WHAT IS GOUT?

Gout is a form of inflammatory arthritis characterized by sudden, severe attacks of pain, redness, and inflammation in joints. Gout occurs when excess uric acid, one of the body’s normal waste products, accumulates in the body forming monosodium urate crystals in the fluid that lubricates the joint linings. Gout is one of the most painful forms of arthritis and is a source of disability for many.

Although the first episode of gout typically affects the base of the big toe, it can affect other joints including the feet, ankles, knees, hands, wrists, and elbows. Gout usually initially affects only one joint at a time, but over time it can become chronic and affect several joints. If left untreated, substantial levels of uric acid in the blood may result in kidney stones.

Gout usually, but not always, develops in people over the age of 40. Men are more likely to get gout, but women become increasingly susceptible to gout after menopause. Gout is strongly associated with obesity, hypertension, diabetes, and genetic factors.

Gout is treatable but treatment may be complicated by co‐existing medical conditions. It is important to identify and treat gout early to mitigate complications. Expert rheumatologists at Columbia University Medical Center’s Arthritis Center evaluate patients to determine if gout is the cause of their arthritis, educate them about treatment measures, and provide a multidisciplinary approach to patient care.
 

SYMPTOMS OF GOUT

The signs and symptoms of gout are almost always acute, occurring suddenly and without warning. These are among the most common symptoms of gout; however, each individual may experience symptoms differently and should consult a physician for diagnosis.
  • Sudden and severe joint pain is characteristic of gout
  • The affected joint or joints become swollen, tender, and red
  • Warmth in the affected joint area
  • Swollen, shiny skin that is red or purple in color covers the affected joint
  • Hard lumps of urate crystal deposits beneath the skin (known as tophi)
  • The first gout attack usually affects the large joint of the big toe, but it can occur in feet, ankles, knees, hands and wrists
  • After the most severe pain subsides, some joint discomfort may last from a few days to a few weeks
  • Kidney stone symptoms may also occur. These symptoms include pain, sometimes excruciating, from the lower back to the groin; difficulty urinating; and a frequent urge to urinate but with minimal amounts of urine passed
   
Figure 1: Toe joint swollen and red with a gout attack

Figure 2: Uric acid crystals are deposited in big toe joint
 

STAGES OF GOUT

Gout is a chronic, progressive disease, which if left untreated may get worse over time. By recognizing the symptoms early and seeking the care of a physician you can reduce the chances of gout reaching the latter stages. Gout can progress through four stages.
 

STAGE ONE

The first stage of gout is known as asymptomatic gout and is characterized by no symptoms. The body will already have excess amounts of uric acid in the blood. There is no discomfort or outward evidence of disease but gout is beginning to form.
 

STAGE TWO

Acute gout is the second stage; it is at this point that gout starts to do damage to the body. The buildup of uric acid causes crystals to form in the joints causing a sudden onset of severe pain. An acute attack of gout is typically evident upon awakening from sleep and residual discomfort may linger for more than a week. Subsequent episodes of gout may not occur for months or even years; however, over time attacks can last longer and recur more frequently.
 

STAGE THREE

The third stage of gout is intercritical gout. It is during this period when the acute gout has subsided and the body exhibits normal joint function; however, uric acid levels in the blood remain high. The disease may be difficult to control if treatment is not started by this stage.
 

STAGE FOUR

Chronic gout is the most destructive stage of the disease and occurs after many years of recurrent gout. At this stage the disease has caused permanent damage to the affected joints producing persistent joint inflammation, joint deformity, and deposits of crystallized uric acid (tophi). Tophi can cause chronic pain, joint destruction, damage surrounding tissues, and cause deformities.
 

GOUT RISK FACTORS

There are a number of factors that increase the risk of developing gout or precipitating flares in established gout.
The following characteristics are associated with the likelihood of developing gout:

  • Men get gout more than women and at younger ages. The onset of gout among men is typically between the ages of 40-60 years, although it may begin earlier for those with a genetic predisposition.
  • Most women experience gout after menopause
  • Obesity
  • Use of medications that affect blood levels of urate (particularly diuretics)
  • Certain medical conditions: diabetes, high blood pressure, high cholesterol, kidney problems
  • Excessive consumption of alcohol, especially beer
  • Joint injury
  • A high-fructose diet, including sweetened soda, and foods high in purines
  • Genetics- one in four people with gout has a family history of the disease
 
An attack may be triggered, in a person with gout, by the following:

  • Regular and excessive consumption of alcohol, especially beer
  • Fasting and/or crash dieting
  • Eating large amounts of purine-rich foods, particularly red meat and shellfish
  • Injury to the joint
  • Dehydration such as occurs around the time of surgery
 

TREATMENT FOR GOUT

The initial goal of treatment of flares of gouty arthritis is to reduce pain and inflammation quickly and safely. Medications such as NSAIDs, colchicine, and corticosteroids may be used to control the attacks of joint pain. However, once the pain and inflammation have been treated it is equally important to address the underlying cause of the gout attack - high uric acid.

To help manage future flares of gout it is important to maintain a uric acid level below 6mg/dl. Medications and lifestyle changes, such as reducing alcohol consumption, limiting intake of meats and fish rich in purines, and maintaining a healthy weight can help to lower uric acid levels in the body. However, in most cases, medication is required.

Gout is a long -term disease affecting quality of life by the episodic attacks and potential for chronic arthritis. Treatment for gout usually requires pain medications for the flares and medications may be required to lower the level of uric acid in the blood. Specific treatment of gout varies based on co-existing medical conditions and other medications. You and your doctor will develop a comprehensive treatment plan based on your current health and medical history.
 

HEALTHY LIFESTYLE CHANGES

Food is not the cause of gout but a high purine diet is one of the contributing factors that can trigger a gout attack if you already have high uric acid levels in your blood. While diet changes alone are usually not sufficient to lower uric acid levels they can help to achieve a healthier lifestyle.
 

High-Purine Foods

Limiting or avoiding these foods if you have a high uric acid level may help reduce the likelihood of triggering a gout attack.

Meats Beef, Lamb, Pork, Duck, Organ meats (such as liver, kidney, and sweetbreads), Gravy
Beverages Alcoholic Beverages – Particularly, Beer
Seafood Scallops, Trout, Anchovies, Roe( fish eggs), Mussels, Sardines, Herring
Vegetables Mushrooms, Cauliflower, Spinach, Asparagus
Other Oatmeal, Peas, Lentils, Dried Beans
 

Low-Purine Foods

In addition to incorporating these foods low in purine content into your diet, a daily exercise regimen and an increase in the amount of liquids you drink each day are important lifestyle changes in managing future gout attacks.

Breads and Grains Breads, Grains, Cereals, Pasta, Rice
Vegetables Tomatoes, Some green vegetables
Beverages Coffee, Milk and milk products
Other Fruits, Cheese, Eggs
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