Gout is a form of arthritis that causes sudden, severe attacks of pain, tenderness, redness, warmth, and swelling (inflammation) in some joints. It often affects one joint at a time, but may affect a few or even many. The large toe is most often affected, but gout can also affect other joints in the leg (knee, ankle, foot) and less often in the arms (hand, wrist, and elbow). The spine is rarely affected.
In the initial period, gout attacks may occur rarely, such as once or few times every several years. Later these can becomes more frequent and may occur several times a year.
Gout attacks can recur from time to time in the same or different joints.
The initial attack may last up to one week, and at times up two weeks unless it is treated.
Over time, gout attacks may occur more often, involve more joints, have more severe symptoms, and last longer. Repeated attacks can damage the joint. Lumpy collections of uric acid called tophi can develop near joints, in the skin, or erode into the bones.
Gout affects more than one million Americans, including:
When gout affects women, it is usually after menopause. Younger patients may be affected by gout if they have been taking certain medicines for long periods of time, are transplant patients, frequently drink alcoholic beverages, have chronic kidney disease, or have certain genetic disorders.
Gout results from excessive amount of uric acid in the body that leads to an abnormal deposit of uric acid crystals (also known as monosodium urate crystals) in the joints and soft tissue. The collection of uric acid in the soft tissue leading to a lump is called tophus (tophi for multiple lumps). Uric acid crystals can also form in the kidney, causing kidney stones.
Monosodium urate is formed from uric acid, a natural chemical in the body. Uric acid comes from the natural breakdown of RNA and DNA (the genetic material in cells). Alcohol and certain foods contain large amounts of uric acid, especially red meats and internal organs (such as liver and kidneys), some shellfish, and anchovies. However, most meats contain uric acid. Patients who eat more meat and fish (and less dairy) or drink more beer and liquor are more prone to gout. A family history of gout may be a risk factor for developing gout, but is not the case in all patients. Certain medications can increase the risk for gout, such as diuretics. Avoiding alcohol and consuming a diet low in animal meats and higher in vegetables and fruits has been shown to help reduce the level of uric acid in the blood and the likelihood of developing gout attacks. Insuring adequate hydration with water and maintaining normal kidney function is important.
Uric acid in low amounts remains dissolved in the blood, and would be less likely to lead to a gout attack. Uric acid in high amounts (higher than 6.8 mg/dL) can lead to crystals that could deposit in joints and make a person more likely to develop gout.
The level of uric acid in your blood can change depending on:
The above mentioned are considered modifiable risk factors.
Not everyone with high levels of uric acid will develop gout. Having a strong family history of gout may increase one’s risk for gout, but this does not mean that everyone with a family history of gout will have the disorder. Often, the effect of heredity is modified by the risk factors mentioned above that affect uric acid, as well as male sex and age.
Gout cannot be diagnosed simply from a blood test, since many people may have elevated blood uric acid levels, but never develop gout. Rather, gout is best diagnosed from the fluid aspirated from an inflamed swollen joint. The fluid is examined under a polarized microscope for the presence of monosodium urate crystals. Gout can be suspected based on the clinical presentation or certain imaging studies.
Fluid is aspirated through a needle from the inflamed joint during a procedure called arthrocentesis. Removing the fluid may reduce pressure within the joint and thereby reduce pain. A lack of crystals does not necessarily rule out a diagnosis of gout. Occasionally, crystals may not be observed the first time, but may be seen if fluid is removed at another time during a subsequent attack.
Since gout can cause debilitating joint pain and in the long term joint damage, it is extremely important that an accurate diagnosis be made. Then, your doctor can prescribe the appropriate specific treatment.
Gout can be treated and controlled. Symptoms are often dramatically improved within 24 hours after treatment has begun. Attacks can be prevented with appropriate therapy to lower the blood uric acid levels and change in lifestyle by addressing the modifiable risk factors.
The goals of treatment are to:
The type of treatment prescribed will depend on several factors, including the person's age, type of medicines he or she is taking, kidney function, overall health, other comorbidities (other medical problems), and other medications they are taking.
Medication used for the treatment of gout include those that treat the gout attack and those that prevent future gout attacks by lowering the uric acid.
Medications that treat gout attacks
Anti-inflammatory drugs will reduce the pain and swelling of attacks. They are usually continued until the gout attack completely resolves. If side effects from the therapy occur, treatment may be changed to a different medication. Your healthcare provider will discuss the potential side effects with you. If you have kidney disease, heart failure, diabetes, ulcer disease, stomach or intestinal bleeding history, or other chronic conditions, the choice of therapy to treat the gout is affected.
Colchicine is usually the medication of choice for gout attacks, if patient does not have renal failure. Colchicine is sometimes used in low doses for a long period of time to reduce the risk of recurrent attacks of gout.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are prescribed to treat sudden gout attacks, if colchicine is not possible. NSAIDs usually reduce inflammation and pain within hours. However, these are contraindicated in certain patients who have impaired kidney function and the above mentioned health conditions.
Corticosteroids (also called steroids) may be prescribed for people who cannot take NSAIDs. Steroids also work by decreasing inflammation. Steroids can be injected into the affected joint or given as pills. Steroids have been used in certain severe gout attacks. These may also be contraindicated in certain cases.
Drugs that lower the uric acid levels
Some patients may need to take medicines that lower the level of uric acid in the blood. (Examples are allopurinol; febuxostat; rarely, probenecid; and, in severe cases, pegloticase). The most commonly used are allopurinol or febuxostat. These drugs are recommended for patients who have elevated uric acid and multiple attacks of gout or kidney stones due to uric acid. The goal of treatment is to reduce the uric acid level to less than 6 mg/dL.
The goal of lowering the blood uric acid is to slowly dissolve joint deposits of monosodium urate. Lowering the uric acid will not treat an acute attack but will, over time, prevent additional attacks from occurring. Sudden lowering of the uric acid level may cause an acute attack of gout. To prevent acute attacks in people who are taking uric acid-lowering drugs, colchicine, or an NSAID is temporarily prescribed. If an attack occurs while taking a medication to lower the uric acid, this medicine should NOT be stopped; stopping and starting the uric acid lowering medication may cause additional attacks.
Side effects of medicine
Not all patients will develop side effects from gout medications. How often any side effect occurs varies from patient to patient. The occurrence of side effects depends on the dose, type of medication, concurrent illnesses, or other medicines the patient may be taking. Before starting these medications, discuss with your doctor side effects and risks of these medications.
Some side effects are more serious than others. If any rash or itching develops while taking allopurinol, the medicine should be stopped immediately and your physician notified.
Dietary changes may play a significant role in controlling the uric acid levels. Limiting certain foods, such as fructose containing corn syrup, that cause an increased production of uric acid and reducing alcohol intake and decreasing the amount of meats/shellfish consumed and insuring adequate hydration have been shown to be helpful.
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or healthcare provider. Please consult your healthcare provider for advice about a specific medical condition. This document was last reviewed on: 11/26/2017