The signs and symptoms of gout almost always occur suddenly, and often at night.
Gout symptoms include:
- Pain and swelling — usually in one or two joints in the feet or legs, most commonly the big toe. During a gout flare, the intensity of the pain is usually described as excruciating (8 to 10 out of 10).
- Limited joint function — After five or more years of recurrent flares, people with gout may develop tophi crystals under the skin and around joints. While generally not painful, tophi can be disfiguring and interfere with normal joint function. The presence of tophi close to bones can lead to bone and cartilage destruction creating further deformities in the affected joints.
- Chronic persistent arthritis — During the early stages of gout, the inflammatory arthritis is intermittent and during the periods between flares, joints may feel and function normally. Years to decades after the initial flare, flares may continue to be a recurrent problem but the intervals between flares become painful on a daily basis.
Adequate treatment with appropriate uric acid-lowering therapies early on in the course of gout should prevent or eliminate gout flares, tophus formation, and bony erosions from occurring.
Read and in-depth post about gout symptoms, causes, and treatments.
What Joints Can Gout Affect?
Gout affects the big toe in 50 percent of all first flares. It can also affect the middle of the foot, ankle, knee, wrist, and elbow. A flare may not always occur in the same joint each time. The pain could be in the big toe during the first flare and then in the knee or other joints in later flares. Men often experience gout flares in the lower extremities. Women are more likely to experience flares in the upper extremities.
The severity of gout can be classified into three manifestations.
Uric acid crystals that have formed over years or decades of high uric acid in the blood, or hyperuricemia, will at some time lead to a sudden onset of severe pain, swelling, and tenderness. This usually occurs in one or two joints in the feet or legs. The intensity of the pain is usually described as excruciating (8 to 10 out of 10). The affected joints are very tender, even to the lightest of touch. Without treatment, these symptoms may last for 5-10 days and weight-bearing is very difficult. Recurrent flares may occur in the same joint or other joints of the upper or lower extremities.
Tophus Formation and Bony Erosions
After five or more years of recurrent flares, people with gout may develop tophi under the skin and around joints. While generally not painful, tophi can be disfiguring and interfere with normal joint function. The presence of tophi close to bones can lead to bone and cartilage destruction creating further deformities in the affected joints.
Chronic persistent arthritis
During the early stages of gout, the inflammatory arthritis is intermittent and during the periods between flares, joints may feel and function normally. Years to decades after the initial flare, flares may continue to be a recurrent problem but the intervals between flares have now become painful on a daily basis. Adequate treatment with appropriate uric acid-lowering therapies early on in the course of gout should prevent or eliminate all three of the gout manifestations from occurring.
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Increased Risk of Gout
Gout is a common form of inflammatory arthritis caused by excess uric acid in your blood, known as hyperuricemia. The body produces uric acid naturally in the body by the breakdown of cells in our bone marrow and from certain foods that we ingest.
However, if the kidneys can’t eliminate enough uric acid, then hyperuricemia — or a high uric acid level — may develop. This eventually can lead to gout and gout attacks. Not everyone with hyperuricemia, however, will develop gout.
Too Much Uric Acid
Too much uric acid production, which accumulates faster than the body can eliminate it, can cause uric acid crystals to form in the soft tissues around an affected joint. Uric acid deposits (monosodium urate) are what ultimately cause intense joint pain. Causes of high uric acid levels include genetics, obesity, taking diuretics, hypothyroidism, niacin (vitamin B3) and, in some cases of psoriasis skin diseases, tumor lysis syndrome and other kidney problems.
Uric Acid Crystals
As acute gout worsens, the excess uric acid crystals can aggregate into masses called tophi. These tophi may not be painful, but can lead to erosion of bone, permanent joint damage and destruction of tissue. This limited joint function may be more likely after five or more years of recurrent flares.
Urate crystals can also participate in the formation of kidney stones as the body tries to eliminate the excess uric acid. Since these crystals can also accumulate in the heart valves and spinal cord, uric acid is also linked to other serious health issues, such as kidney damage, high blood pressure and diabetes, all which can cause related and interconnected health problems that can become significant in some cases.
Uric Acid Levels
When tested, healthy blood uric acid levels register below 6.0 mg/dL. Maintaining healthy levels of uric acid is vital to minimizing risk of gout progression. Like other healthy benchmark numbers for blood pressure, heart rate, cholesterol and blood sugar, knowing the proper levels of uric acid that’s right for you is important, too.
Your doctor can determine your sUA level through a routine blood test. If your sUA is higher than 6.0 mg/dL, your doctor may prescribe medications to reduce uric acid levels in your bloodstream, which helps treat gout.
Lowering Uric Acid Levels
To protect your health and prevent long-term damage while also lowering your risk of gout, talk to your doctor to find out the steps you can take to lower uric acid levels. Routine blood tests should be obtained frequently while starting on uric acid-lowering medications. When you and your doctor have succeeded in reducing the level of uric acid in your blood to below 6.0 mg/dL, you should continue to have the level of your uric acid checked every six months. Medications must be taken as prescribed, and should not be stopped without consulting a doctor.
