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Gout

What is gout?  

Gout is a type of inflammatory arthritis caused by small crystals of a chemical called uric acid that form in the joints. The body’s immune system attacks these crystals, causing pain, redness and swelling in the joint and sometimes in the surrounding tissue.  Gout has both active and inactive periods.  Active periods of gout are known as “attacks” and can vary in severity and length. 

High levels of uric acid cause gout but not everyone with high uric acid levels develops gout. Uric acid results when our bodies break down certain chemicals that occur naturally in our cells and in some high-protein food. Uric acid is taken by the blood to the kidneys where it is disposed of in the urine. When the amount of uric acid in the blood is too high (either because the body produces too much uric acid or because the body cannot get rid of the uric acid it produces), small crystals can form in the joints. These crystals can build up under the skin and form hard bumps called tophi. Uric acid crystals can also deposit in the kidneys causing kidney stones. 

Gout attacks can happen in any joint but often impact those in the lower limbs such as the knees, ankles and feet. Many people experience their first gout attack in the base of the big toe. Initial attacks usually stop after three to 10 days; however, without treatment, attacks can occur again and can last longer. Most people with gout will have another attack within a year. Over time, these attacks may become more frequent, last longer and impact more joints. Recurring gout attacks can cause permanent joint damage so early diagnosis and treatment are key. 

Unlike other forms of arthritis, gout can start sudden but can also stop suddenly. 

What are early signs of gout? 

Gout attacks, particularly early ones, seem to come on suddenly and at the same time as the appearance a red, painful, swollen joint; but in reality, uric acid had been building up for a period of time. Attacks are often “triggered” by something that causes uric acid levels to spike. Triggers include a protein-rich meal, a night of drinking alcohol (especially beer) or a period of dehydration. 

Symptoms often appear at night and get worse over the next eight to twelve hours. Although the initial attack often takes place in the base of the big toe, gout can also attack the knee, heel, ankle or instep. Gout pain is persistent and intense and swelling can progress beyond the original joint. 

How is gout diagnosed? 

To diagnose gout, your doctor will ask about recent medications and diet. They will want to know when the symptoms began, how long they last, how intense they are and which joints are involved. A blood test can determine uric acid levels, but high levels do not necessarily indicate a gout attack. Your doctor may also ask you to repeat blood tests after attacks have gone away as uric acid level tends to drop during an attack. 

Gout can be diagnosed by inserting a needle into the joint and taking a sample of fluid, but a combination of physical examination, blood tests and imaging studies (X-rays and/or ultrasound) are often enough for an accurate diagnosis. 

What are the bumps on my body? 

Bumps can form when uric acid crystals build up. These bumps, called tophi, are usually small and hard and can form anywhere on the body. Often they form on the toes, knees, heels, fingers, ears, forearms or elbows. Tophi are usually painless; however, sometimes they can become inflamed and ooze a thick discharge. Tophi often form several years after the first gout attack and in some cases they appear in people who have never had a gout attack. Tophi can be irritating and are often surgically removed. 

What are the risk factors for gout? 

Since gout is directly related to uric acid levels in the blood, risk factors are primarily associated with the production and excretion of uric acid. 

  • Diet: Red meat, certain seafoods (such as shrimp and oily fish), alcoholic beverages (especially beer) and sugar (especially fructose found in soft drinks) all increases uric acid levels. 
  • High blood pressure: High blood pressure and some medications used to treat high blood pressure (diuretics) increase the risk of gout. Taking low dose aspirin also increases uric acid levels. 
  • Obesity: People with high body weight are more likely to develop gout and at a younger age than those with lower body weight. Over the past twenty years the incidence of gout has nearly doubled, probably due to an increase in obesity in the general population. 
  • Medication: Some medications block the excretion of uric acid in the kidney. In general, diuretics and medications that repress the immune system can increase risk of gout. 
  • Trauma: Gout can be brought on by surgery, heart attack or other physical and even emotional trauma. 
  • Kidney disease: Even mild kidney disease can result in reduced excretion of uric acid from the body. 
  • Heredity: If someone in your family has gout, you have a higher chance of developing the disease since gout does run in some families. However, many people who develop gout do not have a family history of the disease. 
  • Dehydration: Dehydration can contribute to gout attacks. 

