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Gout

Gouty Arthritis

What is Gout?

Gout is a type of arthritis caused by the accumulation of uric-acid crystals in one or more joints, most often the big toe. Gout can occur alone or in combination with any of the following: abnormal amounts of uric acid in the blood (hyperuricemia), acute inflammatory arthritis, deposits of sodium biurate (tophi) in tissues near a joint or in the kidney (renal tophi), and urinary stones (urolithiasis). Either an overproduction or an under-excretion of uric acid may cause gout. However, an elevated uric acid level is not synonymous with gout. In gout, deposits of uric acid in the joints and in cartilage cause inflammation and severe pain. Uric acid crystals in the kidney can form kidney stones (urinary calculi) and can lead to permanent kidney damage or failure.

Most attacks occur without apparent cause. Occasionally, an attack may follow an operation, infection, trauma, alcohol ingestion, starvation, over indulgence in foods with high purine content (meat, fish, fowl, and certain vegetables), ingestion of drugs that cause changes in urate concentration, or minor irritations. Gout may be associated with obesity, high blood pressure (hypertension), narrowing of blood vessels due to atherosclerosis, and elevated lipids (hyperlipidemia).

The first attacks of gout most often occur between the ages of 40 to 60 years. Males are affected by gout more than females. Gout tends to primarily involve the lower extremities. Joints most often involved include the great toe, instep, ankle, heel, wrist, elbows and fingers. Over time, deposits of uratic acid crystals in these joints may cause deformity of the joints.

How is it diagnosed?

Gout signs and symptoms

  • Sudden onset of severe pain in the inflamed joint, usually at the base of the big toe or larger joints.
  • Involved joints are red, hot, swollen, and very tender. Skin over the joint is red and shiny.
  • Fever (sometimes).

History: The first attack of gout usually occurs without warning. It typically occurs at night, waking the individual with severe joint pain. In males, gout most often involves only one joint initially. The great toe is involved in 80% of the cases. In females, the initial attack is more apt to involve multiple joints. The acute attack may be mild, lasting only a few hours to a few days, or it may be severe lasting several weeks.

The symptoms then disappear completely until the next attack. The time between the first attack and a second attack varies widely. Most individuals will experience a second attack within two years. Some individuals may never experience another attack, but most will have a recurrence of symptoms. As the disease progresses, the attacks become more frequent, last longer and have more severe symptoms.

Physical exam: Findings on physical exam may include a warm, tender joint. Pain is elicited with slight pressure. If the individual has had several attacks of gout, he or she may also have excess fibrous buildup in the ears, hands, feet and elbows. The physical exam may be normal if the individual does not seek treatment during an acute attack, however.

Tests: Diagnosis involves aspiration of the joint with examination for urate crystals, or tissue biopsy for evaluation of sodium biurate deposits (tophi) are performed. Sedimentation rate, complete blood count (CBC) with differential, 24-hour urine collection are done to assess uric acid levels. X-rays of the involved joint may be done to rule out other conditions.

How is gout treated?

Rheumatologists will often be involved in the treatment of gout because they specialize in managing this and other forms of arthritis.

A number of medications may be recommended to reduce joint pain and inflammation. To avoid any interactions, patients must advise their physicians if they are taking other drugs.

Medications to treat gout include:

Nonsteroidal anti-inflammatory drugs (NSAIDs)

High doses of NSAIDs such as indomethacin or ibuprofen are the most common treatment for acute gouty arthritis. However, aspirin should not be used for this condition because it can elevate levels of uric acid in the blood. Patients who have a history of ulcers or kidney problems, or those taking anticoagulant medication, may be treated with another type of anti-inflammatory medication, or other medications may be used in conjunction with NSAIDs to protect against unwanted side effects.

Corticosteroids

These medications are strong anti-inflammatory hormones, which may be given to patients who cannot use NSAIDs. Corticosteroids may be given in pill form (in high doses) or via injections into the swollen joint. Patients usually begin to improve within a few hours of treatment, and the attack often completely subsides within a week or so. When used long term, however, these medications may produce side effects, such as weight gain, osteoporosis (bone thinning), cataracts, glaucoma and diabetes, and may contribute to hardening of the arteries (atherosclerosis).

Colchicine

This alkaloid drug is often prescribed when NSAIDs or corticosteroids do not control symptoms. However, it is most effective when taken within the first 12 hours of an episode of acute gouty arthritis. Physicians may prescribe it as often as every hour until joint pain and inflammation begin to improve. When taken orally, side effects may include nausea, vomiting, abdominal cramps or diarrhea. In addition, colchicine may also be prescribed in low doses to prevent further attacks. When taken in low doses, side effects are less likely to occur. Even though the chronic use of colchicine can reduce or prevent attacks of gout, it does not prevent the accumulation of uric acid crystals that can cause joint damage even without attacks of hot, swollen joints.