It’s important to stay well hydrated so that the kidneys can function optimally. Also lowering the intake of certain foods, such as red meat and shellfish, while also cutting back on drinking alcohol, can help reduce the number of gout attacks (also known as flares) you may experience. Making healthy lifestyle choices, including doing regular exercise, avoiding smoking, limiting alcohol intake, and losing weight, can also help. Controlling other health issues, such as high blood pressure, high lipid levels, and diabetes is also important.
Signs and Symptoms of Gout
Gout flares, the most common symptom of early gout, are the result of the uric acid building up around the soft tissues in and around your joints, causing inflammation. Gout attacks include sudden and severe episodes of pain, warmth, and swelling in one or more joints. Even though uric acid builds up slowly over years or decades, most people don’t realize they have gout until they experience a flare. While many call these episodes “attacks,” calling them “flares” is more accurate, as the symptoms may subside, but the underlying cause — high uric acid levels — remains within the body.
Gout attacks can last for several days — usually about three to seven days in the early stage of gout. During periods between flares, joints may seem normal and function as usual, but still contain lots of uric acid that can cause more flares to occur. It’s important to manage gout from the earliest onset of symptoms.
Triggers of chronic gout can include purine-rich foods — such as red meat, organ meats or shellfish — or alcohol consumption, but also other instances, such as surgery, dehydration or trauma. Triggers, including certain foods that bring on symptoms, can vary from person to person. If left untreated for years or even decades, gout can progress from intermittent flares to persistently painful and disabling arthritis.
Is Gout Arthritis?
Gout is arthritis. In fact, it is the most common inflammatory form of arthritis, more prevalent than rheumatoid and psoriatic arthritis. Gout is characterized by recurrent flares consisting of severely painful warm, red and swollen joints. Arthritis is the swelling and tenderness of one or more joints and can refer to more than 100 types of joint diseases, according to the Arthritis Foundation. Osteoarthritis is even more common than gout, but is a noninflammatory form of chronic arthritis.
Types of arthritis can be divided into inflammatory and noninflammatory categories. Gout is considered inflammatory, along with rheumatoid arthritis and psoriatic arthritis. Noninflammatory arthritis, related to osteoarthritis, does not present with warm or swollen joints, instead can be caused by movement and activity, then improved with rest.
Gout is also known as gouty arthritis, but they are the same condition. Historically, there are other forms of gout. In the 1600s and 1700s, European nobility drinking port wine from lead-lined casks developed the condition called saturnine gout. This was caused by lead damaging the part of the kidney responsible for eliminating uric acid. More recently, in the United States, similar lead exposure came from drinking moonshine or exposure to lead-based paints. Saturnine gout differs slightly from typical gout in that frequently multiple joints are inflamed at the same time.
Gout of the Big Toe
For most people, the initial acute attack (or flare) develops in the big toe. Other affected joints can include the ankle, knee, wrist, elbow and middle of the foot. Over time, more than 90 percent of people with gout will experience a flare in their big toe. Men experience flares in lower extremities more often, while women are more likely to experience flares in the upper extremities. Urate crystals are more likely to form in joints that have cooler internal temperatures and the big toe has the coolest temperature of all joints. Previous trauma or other forms of arthritis in a particular joint may influence where gout presents itself.
How to Manage Symptoms of Gout
The management of gout consists of two different approaches. One is to control the severe pain of gout flares as quickly as possible. The other is to reduce the elevated level of uric acid to less than 6.0 mg/dL. Both of these approaches involve different groups of medications. To treat flares, anti-inflammatory medication should be started as soon as possible after the first symptoms of the flare. Medications used for this typically include nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids.
Because some of these anti-inflammatory drugs should be avoided in several of the comorbid diseases associated with gout (diabetes, hypertension, and chronic kidney disease), you should discuss with your physician which approach would be best for you. The most important aspect of treating gout is to have the medication readily available so that you can take it as soon as the flare begins.
The more long-term approach to treating gout involves lowering serum uric acid levels to less than 6.0 mg/dL. Medications used for this include allopurinol, febuxostat, probenicid and pegloticase. Again, discussion with your doctor is important to determine which medicine would be right for you.
How do you know if you have gout?
The best way for your doctor to diagnose gout is to have them drain fluid from the affected joint and demonstrate the presence of urate crystals. This, however, is rarely done. Rather, your doctor will usually rely on your description of the joint pain. Characteristics of gout include: very rapid escalation of pain from no pain to severe pain in a matter of 8 to 10 hours, swelling and redness around the involved joint and exquisite tenderness of the joint to even the gentlest touch. A joint afflicted with gout does not tolerate motion or weight-bearing.
Uric acid levels are elevated in people who have gout, but these levels may not be elevated at the time of an acute gout attack (or flare). Gout flares usually resolve spontaneously after five to seven days, or even sooner if anti-inflammatory therapy is started promptly.
What is the fastest way to get rid of gout flares?
