DID YOU KNOW?
Gout occurs more often in men than women. It affects about two per cent of both men over age 30 and women over age 50 in Canada.
WHAT IS GOUT?
Gout is an inflammatory type of arthritis caused by uric acid crystals. Painful attacks occur when uric acid crystallizes in the joints. Recurring gout attacks can cause permanent joint damage.
Increased uric acid and gout may be associated with a number of different disorders. It is linked to increased risk of heart disease, hypertension (high blood pressure), kidney stones, obesity and high lipid levels in the blood. Most people living with chronic gout can control it with medication. Early diagnosis and treatment lowers your chances of joint destruction. Lifestyle changes are an important part of treatment and can also prevent and manage many of the conditions associated with gout.
WHAT CAUSES GOUT?
Gout is usually associated with a high level of uric acid. Normally, uric acid is present in our body and is excreted by the kidney. There are a number of different factors that may increase uric acid in our body, including higher production of uric acid and the reduced elimination of uric acid by the kidney. The ability to maintain uric acid in dissolvable form is an important body function; people with gout may not be able to do this. When uric acid levels are high, insoluble crystals in the joint can occur, causing inflammation and gout. Not everyone with high levels of uric acid, however, will develop gout.
SEVERAL FACTORS CAN BE ASSOCIATED WITH ELEVATED URIC ACID OR GOUT:
- Genetic defects of uric acid metabolism. These are rare. There may be a family history of gout associated with these rare defects.
- Some medications, which may include water pills taken for edema (e.g. heart failure) and low dose ASA (Aspirin), may block the excretion of uric acid in the kidney.
- Foods rich in purines, which are the building blocks of uric acid in the cell, may raise levels of uric acid. Purine-rich foods include certain seafoods and red meat. Alcohol and fructose found in soft drinks may also increase amounts of uric acid.
- Obesity, hypertension (high blood pressure) and diabetes may be associated with high uric acid levels and gout.
- Estrogen is known to lower uric acid levels and therefore reduces the risk of gout in pre-menopausal women. After menopause, the frequency of gout in women and men is similar.
TRENDS IN GOUT
Evidence indicates that there has been a worldwide increase in the frequency of gout; this may be driven by changes in diet and lifestyle. Although some research may suggest that dietary factors and an inactive lifestyle are not responsible for an increased risk of gout, data still shows that the incidence of gout has doubled in the past 20 years.
TYPES OF GOUT
This type of gout usually involves one joint (often the toe) or a few joints. Attacks may begin at night. Acute gout may be triggered by a purine-rich diet, alcohol use, some medications, surgery, heart attack or trauma. Affected joints are usually red, swollen and tender. Early attacks usually subside after three to 10 days, with some skin peeling away from the affected joint. Without proper treatment, you may have an attack that lasts longer. Over 50 per cent of individuals who have had an acute gout attack will have a recurrence within a year. Over time the attacks may become more frequent, last longer, and involve more joints.
For example: You may go to bed in good health. During the night, you wake up due to sharp pain, usually in the big toe, but sometimes in the heel, ankle or instep. The pain and sensation are so acute that you cannot tolerate the weight of a bed sheet on your toe. The pain is persistent and intense.
The joint that is most commonly affected first is located at the base of the big toe. Almost any joint can be affected, but the joints of the lower limbs are more often involved. Gout can also affect the bursa and tendons, causing soft tissue swelling under the elbow joint. The soft tissues overlying the joint can become red, hot and swollen. The swelling can eventually affect the whole foot and ankle, and wearing a regular shoe over the inflamed toe may become impossible.
In some cases, untreated attacks linger on and the disease becomes chronic with persistent inflammation. The uric acid crystals deposit in and around the joint, leading to destruction of the joint and soft tissues. This is called tophaceous gout. With proper medical attention and treatment, most people will not progress to this advanced stage.
HOW DOES YOUR DOCTOR DIAGNOSE GOUT?
The nature of the attack and the joints involved provide the key to diagnosis. Blood tests may reveal an abnormally high level of uric acid. Having a higher level of uric acid in the blood alone does not mean you have gout. Many people with elevated levels of uric acid do not develop gout. A definitive diagnosis is made by inserting a needle into the joint and taking a sample of fluid, which, when examined properly, reveals the classic appearance of uric acid crystals.
HOW CAN I TREAT GOUT?
The goals of gout treatment are to:
- Provide relief of acute attacks.
- Prevent further attacks.
- Prevent damage to the joints.
- Prevent and manage the complications associated with gout.
Preventive measures include, but are not limited to, changes in lifestyle that can prevent gout attacks as well as associated conditions.
Your doctor may recommend both medical and non-medical therapies for gout. Treatment for acute attacks includes rest, ice, non-steroidal anti-inflammatory drugs (NSAIDs), colchicine and cortisone.
Medical treatment of gout usually falls under the following categories:
- Treatment of an acute attack: This usually involves the administration of anti-inflammatory medications, such as NSAIDs or corticosteroids. Colchicine is used to suppress gout if the attack is caught in the first 24 hours and is usually given orally in tablet form and repeated. It may cause diarrhea if the dose is too high.
- Lowering the uric acid level: While some people with gout may not require treatment to lower levels of uric acid, this is usually necessary for those who experience frequent attacks, have tophaceous gout or have uric acid kidney stones.
Medications for reducing uric acid levels either act to block its formation or increase the excretion of uric acid in the kidney. They should not be used until the gout attack has completely subsided. If your doctor decides that you need to take medication for your gout, you may need to take it forever to prevent more attacks. Be sure to discuss all treatments with your doctor.
Written April 2008 by Hyon Choi, MD, DrPH, FRCPC. Revised and updated April 2011 by David Bell, MD, FRCP (C).