Gout

Definition

Gout happens when uric acid crystals build up in the joints. This causes the joints to be inflamed. If the crystals build up in the kidneys, kidney stones may result.

Causes

Gout typically occurs if you have high levels of uric acid in your blood (called hyperuricemia). But, you could also have normal uric levels and still have gout.

The liver metabolizes uric acid, and the kidneys get rid of it through the urine. Levels of uric acid build up when:

  • Too much uric acid is produced
  • Not enough uric acid is eliminated

If you have gout and hyperuricemia, your body doesn't eliminate enough uric acid.

Risk Factors

These factors increase your chance of developing gout. All causes of hyperuricemia are risk factors for gout.

Risk factors include:

  • Obesity, sudden weight gain, or rapid weight loss
  • Age: over 40 years old
  • Sex: male
  • Family members with gout
  • Diuretics, such as hydrochlorothiazide
  • Certain medications, such as aspirin
  • High-purine diet (uric acid occurs when purines are broken down), for example:
    • Liver and other organ meats
    • Dried beans and peas
    • Anchovies
    • Gravies
  • Alcohol use, especially binge drinking
  • Certain types of cancer or cancer treatments (eg, cytotoxic drugs)
  • Medications (eg, antiseizure, anti-rejection medications)
  • Dehydration
  • Hypercholesterolemia
  • Kidney disease

Symptoms

Symptoms include:

Acute Gouty Arthritis

  • Sudden onset of severe pain in an inflamed joint, usually starting in the big toe
  • Joints that are red, hot, swollen, and very tender
  • Increased pain 24-36 hours after the onset of symptoms

Gout of the Big Toe

© 2008 Nucleus Medical Art, Inc.

Recurrent Gouty Arthritis

Most people with gout have another attack within two years. This attack may affect many different joints. With recurrent gout, tophi can form. Tophi are chalky deposits of uric acid that commonly occur in the elbows and earlobes.

Diagnosis

The doctor will ask about your symptoms and medical history, and perform a physical exam. A sample of fluid from the affected joint will be taken. This fluid will be tested for uric acid crystals.

Other tests may include:

  • Blood and urine tests—to measure the level of uric acid in your blood and to assess kidney function
  • X-rays—to check for joint destruction

Treatment

Treatment depends on whether the gout is acute or recurrent.

Acute Gouty Arthritis

In general, the sooner treatment begins for an acute attack, the more effective it is. Treatment depends on:

  • Onset of symptoms
  • Number of joints affected
  • Previous responses to treatment
  • Overall health

General Measures

Putting a warm pad or an ice pack on the joint may ease the pain. Keeping the weight of clothes or bed covers off the joint can also help.

Medications

  • Nonsteroidal anti-inflammatory drugs (NSAIDs), for example:
    • Indomethacin
    • Ibuprofen
    • Naproxen
  • Corticosteroids—used if NSAIDs are not effective or not recommended
    • A study found that people given corticosteroid plus acetaminophen had fewer adverse affects than those given NSAID plus acetaminophen.*
  • Colchicine—used to prevent gout attacks, but seldom used as a treatment for an acute attack. Note: This drug has many adverse effects, so it is rarely used first.
  • Aspirin—not recommended because it can increase uric acid levels

Recurrent Gout

General Measures

  • Consume a low-purine diet.
  • Avoid alcohol.
  • If you're overweight, lose weight gradually. Rapid weight loss can cause a gout attack.
  • Ask your doctor if any of your medications cause high uric acid levels.
  • Drink a lot of fluids.

Medications

If you have recurrent gouty arthritis or an initial attack with hyperuricemia, you may be given medication:

  • To lower the production of uric acid (eg, allopurinol)
  • To increase the excretion of uric acid by the kidneys (eg, probenecid or sulfinpyrazone)

Under some cases, low dose colchicine may also be used to prevent recurrent attacks.

Prevention

To reduce your chance of getting gout:

  • Eat a low-purine diet.
  • Limit how much alcohol you drink. Avoid binge drinking.
  • Drink a lot of fluids.
  • Lose weight gradually.
  • Talk to your doctor about your risk for high blood pressure and heart attacks. These conditions are associated with gout.

RESOURCES:

Arthritis Foundation
http://www.arthritis.org/

American Arthritis Society
http://www.americanarthritis.org/

CANADIAN RESOURCES:

Arthritis Research Centre of Canada
http://www.arthritisresearch.ca/

Canadian Arthritis Network
http://www.arthritisnetwork.ca/

References:

Braundwald E, Fauci AS, Kasper DL, et al, eds. Complications of hyperuricemia. Harrison's Principles of Internal Medicine. 15th ed. New York, NY: McGraw Hill; 2002.

Gout. The American College of Rheumatology website. Available at: http://www.rheumatology.org/public/factsheets/gout.asp. Updated June 2006. Accessed June 27, 2008.

Rott KT, Agudelo CA. Gout. JAMA. 2003;289:2857-2860.

Terkeltaub RA. Clinical practice. Gout. N Engl J Med. 2003;349:1647-1655.

*7/19/2007 DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : Man CY, Cheung IT, Cameron PA, Rainer TH. Comparison of oral prednisolone/paracetamol and oral indomethacin/paracetamol combination therapy in the treatment of acute gout-like arthritis: a double-blind, randomized, controlled trial. Ann Emerg Med. 2007;49:670-677. Epub 2007 Feb 5.



Last reviewed February 2008 by Jill Landis, MD

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.


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