Gout is a form of arthritis that causes sudden, severe episodes of pain, tenderness, redness, warmth and swelling of the joints. It is the most common type of inflammatory arthritis in men over the age of 40. Women are usually protected from gout until after menopause.
Causes of gout
Gout is the result of deposits of needle-like crystals of uric acid in the joint spaces. Uric acid, a substance that results from the breakdown of purines in the body, usually dissolves in the blood and passes through the kidneys into the urine. In people with gout, the uric acid level in the blood becomes elevated. This is called hyperuricaemia and can be due either to the increased production of uric acid, eg. due to consumption of food rich in purines, or decreased excretion of uric acid from the kidney, eg. renal impairment.
Symptoms of gout
An attack often occurs very suddenly with the maximum intensity of pain reached within a few hours. The joint involved can be extremely painful and is often swollen, warm and red. This rapid development of joint pain is a feature that differentiates gout from most other forms of arthritis. The most common joint affected is the first joint of the big toe. Other joints that may be affected are the knee, ankle, foot, hand, wrist and elbow joints. The shoulder, hip joints and the spine are rarely affected.
Risk factors of developing gout
- Most people with gout have hyperuricaemia although not all people with hyperuricaemia have gout.
- Being overweight
- Excessive food intake increases the body’s production of uric acid.
- Excessive consumption of alcohol
- Alcohol interferes with the excretion of uric acid from the body.
- Food with high purine content
- Use of certain medications such as:
- Start of a uric-acid lowering treatment
- Crash diet
- Joint trauma
- Surgery or sudden, severe illness
Besides evaluating the symptoms, performing a clinical examination and measuring the blood uric acid levels, the most conclusive test for gout is the joint aspiration procedure. This is a simple procedure where a needle is used to remove a sample of fluid from the affected joint. The presence of uric acid crystals (monosodium urate crystals) confirms the diagnosis of gout. However, the absence of such crystals does not rule out gout. Most people with gout have hyperuricaemia but hyperuricaemia may not be present during an acute attack. Hyperuricaemia alone does not mean that a person has gout.
The treatment of gout depends on the stage of the disease.
- For an acute attack:
- The crucial step is to provide pain relief and shorten the duration of inflammation.
- The goal in the management of gout is to prevent recurrent or future gouty attacks with the ultimate objective of preventing joint damage.
- Treatment is tailored for each person and medications are used to:
- Relieve the pain and swelling during an acute episode.
- Prevent future episodes.
- Prevent or treat tophi, which are nodules of crystallised uric acid formed under the skin that can become swollen and cause pain during gout attacks.
Medication for acute episodes
Non-steroidal anti-inflammatory drugs (NSAIDS) for example, Naproxen, Mefenamic acid, Indomethacin, or Diclofenac are commonly used to relieve pain and swelling during an acute gout episode.
- NSAIDS usually begin to work within 24 hours.
- Their side effects include stomach upset, skin rashes, fluid retention or kidney problems and stomach ulcers.
- They should be used cautiously in patients with kidney impairment and stomach ulcers.
- Newer drugs called COX-2 inhibitors may be safer for the stomach.
- Corticosteroids work quickly as well and can be taken by mouth or injected directly into an inflamed joint to relieve the pain and swelling of an acute episode of gout.
- Colchicine gives prompt relief when taken at the first sign of an attack.
- Common side effects include abdominal cramps or diarrhoea.
- Lower doses of colchicine can be taken daily to prevent future attacks.
Medications that control uric acid levels
- Long term management of patients with gouty arthritis is to reduce blood uric acid levels so that future episodes of gouty attacks can be prevented. This is achieved by medications such as Allopurinol or uricosuric agents (i.e. medications that result in increased urate excretion from the kidneys).
- These medications do not relieve the pain and inflammation of an acute episode and are usually started after the acute episode of gout is treated.
- They may occasionally cause you to have more gout episodes when they are first started, hence you may be prescribed Colchicine or NSAIDS to be taken at the same time.
- Allopurinol decreases the blood uric acid level and has to be taken daily.
- It can also reduce tophi size and prevent formation of crystal deposits in joints and other tissues.
- The most common side effect is skin rash and Allopurinol has to be discontinued if you develop any rashes or itch.
- Allopurinol is usually taken daily, and for years.
- It should not be stopped during an acute episode of gout.
- Uricosuric drugs such as probenecid lower the blood level of uric acid by increasing its excretion in the urine.
- They are not as effective as Allopurinol and do not work as well in people with renal impairment.
- Patients should drink plenty of water as the excretion of uric acid in the urine may lead to the formation of stones in the kidney.
Ultimately, your doctor will advise you regarding the types of medication(s) you need and monitor their side effects.
Other problems in gout
Gout may be associated with high blood pressure, diabetes, kidney diseases and obesity. It may be important to screen for these diseases. Uric acid crystals can form deposits in the kidneys or the ureter leading to renal or ureteric stones. This can lead to renal impairment.
Dietary advice if you have gout
Diet plays an important role in the management of gout. Patients with gout should avoid foods with high purine content. It is also important to drink lots of water (at least 2 litres per day) unless instructed by a doctor not to do so. Patients should also reduce their consumption of alcoholic beverages and reduce weight. However, crash dieting is not advised.
Foods high in purine content (restrict your intake)
- Asparagus, cauliflower, mushroom, oatmeal, wholegrain, wheat germ, red meat
Foods highest in purine (abstain completely if possible)
- All internal organs of animals and birds, liver, kidney, brain, pancreas
- Rich game – venison, gamebird pigeon, black chicken
- Meat extracts – gravies, chicken essence, bak kut teh
- Certain fish / shellfish – salmon, herring, mackerel, anchovies, sardines, cockles, mussels, scallops, prawns
- Certain vegetables – spinach, peas, beans, peanuts, carrots
- Products of beans – beancurd, soya bean drink, bean sprout, bean cake, moon cake, legumes
- Fruits – strawberries, strawberry jam, durian, tomato, tomato sauce
- Alcohol – beer, champagne, brandy, whisky, port
Specialist services available at the following institutions:
- Singapore General Hospital Tel: 6321 4377
- KK Women's and Children's Hospital Tel: 6294 4050 (services for women only).
See Gout-Friendly Foods: What Foods to Eat When You Have Gout.
Article contributed by the Dept of Rheumatology and Immunology at:
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