Colchicine may also be administered intravenously (I.V.), but this form of therapy should be performed only by a physician experienced in it. When done improperly, I.V. colchicine therapy can have severe side effects, including bone marrow toxicity, kidney failure and, in some cases, even death.
Once the acute gouty arthritis is under control, treatment for gout focuses on preventing recurrent attacks and decreasing the levels of uric acid in the blood. Therapy to lower blood levels of uric acid, which may lead to the formation of uric acid crystals in the tissues and joints of the body, may include:

Uricosurics

These medications help the kidneys eliminate excess uric acid in the urine. Uricosurics should be taken with plenty of fluid (at least 68 ounces or 2 liters a day) to prevent the formation of uric acid kidney stones. These drugs are usually prescribed when gout is caused by under-excretion of uric acid, which occurs in most cases. However, uricosurics should not be used by patients with reduced kidney function or those with tophaceous gout.

Allopurinol

This xanthine oxidase inhibitor decreases the production of uric acid by the body and is the most reliable way to lower levels of uric acid in the blood. However, common side effects include stomach pain, headache, diarrhea and rashes.

In very rare cases, some people can develop an extremely severe allergic reaction to allopurinol, which can lead to kidney and liver toxicity as well as become life-threatening. Patients who develop a rash or a fever following use of this agent should seek immediate medical care.
To be effective, medications to reduce uric acid in the blood must be taken regularly and long-term. Stopping the medications often results in recurrence of gout later.

In addition, medications to treat hyperuricemia (high blood levels of uric acid) should not be administered during an episode of acute gouty arthritis because they may intensify and/or prolong the attack. They should be administered only after symptoms (e.g., joint pain and inflammation) subside.

In instances of medication-induced hyperuricemia, switching medications is often the only course of action necessary.

Surgery is rarely needed for gout unless significant joint damage has occurred from lack of effective and timely treatment. Sometimes surgery may be performed to remove large tophi that are draining (oozing), infected or interfere with normal joint movement. In very severe cases, patients may have to undergo joint replacement surgery (arthroplasty).

Treatment for gout should begin early to prevent long-term complications, such as chronic tophaceous gout, the formation of kidney stones and kidney damage. In secondary gout, treatment of the primary condition causing gout may control the disease.

Medications

  • Nonsteroidal anti-inflammatory drugs to control inflammation in the painful joints.
  • Prescription medications such as colchicine, indomethacin or prednisolone may be used to control the pain of the acute attack.
  • For some patients, lifelong medication, such as allopurinol to decrease uric acid production or probenecid to increase the kidneys’ excretion of uric acid. These medications have significant side effects and adverse reactions. Obtain as much information as possible regarding their use.

Deltasone (Prednisone), Motrin (Ibuprofen), Aleve (Naproxen), Medrol (Methylprednisolone), Decadron (Dexamethasone), Zyloprim (Allopurinol), Aristocort (Triamcinolone)

Activity

Acute attacks will end sooner with complete rest.

Diet

  • Don't eat liver, sweetbreads, kidney, anchovies or sardines.
  • Drink 10 to 12 glasses of water daily. Large amounts of fluid keep the urine diluted (helps prevent kidney stones).
  • Don't drink alcoholic beverages, especially beer or red wine (they can worsen or trigger an attack).
  • If you are overweight, begin a medically approved weight loss diet. Do not go on a crash diet, as quick weight loss may bring on a gout attack.

What might complicate it?

Complications include death of bone tissue due to insufficient blood supply (avascular necrosis), bone deformity, kidney damage, chronic arthritis, and high blood pressure (hypertension).

Predicted outcome

Most individuals will experience repeated attacks of gout. Kidney damage occurs in up to ten percent of individuals with gout.

Alternatives

Other possibilities include rheumatoid arthritis, cellulitis, calcium pyrophosphate dihydrate crystal deposition disease (CPPD), osteoarthritis, septic arthritis, traumatic arthritis, bursitis, and tendinitis.

Appropriate specialists

Internist, nephrologist and rheumatologist.

Seek Medical Attention

Consult with or see your doctor if you have the following:

  • You or a family member has symptoms of gout.
  • The following occur during treatment:
    • Fever of 101°F (38.3° C) or higher.
    • Skin rash, sore throat, red tongue or bleeding gums.
    • Marked swelling of feet or abrupt weight increase.
    • Diarrhea or vomiting.
  • Symptoms are not relieved in 3 days despite treatment.

Last updated 12 July 2015