Gout is the most common form of inflammatory arthritis. It is a serious, lifelong disease that needs ongoing treatment and requires some changes to lifestyle habits to achieve control. If left untreated, advanced gout can lead to the same level of work loss, physical disability, and diminished quality of life as is seen in advanced rheumatoid arthritis.
What is gout?
Gout is one of the oldest known medical conditions and, in the past, was called the “disease of kings.” It is historically associated with eating rich foods and consuming a lot of alcohol, particularly beer. Many people have a lot of guilt associated with their disease – stemming from the myth that gout is self-inflicted from poor dietary and lifestyle habits.
Over the past 30 years, the percentage of people developing gout has been steadily rising. People in industrial societies now have access to rich food, live longer and are not as physically active as in the past. Understanding the disease and following treatment advice from a medical professional is important.
The signs and symptoms of gout almost always occur suddenly, and often at night.
- 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.
The severity of gout can be classified into three manifestations.
Uric acid is naturally produced in everyone’s body. Too much uric acid can put people at risk for gout. As cells die, they release substances called purines, which are also found in some foods. Purines break down and are eliminated as uric acid. Uric acid passes mostly through the kidneys.
If the body makes too much uric acid, or if the kidneys are not efficient in getting rid of it, hyperuricemia (high uric acid in the blood) develops. Hyperuricemia is necessary to develop gout. Lowering uric acid to a healthy range – 6.0 mg/dL or below – is the most important step to successfully managing gout.
Not everyone with hyperuricema will get gout, but once it develops, it is likely to return unless treated by medicine to lower uric acid. Medication to lower your uric acid level and some changes to your diet and exercise habits can reduce the amount of uric acid you have.
After years of hyperuricemia, the extra uric acid in the body can turn into tophi crystals in your joints and in other tissues. These crystals are what set the stage for a painful flare of gout.
The following is a list of common risks that can lead to gout flares.
- Heart disease — Uric acid is a known risk factor for both hypertension and heart disease. Many epidemiological studies show a link between uric acid and coronary disease, including stroke and heart attack. Left untreated, gout can be very dangerous, with new research showing that having gout doubles a person’s risk for heart attack or stroke.
- Kidney disease — those who have gout are more likely to get kidney disease. Likewise, those who have kidney disease are more likely to suffer from gout and elevated uric acid levels.
- Ongoing deposits of uric acid crystals — During this stage, known as intercritical gout, someone is in between gout flares and has no symptoms with joints functioning normally. However, uric acid continues to accumulate, leading to additional and more painful flares of gout than before, unless the uric acid is lowered to 6.0 mg/dL or below, depending on the doctor’s recommendation. These flares can also last twice as long (one to two weeks) and twice as often (every four to six months).
- Chronic, persistent joint complaints and deformities — After years of untreated or undertreated early gout, the disease can progress to a stage with chronic, persistent joint complaints and deformities as well as the appearance of tophi, or masses of uric acid crystals under the skin and around joints. Tophi break through the skin and appear as white or yellowish-white, chalky nodules.
- Finger or toe amputations — In 10-15 percent of patients, tophi are severe and disfiguring. Some patients need specialized shoes. In patients with extreme cases, they have needed finger or toe amputations.
- Decline in quality of life — There is a reported decline in quality of life when gout is uncontrolled. Gout not only takes a physical toll on the body, but it also takes a mental toll.
Upon examination, the doctor might suspect gout. A CT scan, ultrasound, MRI and or a synovial joint fluid aspiration will be done to assess for crystals that are proof-positive of a gout diagnosis. A blood test will likely be done to check serum uric acid (sUA) levels.
While a blood test doesn’t provide a definitive diagnosis of gout, it helps the physician understand whether this is a potential diagnosis.
Patients should provide the doctor with a thorough health history, answering these and other questions:
- Have you had an experience like this before?
- Have you been diagnosed with hyperuricemia (uric acid levels above 6.8 mg/dL)?
- Has anyone in your family been diagnosed with gout or hyperuricemia?
- Do you have diabetes, kidney disease, hypertension or heart disease?
- Have you had a recent joint injury?
- Do you consume a lot of sugar in your diet?
- If female, have you been through menopause?
Once diagnosed with gout, a new patient will likely be given medications to treat his or her disease. Like many other medications for blood pressure or high cholesterol, urate-lowering medicines are meant to be taken daily for life. They should not be discontinued—even when a gout flare is over.
Though it seems like your health is back to normal, the underlying cause of the disease—elevated serum uric acid—needs to be controlled. Medications for pain and inflammation can be stopped, as directed after pain and inflammation are subsided—but urate-lowering therapy must be continued for life.
