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?

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?

Drugs are the mainstay of treatment. During an acute attack, these may include non-steroidal anti-inflammatory or corticosteroids, pain relievers (analgesics), and colchicine (a specific anti-gout agent). The individual's response to colchicine may be used for diagnosis as well as treatment. In chronic gout, the drugs used are ones that increase the excretion of uric acid in the urine (uricosuric agents) and drugs that block the production of uric acid (allopurinol). Most individuals are urged to limit their consumption of organ meats and alcohol (both of which are known to interfere with the elimination of uric acid) and to lose weight if they are obese.

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.

Information	Brand	Generic	Label	Rating
	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.

Last updated 28 May 2012