Family doctor

Overview of Gout

• Gout is a painful inflammation of a joint, which comes on suddenly. It usually involves only one joint at a time.
• It is due to a chemical called uric acid, which normally stays dissolved in the bloodstream.
• If the level of uric acid in the blood goes too high it settles as crystals in a joint such as the big toe or the knee or in the kidney. This will cause great pain.
• It is nine times more common for men than women, especially after the age of 40 and is more common for certain races such as Polynesians.
• It is important for the gout sufferer to avoid situations that might bring on gout such as eating certain foods, drinking too much alcohol, and becoming overweight.
• Drugs can help but you need to learn how to use the drugs prescribed. There are three types of drug treatment - those used to treat an acute painful gout attack, those used to block production of uric acid, and thirdly those that speed up uric acid excretion through the kidney.
• Gout is not just a nuisance disease. It can lead to serious kidney damage and in association with obesity and high blood pressure can increase the risk of strokes and heart attacks.

What is gout?

"The disease of kings and the king of diseases," GOUT, is caused by an excess of URIC ACID floating in the blood.

Uric acid is a breakdown product of metabolism and at normal levels stays dissolved in the bloodstream as it travels to the kidney and passes out in the urine. However when the levels get too high it settles and forms crystals a bit like ordinary table salt.

The crystals tend to form around one joint such as the great toe joint or in the knee or elbow, or the crystals can form a hard stone within the kidney. They can cause lumps under the skin known as TOPHI. Uric acid crystals are very irritating to the body and set off a marked inflammation with pain, heat and redness.

The excess of uric acid is nine times more likely to happen in men than women especially as middle-age approaches and in people from certain races, e.g. Polynesians. Gout is more common in women after the menopause.

The excess of uric acid can be caused by the following:

• An increase in manufacture by the body
• The kidneys not passing enough uric acid in the urine
• Increased intake of foods containing PURINES which are changed to uric acid inside the body. Sweetbreads, brains, shellfish, dried peas, and beans are particularly high in purines.
• Too much alcohol leading to dehydration i.e. reduced water in the bloodstream. Water is needed to keep uric acid dissolved in the blood to stop it settling out as crystals. So for gout sufferers it is a good idea to "mix water with wine".
• Certain drugs which cause an increase in uric acid e.g. thiazide diuretics used for treating high blood pressure or low dose aspirin used for heart attack prevention.
• An injury to a joint. This can be a minor injury such as stubbing a toe.
• Other causes of dehydration such as a surgical operation.
• Certain diseases which can result in raised uric acid e.g. leukaemia or lymphoma.

Gout often occurs in people with obesity, high blood pressure, high cholesterol in the blood and diabetes, which makes for a higher risk of heart attacks and strokes.

Sometimes there is no obvious cause for a gout attack.

Quite frequently people are found to have a high uric acid level in the blood but never get attacks of gout. The reason for this is unknown. This condition is called HYPERURICAEMIA.

What are the symptoms?

1. A sudden attack of gout (acute gout) shows up as:

• sudden, severe joint pain
• joint swelling
• shiny red skin around the joint
• extreme tenderness in the joint area

When gout first appears, long gaps may occur between attacks. An attack may last a week or so and everything seems to go back to normal. However, without treatment, attacks may happen more often and last longer and may lead to damage to the affected joints. If a joint is damaged after an attack it may feel stiff with reduced movement.

2. Kidney stones may appear as severe cramping pain in either the right or left side of the abdomen towards the back. Sometimes the pain radiates around towards the groin on the same side. This pain can come on quite suddenly causing the sufferer to roll around in pain and even vomit with pain. Kidney stones can occur in people with high uric acid who have never had an attack of acute gout and kidney damage can occur without ever having a painful kidney stone.

3. People with high uric acid can develop TOPHI. After several years, the uric acid crystals can build up around joints and surrounding tissues. They form lumps under the skin called TOPHI. These are often found in or near joints previously attacked by gout and also on the elbow, over the fingers and toes, and in the outer edge of the ear. They can damage joints.

Diagnosis of Gout :

If you are a middle-aged man or a woman past menopause and have a family history of gout it is worth having a blood test to see if you have hyperuricaemia - high blood uric acid without gout. This would allow you to take precautions to prevent gout and kidney stones.

