things related to gout, moderation is key.
High Fructose Corn Syrup (HFCS) Containing Beverages
Most sweetened carbonated soft drinks contain high levels of the sugar fructose. Overconsumption of these beverages can also trigger flares.
Specific Diets
It’s important to avoid the foods and beverages listed above, but it should be noted that the way one eats food can also trigger a gout attack. Specifically, fad diets such as “crash” diets or those rooted in high-protein intake can impact one’s body negatively. It’s always important to consult a medical professional before making any sudden dietary changes.
Medication
Certain medications can also increase the frequency of gout attacks. These include diuretics and blood pressure-lowering medications like hydrochlorothiazide (HTCZ).
Who to See about Your Gout
The first stop that one should take when it comes to a diagnosis is to see their primary care physician (PCP) the same day they notice a flare starting. If the symptoms match, the PCP will test their uric acid levels—if it is above 6.8 mg/dL and flares are present, they likely have gout.
The Gout Education Society has a helpful service to find local specialized care: the Gout Specialists Network (GSN). Made up of rheumatologists, nephrologists, PCPs and more, the GSN was created to help those inflicted find care that aligns with the Gout Education Society’s and ACR’s treatment outlines.
Gout patients can get started today by filling out the quick survey and get connected with a variety of nearby help on the GSN website.
Treating Gout
There are three main goals for you and your health care provider when treating gout: reduce uric acid levels, prevent/reduce gout attacks, and relieve gout pain as quickly as possible when it occurs.
Overview of Treating Gout
With these three areas of managing gout in mind, doctors put together regimens that are safe and effective for each individual gout sufferer keeping in mind the other medic al problems the patient might have.
Lowering Uric Acid Levels
The first and arguably most important step to treating gout is to attack the underlying cause of the disease: elevated uric acid levels. Gout occurs when there is too much uric acid in one’s system, so by reducing the amount of uric acid, one can curb future gout attacks and joint destruction.
Whether one’s body produces uric acid at an increased rate or it has a problem eliminating it, there are methods to lower uric acid levels. Below is a non-exhaustive list of urate-lowering therapies (ULTs) that are commonly prescribed.
Allopurinol
The most common ULT is allopurinol. It decreases the body’s production of uric acid. Taken orally, this ULT is the first choice for reducing blood uric acid. All patients are started on low doses (50 to 100 mg per day), which is gradually increased until the uric acid level is less than 6.0 mg/dL. Typically this dose is between 300 and 500 mg per day. Allopurinol should be discontinued if a rash develops soon after starting this therapy.
Generic options of allopurinol are available, however, some example name brands of the medication are Lopurin® and Zyloprim®.
Febuxostat
Another common ULT, febuxostat decreases the body’s ability to generate uric acid through a mechanism similar to allopurinol. Taken orally daily, the medication will reduce blood uric acid levels over time. Febuxostat can be taken by people with mild to moderate kidney disease, kidney stones or liver disease. The medication can also go by the name brand version of Uloric®.
Probenecid
Another ULT, probenecid is an oral medication that is focused on increasing the kidney’s ability to remove uric acid from the body. Unlike allopurinol and febuxostat, probenecid is not recommended for those with abnormal kidney function, especially kidney stones. Probenecid may go by two brand names: Benemid® and Probalan®.
Pegloticase
Pegloticase, also known as Krystexxa®, is an intravenous infusion of an enzyme given every other week. Unlike the other ULTs described above, pegloticase works by rapidly breaking down uric acid in the blood and uric acid crystals in and around the joints. Pegloticase is indicated for gout sufferers with advanced disease. Or unable to be controlled with the oral ULTs mentioned above. People with G6PD deficiency should not be given pegloticase.
Pain Relief
The other key piece of gout treatment is relieving the severe pain associated with attacks of gout. The pain, redness and swelling are caused by an interaction between uric acid crystals and immune cells within the joint resulting in intense inflammation. Countering this inflammation is the best approach to fight the gout flares.
A gout attack progresses rapidly from no pain to debilitating pain in eight to 10 hours. For optimal treatment of this pain, the anti-inflammatory medications listed below should be started as rapidly as possible.
This has led to the “pill-in-the-pocket” recommendation. This means that whichever anti-inflammatory approach you and your doctor agree on, it should be readily available whether the flare occurs in your bed at night, or on vacation, or at work.