How common is gout? 

Gout is the most common inflammatory arthritis for men, affecting about 5.2% of all adult Canadian men.  In contrast, only 2.4% of Canadian women have gout.  People aged 65 years or older are more commonly affected.   

Why is treatment for gout so important? 

Gout attacks tend to increase in length and frequency without treatment and can even become chronic. The ongoing presence of the uric acid crystals in and around the joint can lead to destruction of the joint and the soft tissues around the joint.  

Fortunately, with proper medical attention and treatment, few patients progress to this advanced stage. Most people living with chronic gout can control the condition with medication. Lifestyle changes are an important part of treatment and can help prevent and manage many conditions associated with gout. Early identification and treatment reduces the chance of permanent joint damage and can reduce the number and severity of attacks. 

When having an attack 

When having a gout attack, take these steps to bring pain and swelling under control: 

  • Take an anti-inflammatory medication as soon as possible, but only on the advice of your doctor 
  • Ice, elevate and rest the joint 
  • Drink plenty of fluids—but no alcohol, pop or sugary drinks 
  • Pay attention to the joint(s) involved, the intensity and changes in pain, the length of the attack 
  • Call your doctor to set an appointment to be assessed and have blood work done 
  • Relax —avoid stress since it can aggravate gout 

Medications 

Preventing further gout attacks, and the joint damage they can cause, is the goal in treating gout. A number of medications do a good job of preventing pain and swelling in the short-term and others lower uric acid levels over the long-term. You should discuss both short- and long-term options with your doctor. 

Non-steroidal anti-Inflammatory drugs (NSAIDs) 

Non-steroidal anti-inflammatory drugs (NSAIDs) are used to treat pain and inflammation. The term “non-steroidal” means that they do not contain steroids. NSAIDs are a commonly used drug and there are many different types and brands. Many can be obtained without a prescription. These medications control the symptoms of gout, but do not alter the course of the disease. NSAIDs can be taken as needed or taken regularly to control symptoms. You and your doctor can decide what is suitable for you. 

Colchicine  

For those unable to take NSAIDs, colchicine is an option. Colchicine has been used to treat gout for more than 2,000 years, and helps relieve the pain and swelling of gout attacks. A high percentage of patients cannot take colchicine due to its side effects. You and your doctor can decide if colchicine is suitable for you. 

Corticosteroids  

For those who cannot take either NSAIDs or colchicine, corticosteroids can be a good alternative. These are given either orally or as injections into the affected joints. Injections tend to work quickly; within a few days or even within a few hours for some patients. Steroid injections are safe for most people; however, steroid injections should only be given three or four times per year.  

Medications that reduce uric acid levels  

Medications that reduce uric acid levels will prevent future gout attacks and keep the condition from becoming chronic. Going on these medications can end up being a lifetime commitment since going on and off medications that control uric acid levels can bring on gout attacks. For this reason, doctors typically wait to see how regular gout attacks are before prescribing such medications. Two to three attacks a year is often the number looked at before prescribing this type of medications.  

Surgery  

Fortunately, surgery is rarely required for gout. Occasionally surgery must be considered for patients who have suffered from gout over a long period of time. It is used to remove particularly problematic tophi or to repair badly damaged joints. Generally, with proper medication and treatment, these severe situations are avoided. 

Given its direct link to uric acid levels, managing gout depends primarily on a strategy for eating well and managing the intake of foods that contribute to increased uric acid levels. Healthy kidney function is important as well since uric acid is removed from the blood by the kidneys. The kidneys rely on the heart to efficiently pump the blood through the body. People who are overweight are more prone to heart disease, so staying physically active and managing weight assist in controlling gout. 