Standard urate-lowering medicines are:
- Allopurinol – This is an oral prescription that helps lower serum uric acid levels. This medicine is also known by brand names Lopurin® and Zyloprim®. When started on this drug, your doctor will likely gradually increase the dosage to a standard prescription dose.
- Febuxostat – This is another urate-lowering therapy that can be prescribed under the brand name Uloric®. This medication is taken orally and decreases the body’s production of uric acid. It can be taken by people with mild to moderate kidney or liver disease.
Some general potential side effects of allopurinol are changes in taste, diarrhea, indigestion, and stomach pain or cramps. For febuxostat, some minor side effects are changes in appetite, constipation or diarrhea, nausea, hot flush to face or skin, stomach upset, or pain. It’s important that if they persist or there are questions, call a doctor.
Though only 1 in 1,000 patient cases, there is a more severe hypersensitivity reaction to allopurinol, with fever or rash that can cover the body and deterioration of liver and kidney function. At-risk patient populations (Han Chinese, Southeast Asians, and Koreans with kidney disease) can be screened for a genetic marker (HLA-B5801) that can predict this reaction. To alleviate this hypersensitivity, doctors will start a patient on a low dose with a step-up plan to the optimal medication dose.
There are several options given to get the pain under control. By mouth, they are typically taken while the gout flare lasts. It is important to take medications as prescribed to eliminate the inflammation. If experiencing stomach upset when taking medications, your doctor, or a practice nurse, will guide you on taking your medication with food or switching to another medication.
Standard medicines prescribed for pain and inflammation for gout are:
- Nonsteroidal anti-inflammatory drugs (NSAIDS) – Several—like Advil®, Aleve® and Motrin®—are available in over-the-counter dosing. Your doctor may also give you a prescription dose. Other brand-name NSAIDs include Celebrex®, Indocin®, Naprosyn® and Tivorbex®.
- Glucocorticosteroids – Cortisone can be taken orally or injected, and quickly suppresses the inflammation of an acute gout flare. It may be prescribed under the brand names Deltasone® (prednisone), Kenalog®-40 or Medrol®.
- Colchicine – This is usually most effective when taken within the first 12 hours of an acute flare; however, other medications may still be needed for treating pain. A common dosing schedule is to take two, 1.2 mg tablets together at once, then a third tablet one hour later, followed by one tablet 2-3 times per day over the next week. Patients may have side effects such as nausea, vomiting, abdominal cramps, or diarrhea. Brand names include Colcrys® and Mitigare®.
It is important to note that gout flares often occur when a patient first starts taking medications to lower uric acid levels. Patients can help prevent flares when starting these medications by also taking low‐dose colchicine or NSAIDs. Often, doctors advise patients to keep taking colchicine in a low, preventive dose together with the uric acid-lowering medicine for at least six months.
If you are taking a uric acid-lowering drug, your doctor should slowly raise the dose and keep checking your blood uric acid levels regularly. Once your uric acid levels reach or drop below a healthy 6.0 mg/dL, crystals tend to dissolve and new deposits of crystals can be prevented.
With severe tophi that limit a patient’s quality of life, physicians may choose to prescribe pegloticase, also known as Krystexxa®, given by intravenous infusion every two weeks to more aggressively dissolve gout crystals. Several gout specialists give infusions at their offices, where patients are monitored throughout the treatment, which takes two to four hours, including pre-infusion medication and post-infusion monitoring. This more aggressive treatment is used without other drug therapy and can reduce uric acid levels significantly and quickly and eliminate the tophi, often within eight to nine months.
Some side effects of pegloticase are muscle pain, nausea, vomiting, and upset stomach – which need to be addressed by a doctor if they persist or are bothersome.
In other advanced cases, a combination of drugs is used: allopurinol, febuxostat, lesinurad, and probenecid. When there are severe tophi, these drugs will likely take longer to eliminate because it takes more time to reduce uric acid levels.
Doctor-Patient Relationships (what to expect from your doctor)
If you have gout, your PCP will most likely prescribe medications to lower uric acid levels. Most patients will be managed by traditional medications, like allopurinol, to lower uric acid. Patients may also be told to take Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) to manage pain during a gout flare.
When gout persists over time, PCPs will often refer patients to a rheumatologist who specializes in gout care. Patients can also request a referral to a rheumatologist—particularly when gout flares are more frequent and not well controlled.
When gout becomes advanced, patients should always be treated by rheumatologists who have experience in caring for patients who need infusion treatments every few weeks and/or suffer from deforming tophi nodules and damage to bone structure.