Treat the pain as soon as it starts with a non-steroidal anti-inflammatory drug, colchicine, or a corticosteroid, depending on what is suggested or prescribed by your doctor. You should always have some type of this medication on hand so that you can start treatment as early as possible. When tolerable, a cool compress or ice can help relieve pain and swelling caused by a gout attack.
Full anti-inflammatory doses of NSAIDs, colchicine or corticosteroids are needed to improve symptoms, but should only be continued for seven to 10 days, or at least two to three days after the gout attack (or flare) resolves.
Permanent Joint Damage
Once the flare symptoms are over, be sure to talk to your doctor before another one begins and develop a gout management plan. This way, you will have a course of anti-inflammatory medication ready when the gout attack strikes. Each person has a different experience with gout symptoms and has unique health and treatment needs. Do not base your treatment plan or your progress toward managing symptoms with unproven remedies. If untreated, gout can cause permanent joint damage, even in between flares.
Intense Pain and Swelling
Gout symptoms cause pain that is so severe that some people can’t even tolerate a bedsheet touching their affected joint. Research shows some people believe the intense pain is worse than a severe burn, kidney stones, breaking a bone, being hit by a car or childbirth. If untreated, the length of each gout attack gets longer and the severity of each flare gets worse.
Risk Factors of Gout
Most people with gout have a genetic predisposition, and will have one or more family members who also have gout. People with chronic kidney disease, diabetes, and heart disease, as well as other cardiovascular or metabolic diseases, are also at higher risk of gout. Obesity causes a person to have a two to three times higher risk than someone of a healthy weight of developing gout.
Gout occurs more often in men than women because women have more of the hormone estrogen, which helps flush out more uric acid. However, post-menopausal women are also at high risk for gout. Men usually have their first gout attack between ages 40 and 55, but it is not uncommon for men in their 30s to develop gout. Generally, women don’t experience gout attacks until their 60s or 70s.
People of certain ethnic backgrounds are more likely to have gout than others, including those who are African-American or have Pacific Islander ancestry.
Gout affects people who have cardiovascular and other metabolic diseases. Everyone with gout is at risk for at least one or two simultaneous conditions, or comorbidities, associated with gout. These include hypertension, cardiovascular disease, chronic kidney disease, Type 2 diabetes, elevated cholesterol, and esophageal reflux.
Greater Risk of Heart Disease
Gout affects a person’s risk of heart attack or stroke, doubling someone’s chances of either condition. Hyperuricemia has been linked to a higher risk of death and other heart-related complications. Women with gout are three and a half times more likely to have a heart attack than men with gout.
Increased Risk of Diabetes
About one of every four people who have gout also suffers from diabetes. For those who have diabetes, insulin resistance may play a role in developing gout. Obesity and high blood pressure, which are also risk factors for gout, are also signs of insulin resistance. Some medications, such as corticosteroids and NSAIDs, which are used to treat gout and gout pain, can cause further damage when taken by someone with diabetes. It is important to let your doctor know, so you can be prescribed the right medication that works best for your disease control.
Increased Risk of Kidney Disease
Because the kidneys remove uric acid from the body, anything that causes the kidneys not to function normally, can potentially lead to elevated uric acid levels and gout. Kidney stones are sometimes caused by elevated uric acid levels. People with gout are also more likely to develop kidney stones.
Diagnosis of Gout
Gout can be diagnosed by two methods. The most accurate way is for a gout specialist to perform a joint fluid test, removing fluid from a swollen joint then testing that fluid for the presence of uric acid crystals. More commonly, your doctor will make a diagnosis by determining a history of an extremely painful, swollen joint(s) that lasts for four to seven days when you also have hyperuricemia (or a level of uric acid greater than 7.0 mg/dL).
How Is Gout Treated?
There are two goals in acute gout treatment. The first goal is to rapidly eliminate the pain associated with gout attacks (or flares). The second goal is the most important to the overall management and “cure” of gout, and that is to reduce the serum uric acid level to less than 6.0 mg/dL, using urate-lowering therapies such as allopurinol, febuxostat, probenicid and pegloticase.
Active gout flares are best treated with certain medications such as NSAIDs (like ibuprofen or naproxen), colchicine or corticosteroids. Colchicine can be used singly or in combination with either NSAIDs or corticosteroids. The most important part of treating a gout flare is to start anti-inflammatory medications as soon as possible and this usually means having immediate access to those medications. It is especially important not to discontinue the urate-lowering therapy you may also be taking during gout attacks.
When starting uric acid-lowering therapies, such as allopurinol or febuxostat, your doctor will prescribe them at a low dose, which is gradually escalated until your levels of uric acid have been lowered to less than 6.0 mg/dL.
Alternative Medication and Lifestyle Changes
There are many alternative over-the-counter therapies that are touted for the treatment of recurrent gout and those that claim to prevent gout or reduce gout attacks. Few of these have been scientifically tested for effectiveness and none have proven to aid in the long-term management of gout. It is best to stick with the medications outlined in the sections above.
A well-balanced diet eating foods low in purines and physical activity are the best lifestyle modifications to lower uric acid, prevent gout attacks and treat gout. The diets most often recommended for people with gout to prevent future flares are the Mediterranean diet and the DASH diet.