Food choices  

Managing gout is as much about what not to eat as it is about what to eat. In general, those suffering from gout need to avoid the following foods: 

  • Processed meat 
  • Red meat and organ meats (liver, tongue and sweetbreads) 
  • Shellfish (such as shrimp, lobster and mussels) 
  • Oily fish (such as herring, sardines and mackerel) 
  • Sugary beverages (including pop and some juice) 
  • Any food, drinks or sauces that contain corn syrup 
  • Excessive alcohol (any amount of alcohol affects uric acid production and disposal, but more than one drink/day for women and more than two drinks/day for men is especially dangerous) 
  • Beer, in particular, has been linked to gout attacks 
  • There are some foods that gout patients had found helpful 
  • Skim milk and other low-fat dairy products 
  • Cherries and citrus fruits  
  • Vitamin C supplements (500–1,000 milligrams daily) 
  • Coffee 

Eating well to control weight  

Gout is more common in overweight people so losing weight and maintaining a healthy body weight helps manage gout. Losing weight reduces uric acid levels in the blood and for many the more weight they lose, the more their uric acid levels decrease. Maintaining a healthy weight also decreases the risk of heart disease which has been shown to contribute to gout symptoms. 

Proper nutrition is vital to controlling body weight. Here are three ways to cut back on excess calories: 

  • Reduce fat intake: A healthy diet should include a small amount of unsaturated fats and limited amounts of saturated and trans fat. Choosing the right amount and types of fats help you achieve and maintain a healthy body weight. 
  • Reduce sugar intake: Sugar contains “empty” calories and has no nutritional value. 
  • Eat more vegetables and fruit: Vegetables and fruit should make up the largest component of your diet. Having said that, people suffering from gout need to choose the least sweet fruits to reduce sugar intake. Try to have at least one vegetable or fruit at every meal and while snacking. Besides being an excellent source of energy, vegetables and fruit boost your fibre intake, which helps with weight management. They are also loaded with antioxidants, which help boost the immune system and may help maintain healthy joints. 

Try to avoid triggers  

Gout is often brought on by external stresses so being aware of these and avoiding them where possible can assist in preventing further attacks. These are some of the triggers that can bring on gout attacks: 

  • Joint injury 
  • Surgery 
  • Infection 
  • Diuretic medications 
  • Forgetting to take your gout medication 
  • Crash diets and fasting 
  • Drinking too much alcohol 
  • Eating large quantities of foods high in purines 
  • Dehydration 

Cold therapy and heat  

During a gout attack using cold can help reduce pain. Cold reduces blood flow to the injury which helps reduce swelling and inflammation. Cold should not be applied for longer than 20 minutes at a time. As a general rule, 20 minutes on, 20 minutes off, works well. Always use a protective barrier, such as a towel, between any cold pack and the skin. 

Heat should NOT be used DURING a gout attack since applying heat can make symptoms worse. However, between attacks, taking a warm shower and using warm packs (such as hot water bottles or microwavable heating pads) are great ways to help reduce general pain and stiffness. Heat is ideal for: 

  • relieving pain and stiffness 
  • relieving muscle spasms and tightness 
  • enhancing range of motion 

Using a commercial cold pack or a homemade one (from crushed ice, ice cubes or a bag of frozen vegetables) can be helpful. Cold is ideal for: 

  • swelling 
  • decreasing pain 
  • constricting blood flow to an inflamed joint 

Relaxation and coping skills  

Developing good relaxation and coping skills can help you maintain balance in your life, giving you a greater feeling of control over your gout and a more positive outlook. Relaxing the muscles around a sore joint can help to reduce pain. Although gout attacks tend to be very painful, there are ways to help you relax. Try deep breathing exercises, a relaxation podcast or listen to music. Imagine or visualize a pleasant activity, such as lying on a beach. 

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Contributors

This information was last updated September 2017, with expert advice from:

Gregory Choy, MD, FRCPC
Rheumatology Division, Sunnybrook Health Sciences Centre, University of Toronto

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