Gout is a condition in which uric acid, a waste product that occurs naturally occurring within the body, rises above normal levels. Rather than being flushed by the kidneys and through the urine, as it normally is, it forms crystals and deposits in the joints. These deposits give rise to inflammation of the joints, causing pain, swelling, redness and tenderness of the area. Most typically the joint affected is that of the big toe, but gout can also affect the ankle, knee, foot, hand, wrist and elbow. Uric acid crystals may also form deposits in other areas such as under the skin or in other soft tissues, and in the kidney or urinary tract.

Gout is predominantly a disease of adult men. It is the most common cause of inflammatory arthritis in men over age 40, and men have at least four times greater likelihood of developing gout than women. Gout is uncommon in men under 30 years of age, and often occurs between the ages of 40 and 50. Women rarely develop gout before reaching menopause, and more often do after the age of 60.

The onset of gout is usually quick and unexpected. Often, people who develop gout will do so during the night while sleeping, after having gone to bed in good health. During the night, they are awakened by acute pain in the big toe or, more rarely, in the heel, ankle or instep. This pain has been described as feeling at first like a bucket of cold water has been poured over the affected area, with the pain increasing to a violent stretching, tearing sensation. There is also a pressure and tightness around the area, and the pain becomes so acute that not even the weight of a bed sheet can be tolerated. The soft tissues, such as the muscles and tendons, around the joint can become hot, red and swollen, and wearing of a regular shoe may become impossible.

Joints Affected
Gout typically affects the joint at the base of the big toe. In over half of all initial attacks, this is the first joint affected. Almost any other joint can be affected, but the joints of the lower limbs are more commonly than those of the upper limbs.

The majority of initial gout attacks involve only one joint, and, with treatment, subside within three to ten days. Over 50% of people who have had an acute attack of gout will have a recurrence within the year. Over time the attacks may become more frequent, longer lasting and often involve more joints.

For some people the attacks linger, and the disease becomes chronic. The crystals of uric acid deposited inside the joint and in the surrounding soft tissues lead to destructive changes in the joint and cause persistent inflammation.

Non-Joint Involvement
Uric acid crystals can be deposited in soft tissues and form what are known as 'tophi.' These appear as whitish or yellowish deposits under the skin. They cause local irritation of the soft tissues, leading to redness of the area. Sometimes the deposits can break through the skin. Tophi may occur at any site but commonly occur in the fingers or toes, at the backs of the elbows, behind the heels, or around the outer edges of the ears. Uric acid crystals can also form deposits in the kidney or urinary tract.

A number of factors seem to contribute to gout. Acute gout may be triggered by events such as surgery, heart attacks, or trauma. Use of alcohol or some medications, such as certain diuretics (also known as water pills), particularly those used to treat high blood pressure, can set off a gout attack. Certain foods, such as seafood and liver, and beverages, such as coffee and tea may contribute to the incidence of gout. A family history of gout is common for those who develop it, and this may be a result of genetic predisposition or environmental factors.

The goal in treating gout is to safely provide relief of acute attacks, prevent further attacks and damage to the joints, and prevent the formation of tophi or kidney stones. Establishing the correct diagnosis is important, because something can be done to manage most forms of arthritis, and most therapies work best when started early in the disease.

Your doctor may be able to identify that you have gout by examining the joint that is painful and hearing about the onset of symptoms. He or she can confirm the diagnosis by inserting a needle into the joint and taking a sample of fluid from it. This fluid is examined under a microscope for evidence of uric acid crystals. A 24-hour urine test, showing the amount of uric acid in your urine, can also help your doctor determine the cause of your gout and the type of treatment you need.

Blood tests will also reveal an abnormally high level of uric acid. However, blood tests are not used in predicting the incidence of gout or in diagnosing it, because having an elevated level of uric acid in the blood does not mean you have gout. Fewer than one in five people with elevated levels of uric acid in the blood actually develop gout, and unless a person’s uric acid level in the blood is very high (in which case it can lead to kidney complications) it on its own does not require treatment.

A variety of treatments can help you manage your gout. Your active involvement in developing your treatment plan is essential.

Medicine

If left untreated, an acute attack will usually end by itself in seven to 10 days. Medication is one of the main ways to treat both acute and chronic attacks of gout.

NSAIDs
Nonsteroidal anti-inflammatory drugs (NSAIDs) usually form the first line of treatment in an acute attack. NSAIDs reduce pain when taken at a low dose, and relieve inflammation when taken at a higher dose. The most commonly used NSAID to treat gout is Indocid. It, like the other NSAIDS sometimes used to treat gout (Naprosyn, Orudis, Voltaren, Tolectin) can be purchased only with a prescription. All, if taken in full doses, usually have the same levels of anti-inflammatory effect. However, different individuals may experience greater relief from one medication than another. Taking more than one NSAID at a time increases the possibility of side effects, particularly stomach problems such as heartburn, ulcers and bleeding. People taking these medications should also consider taking something to protect the stomach, such as misoprostol (Cytotec).

 
Corticosteroids
For severe pain and inflammation, doctors can inject a powerful anti-inflammatory drug, called a corticosteroid, directly into the affected joint. Cortisone is a steroid that reduces inflammation and swelling. It is a hormone naturally produced by the body. Corticosteroids are man-made drugs that closely resemble cortisone. An injection can provide almost immediate relief for a tender, swollen and inflamed joint. However, this treatment can only be used rarely, since corticosteroids can weaken cartilage and remove the minerals from (and therefore weaken) the bone, resulting in further joint weakness.