When patients suffer from other health issues—like kidney disease—gout should be co-managed by both the PCP or rheumatologist and with another health specialist (i.e., a nephrologist for kidney disease). It is important to keep other health issues in mind when prescribing gout treatment.
Prevention and Diet
Preventing gout requires the reduction of the urate burden on your body. By reducing the level of uric acid in your body, you can curb crystal buildup around your joints thus managing painful flares. While the best way to achieve this is through uric acid-lowering therapy, dietary and lifestyle changes can help by attacking certain risk factors of gout.
At best, a healthy diet can reduce your uric acid by 1.0 mg/dL; however, a healthy diet can help obesity – a risk factor that leaves someone three times more likely to develop gout. Dietary changes can also help you recognize foods that cause flares and avoid them. As such, setting and keeping up with good eating habits should be a goal alongside uric acid-lowering therapy.
No food and drinks “cause” gout, but overindulgence in foods rich in purines can bring on painful flares. This includes foods such as:
- Red meat
- Organ meats
- Processed foods
It’s recommended that a diet consists of low-purine foods if you have gout. The DASH diet and Mediterranean diet are good models to follow when trying to eat healthier. Foods to consider as a part of your diet include:
- Lean proteins like fish and chicken are fine in moderation (around 4 to 6 ounces per day).
- Low-fat and nondairy products
- Fresh fruits
- Nuts, nut butter, and healthy grains
- Vegetables: luckily there is a wide variety of vegetables to choose from for your healthy diet.
Lifestyle changes can also reduce the impact of gout on your body. Regular exercise is a helpful method to keep your body in good shape. The CDC recommends moderate-intensity physical activities for at least 30 minutes most days of the week for adults. Maintaining healthy body weight is also important; crash diets and other fast weight loss can increase uric acid levels in the body. Staying hydrated is vital as well, research shows that drinking adequate water might guard against kidney stones and constipation – two conditions that can be impacted by gout.
Other healthy benchmarks to keep track of:
- LDL Cholesterol
- 130 mg/dL or below
- Heart Rate
- 60-100 beats/minute
- HDL Cholesterol
- 40-60 mg/dL
- 200 mg/dL or below
- Blood Sugar
- 100 mg/dL or below if fasting
- Blood Pressure
- 130-80 or less
Who it affects
Men comprise the majority of gout patients. Of the 9.2 million people with gout, about 6.1 million are male. Gout can strike in anyone at any age, but it is most likely to affect men who are 40 or older and women post-menopause. About 2.2 million gout patients are women.
People with kidney disease are also among the most affected by gout. Gout is also strongly linked to obesity, hypertension (high blood pressure), hyperlipidemia (high cholesterol and triglycerides), and diabetes. Because of genetic factors, gout tends to run in some families. Gout rarely affects children, but pediatric gout is possible.
Gout is an extremely painful form of inflammatory arthritis caused by an accumulation of uric acid crystals in the joints. These crystals can also deposit in other tissues throughout the body, such as the kidney, which can lead to kidney stones. Gout is more common in men over the age of 45, but it can occur in anyone at any age. Factors ranging from a family history of gout to having other health issues such as high blood pressure, diabetes, or kidney disease, can increase the risk for developing gout.
Gout is Serious
When asking “what is gout?” it’s important to know that during a gout attack, a person experiences sudden and severe episodes of pain, warmth and swelling in one or more joints. While gout often begins in the big toe, attacks can spread to the feet, ankle, wrists, hands and elbows and cause permanent joint damage.
The pain during a gout attack is often so excruciating that many go to an emergency room for relief.
Treatment is Necessary
Despite the severity of gout, just 10 percent of sufferers are getting needed, ongoing treatment.
Left untreated, gout can lead to permanent joint damage and other health issues such as kidney stones. Extensive destruction of the joints and large tophi (crystals which form under the skin) can lead to deformities – particularly of the hands and feet – and result in loss of normal use.
What is gout?
While gout is a lifelong condition, it can be managed – or even completely controlled – by sticking with a proper treatment plan that combines the right medication with diet and lifestyle changes. Because gout is associated with other serious health issues, an accurate diagnosis and ongoing management is critical.
On a pain scale of one to 10, most gout patients rank their pain as a nine or a 10. Many report that during an attack, the affected joint feels as if it is caught in a mechanical device. Even the thought of a bedsheet touching the joint is enough to make them cringe.
Gout attacks come on quickly and can last for several days. After a first attack, most people will experience another painful flare within a year. More than three in four gout sufferers will have another attack within two years. Subsequent attacks often are more severe and last longer.