Below is a list of some of the more common treatment options one may receive from a medical professional.
Colchicine
One of the most common forms of pain relief for gout attacks is colchicine. Taken by mouth, this medication helps reduce swelling and inflammation. There are a few name brands of colchicine: Colcrys®, Mitigare® and Colbenemid®.
Like other aspects of gout, timing is key to the success of this treatment. Colchicine is most effective when taken within 12 hours of the onset of gout symptoms. Beyond this, it’s important to follow any dosing instructions given by a medical professional.
Commonly, those taking colchicine will be told to take two 0.6 mg tablets together at once during the onset of symptoms. This is then followed by a third tablet one hour later. For the next week or for the duration of pain, one tablet should be taken one to two times per day.
NSAIDs
Nonsteroidal anti-inflammatory drugs (NSAIDs) are another common type of medication to fight severe pain and painful inflammation during attacks of gout. Similar to colchicine, NSAIDs attack the gouty inflammation and pain during acute gout attacks, however, the mechanism of action is different.
Commonly found as over-the-counter options like Advil®, Aleve® and Motrin®, NSAIDs have prescription options named Celebrex®, Indocin® or Naprosyn®.
NSAIDs can be taken at the maximum recommended dose until the pain subsides. It is also important to speak to a medical professional to ensure that NSAIDs are okay within one’s treatment regimen.
Glucocorticosteroids
Glucocorticosteroids, or cortisone, can be injected into the joint or taken by mouth. Like the other treatments listed, this option aims to quickly attack joint pain from acute gout attacks. Commonly, glucocorticosteroids are prescribed under the names Prednisone®, Deltasone®, Kenalog® or Medrol®.
Lifestyle Changes
While not as effective as medications, lifestyle changes are an important component in the overall care of people with gout. Weight loss, exercise and a balanced diet are important factors for good health, but rarely adequate by themselves for the treatment of gout.
Go for Six
Knowing one’s level of uric acid is the key to keeping the disease at bay. The Gout Education Society recommends that to prevent gout attacks, one should reduce and maintain their uric acid level to less than 6.0 mg/dL. Furthermore, anyone diagnosed with gout, should have their uric acid levels via a blood test checked regularly.
Maintain a healthy weight
Obesity is a risk factor for developing gout. In fact, it leaves one three times more likely to develop gout. While reducing one’s weight is beneficial from a holistic view, it’s important to note that it may only impact the levels of uric acid in one’s body by less than 1 mg/dL.
There are several ways to get started on this effort. However, one should always check with a PCP before starting any new lifestyle changes.
Dietary Changes
Not only will dietary changes impact one’s weight, but they can also reduce the risk of gout attacks. While there is no specific “gout diet” recommended by the Gout Education Society, the DASH diet (Dietary Approaches to Stop Hypertension) and the Mediterranean diet are both good options to consider.
Both diets highlight foods that impact the underlying causes of elevated uric acid, and reduce the consumption of foods known to cause flares.
Furthermore, it’s important to look at foods that are helpful to avoid, including organ meats, shellfish, and high-fructose corn syrup. These foods are high in purine content, which can increase levels of uric acid in the body.
While these foods are known to increase the risk of gout attacks, avoidance isn’t necessary. Rather, one should focus on consuming them only in moderation.
Exercise Frequently
According to the CDC, adults should engage in 30 minutes of moderate-intensity physical activities most days of the week. This could include activities like a brisk walk, swimming, bicycling, or even mowing the lawn.
Stay Hydrated
Water helps transport nutrients and waste around the body, as such it is important to drink an adequate amount each day. Most dietitians recommend consuming at least 64 ounces of water daily, or more when exercising.
Healthy benchmarks
Lastly, a healthy body is better equipped to combat gout. Several benchmarks such as high blood pressure, cholesterol levels and blood sugar are all important to consider. Here are some other benchmarks to follow:
- LDL (Bad) Cholesterol – 100 mg/dL or below
- HDL (Good) Cholesterol – 40-60 mg/dL
- Cholesterol – 200 mg/dL or below
- Heart rate between 60-100 beats/minute
- Blood sugar 100 mg/dL or below (when fasting)
- Blood pressure 130/80 or less