Colchicine
Colchicine is a medication that has been used since the 1800s to treat gout. It is very effective, however it is not used as frequently as NSAIDs because it tends to cause side effects such as nauseau, vomiting and diarrhea after being taken only a short time.

Ongoing treatment

After an acute attack has settled down you and your doctor will have to decide whether to treat the underlying problem that caused the gout. People with recurrent attacks of gout, or who develop the soft tissue lumps (tophi), or who have kidney disease will usually require ongoing treatment.

Based upon tests, which will probably include a 24-hour urine sample, your doctor will determine which medication is appropriate for you. Some individuals will be overproducing uric acid, while others will be failing to eliminate enough uric acid. Different types of medications are used in each instance. Medications commonly used to treate inadequate elimination of uric acid include probenicid or sulfinpyrazone. For those who overproduce uric acid, treatment is allopurinol. Allopurinol is a long-term medication, and suddenly stopping and starting this medication can also trigger gouty attacks.

There are a number of other medications used for treatment of other conditions that alter how uric acid is excreted through the kidneys. Diuretics, which are often used to treat high blood pressure, affect amounts of urine excretion. Aspirin (ASA) can also be a problem for those with gout.

If you have ongoing problems with gout, your doctor will probably take periodic blood and urine tests to measure the levels of uric acid in your blood and kidneys in order to monitor whether treatment is effective. The goal is to lower the uric acid level to a normal range.

Diet

Elevated levels of uric acid can be from either your body producing too much uric acid or from not excreting enough uric acid through the kidneys. Overproduction of uric acid may be the result of certain beverages and food.

You should also avoid certain animal proteins, such as: seafood; liver; kidney; heart; gizzard; sweetbreads; meat extracts; and gravy

Sudden dramatic changes in diet and weight gain/loss can be associated with gout attacks.

Heat/Cold

Heat or cold application can provide temporary relief of pain. Heat helps to reduce pain and stiffness by relaxing aching muscles and increasing circulation to the area. There is some concern that heat may worsen the symptoms in an already inflamed joint. Cold helps numb the area by constricting the blood vessels and blocking nerve impulses in the joint. Applying ice or cold packs appears to decrease inflammation and therefore is the method of choice when joints are inflamed.

Exercise

There are three main types of exercises:

• Range of motion exercises reduce stiffness and help keep your joints moving. An example of a range of motion exercise for your foot is to move it, starting from your ankle, in a circle.
• Strengthening exercises maintain or increase muscle strength.
• Endurance exercises strengthen your heart, give you energy and control your weight. These exercises include walking, swimming and cycling.

Moderate stretching exercises can help keep the muscles and tendons around the affected joint more flexible and strong. Low-impact exercises like swimming, walking, water aerobics and stationary bicycling can all help you maintain strength and flexibility and increase your endurance. Always consult a doctor before beginning an exercise program.

Protect Your Joints

Protecting your joints means using them in ways that avoid excess stress. Benefits include less pain and greater ease in doing tasks. Three main techniques to protect your joints are:

Pacing, by alternating heavy or repeated tasks with easier tasks or breaks, reduces the stress on painful joints and allows weakened muscles to rest.

Positioning joints wisely helps you use them in ways that avoid extra stress. Use larger, stronger joints to carry loads. For example, use a shoulder bag instead of a hand-held one. Also, avoid keeping the same position for a long period of time.

Using helpful devices, such as canes, luggage carts, grocery carts and reaching aids, can help make daily tasks easier. Using grab bars and shower seats in the bathroom can help you to conserve energy and avoid falls.

Relaxation

Developing good relaxation and coping skills can give you a greater feeling of control over your arthritis and a more positive outlook.

The Cochrane Musculoskeletal Review Group (CMSG) is a specialized group of researchers and consumer representatives that belong to the Cochrane Collaboration, an international not-for-profit organization that encourages informed decisions about health care by preparing, maintaining and promoting reviews of the effects of various health care treatments.

CMSG members review the best available literature to determine the best evidence to support specific arthritis treatments. They explore the evidence for and against the effectiveness and appropriateness of treatments (medications, surgery, education, etc) in specific circumstances. The results are medical reviews that are then included in The Cochrane Library and made available to health professionals around the world.

For members of the public who also want to be informed about the evidence concerning health care practices and decisions in their lives, the Cochrane Musculosketal Review Group have summarized their reviews into consumer fact sheets. For the Cochrane consumer reviews related to gout, visit www.arthritis.ca/cochrane.

Medications have made the management of gout very effective. Those people who have occasional attacks can usually manage them well with treatment, which includes making changes to the way they live (types of foods eaten, control of weight, etc.). Those with chronic gout can control the level of uric acid through the ongoing use of medication. It is possible, that after years of treatment, the total body stores of uric acid could remain low and it may be possible to discontinue taking medication.

Along with the physical symptoms of arthritis, many people experience feelings of helplessness and depression. Learning daily living strategies to manage your arthritis gives you a greater feeling of control and a more positive outlook. To get the best results, people affected by arthritis need to form close ties with their doctors and therapists, and become full partners in their treatment. From our perspective, it's all part of 'living well with arthritis.' There are several resources you can use in finding out how best to manage your own arthritis. Here are a few:

• The Arthritis Self-Management Program (ASMP) is a unique self-help program offered by The Arthritis Society to help you better control and manage your arthritis.
• The Open Forum within this Web site is an opportunity to discuss and share information with other visitors - people who, through their own experiences, may be able to offer some useful insights.

Of course, there are many other valuable resources for people with arthritis. If you're unclear about where to look for help, be sure to call The Arthritis Society at 1-800-321-1433.