If you have sudden onset of a single painful red swollen joint such as a great toe or knee, your doctor may suspect gout and arrange some tests. Unfortunately measuring the blood uric acid level during an attack of gout may not help. Often the uric acid level is normal or low. Presumably this is because the excess uric acid has settled out of the blood into the joint as crystals.

The best immediate test to diagnose gout is for your doctor to instill local anaesthetic into the skin over the painful joint and to suck out fluid for examination for uric acid crystals under a special microscope. This is easy in the knee but harder in smaller joints. Other diseases can imitate gout, for example pseudo gout or a joint infection. Your doctor may arrange blood and urine tests after the gout attack has settled. These may well be done after an overnight fast test. The tests will be to find out information such as:

• Are you a high uric acid producer or do your kidneys hold back uric acid instead of excreting it?
• Do you have signs of kidney damage?
• Do you have abnormal blood lipids? This is the term for cholesterol and other fats floating in the blood. This test is carried out because of an increased risk of heart attacks and strokes for people with high uric acid, high lipids, high blood pressure and obesity and is best carried out after an overnight fast test.
• Do you have signs of diabetes? This is also best determined after an overnight test.
• Do you have normal liver function tests? One of the drugs used to control gout long-term can upset liver function tests.

How is gout treated?

An attack of acute gout needs rapid treatment to ease the severe pain. Four drug treatments exist and all should be accompanied by drinking lots of fresh water (N.B. the exceptions to this rule are persons with heart failure or kidney failure). Drug names used here are "generic names" i.e. the name of the active chemical in the drug is used, not the "trade name". Many of these drugs are sold under several different trade names.

Colchicine is one of the oldest drugs used in medicine today. It works best taken early in an attack and can be a very toxic drug if not used carefully. Your doctor will give very careful instructions and you must follow them exactly. When colchicine causes diarrhoea it is getting up to the toxic dose and the dosage must be cut back.

Non-steroidal anti-inflammatory drugs (NSAIDS) can be very effective. There are several on the market, e.g. diclofenac, naprosyn, indomethacin ibuprofen. All of them can cause stomach upset or make asthma worse and long-term use can cause stomach ulcers and kidney problems so they need to be used with care, especially in older people.

Simple painkillers such as paracetamol can help especially in tandem with colchicine or a NSAID. It is best to avoid aspirin when you are taking an NSAID because of a double assault on your stomach lining.

Steroids such as prednisone can be effective.

Long-term prevention of gout and kidney stones:

The key treatment lies with the person suffering the problem. If you are overweight, do not fast or try to diet too severely because that can raise your uric acid level and make the gout worse. Usually you can eat what you like within limits.

If you have kidney stones due to uric acid, you may need to avoid or limit foods which may raise uric acid levels such as brains, tongue, tripe, kidneys, mushrooms, asparagus, large amounts of meat, meat soups and gravies, sardines, anchovies, liver, sweetbreads, shellfish, dried peas and beans. You can drink coffee and tea. Too much alcohol may raise your uric acid level by drying out the blood. Alcohol makes you pass more urine and takes water out of your bloodstream and thus brings on a gout episode. Drink at least 10 big glasses of non-alcoholic fluids daily, especially if you have had kidney stones. This will help flush the uric acid crystals out of your body (but mind the warning above for those who have heart failure or kidney failure).

Allopurinol is often used if you are an over producer of uric acid and can be used to prevent kidney stones in people with hyperuricaemia without gout attacks. In practice allopurinol can be a difficult drug for three reasons. Firstly, it must not be started close to a gout attack or it will bring the attack back on. Secondly, it must be taken continuously. If it is stopped and restarted it can bring on acute gout - the very thing it is designed to stop. The reasons for this are not really known. Thirdly, the dosage has to be adjusted to suit the individual to avoid liver upset. For the first reason, allopurinol is often used with colchicine or an NSAID for the first six weeks to 3 months to prevent an acute attack until allopurinol has reduced the blood levels of uric acid.

1. Two drugs called probenecid and sulfinpyrazone are used long-term to increase the excretion of uric acid and also may make gout worse in the first few weeks of treatment. Your doctor needs to adjust the dosage depending on the level of uric acid in the your blood.

2. Operations for gout are only occasionally used. Replacement of large TOPHI joints damaged by gout are sometimes carried out and large or infected joints are sometimes operated on. Kidney stones also may need surgical removal.

Getting help

It is best not to delay getting an accurate diagnosis. See your family doctor for treatment of your gout .Careful follow up and adherence to medication is required to ensure successful treatment of gout.