Gout

Gout is a condition that causes pain, inflammation and swelling in one, or more, of the joints. It usually affects the big toe, but can develop in any joint in the body. Gout tends to occur in 'attacks', which usually last for a period of between 3-10 days, after which the joint should feel normal and pain-free again. However, these attacks are almost impossible to predict and, if left untreated, can cause future attacks to be more frequent and last for longer.

Gout is caused by the build up of uric acid (urate) in the blood stream. Urate is a normally harmless waste product which is produced by the body when it breaks down substances known as purines. Purines are found naturally in the body and also in some foods and certain alcohols, such as beer, stout, and port.

Gout affects approximately one in 200 adults, most commonly men between 30-60 years of age. Gout very rarely affects women because they tend to have a lower level of urate in their bloodstream. When women do develop the condition, it tends to be after the start of the menopause. In rare cases, young people and children can also be affected.

Although gout is a relatively common condition, there are a number of effective treatments and medicines which can help ease pain, reduce inflammation, and prevent future attacks.

It is difficult to predict when an attack of gout will occur. Symptoms can develop rapidly over a few hours, and will usually last for between 3-10 days. After this time, the joint will start to feel normal again, and any pain or discomfort should eventually disappear completely.

The primary symptom of gout is acute (sudden and severe) joint pain, usually in the joint of the big toe. Symptoms will often develop during the night, although they can occur at any time. Other symptoms of gout include:

• inflammation,
• red and shiny skin over the affected joint,
• peeling, itchy and flaky skin over the affected joint, and
• swelling.

The intense pain that gout causes can make walking and getting around difficult. Even the light pressure of a bed cover, or blanket, can be painful.

70% of people will experience their first gout attack in the big toe, and 90% of those with gout will experience pain in this joint at some point. However, although gout is most common in the big toe, it can affect any of your joints. It can also occur in two or more joints at the same time. Affected joints may include:

• heels,
• ankles,
• knees,
• fingers,
• wrists, and
• elbows.

The sooner symptoms are treated, the more quickly the pain will pass. You may experience symptoms every few weeks, months, or years, but it is impossible to predict when the condition will recur. 62% of people experience a repeat attack of gout within a year. However, some people will only ever experience one attack in their lifetime.

Urate

Gout is caused by a build up of uric acid (urate) in your blood. Urate is a normally harmless waste product which is formed when the body breaks down substances known as purines. Two thirds of your urate is produced by your kidneys. The other third is produced by your digestive system. Purines are found naturally in the body, but are also found in some foods and certain types of alcohol.

Urate normally dissolves in your blood, and passes through your kidneys into your urine, ready to be excreted by your body. If you produce too much urate, or excrete too little, the urate builds up and can sometimes cause small sharp crystals to form, usually in a joint, or in the surrounding tissue. It is these crystals that cause the pain, swelling and inflammation associated with gout.

Risk factors

There are some factors which can increase the level of urate in your blood, and therefore also increase your chances of developing gout. These are outlined below.

• Men - gout rarely affects women. This is because men tend to have a naturally higher concentration of urate in their bloodstream.
• High purine diet - some foods, and certain types of alcohol, are high in purines. Foods such as kidneys, liver, anchovies, herring, and products that contain yeast, can be high in purines. Beer and spirits are also high in purines. Eating lots of purine-rich food and drink can increase your level of urate significantly (see 'prevention' section).Medicines - certain types of medicine can increase your urate level. For example, chemotherapy drugs often affect urate levels.
• Obesity - if you are overweight, losing weight can significantly reduce your urate levels.

There are a number of other medical conditions which can also increase your risk of developing gout. These are detailed below.

• Psoriasis - causes skin cells to reproduce too quickly, leading to red, flaky and crusty skin.
• Hypertension - persistently high blood pressure.
• Diabetes
• Reduced kidney function - for example, after a kidney transplant, or if you have kidney failure
• Hyperlipidaemia - high fat and cholesterol levels in your blood.
• Vascular disease - when your arteries become thickened, narrowed, or blocked.

Studies have shown that gout often runs in families. 20% of people with gout have a close family member who also has the condition.

Gout tends to attack joints in the feet and hands because the temperature in these joints is usually lower than in the rest of the body. When urate is in your blood, it is carried by a substance known as plasma. Plasma is the liquid part of your blood responsible for carrying proteins and chemicals. When it is cooler, the urate in your blood separates out from the plasma, allowing it to build up and form into the urate crystals which cause the pain associated with gout.

In some cases, it is not known what triggers a gout attack. Some people with high levels of uric acid in their system never suffer from gout, and some people who are affected by gout have a normal level of uric acid.

There is no single test or examination that can confirm a diagnosis of gout. Instead your GP will look at your symptoms and medical history in order to make a diagnosis. There are lots of conditions than can cause joint pain and swelling. Gout is just one of over 200 different forms of arthritis (any condition which causes inflammation, pain and swelling in the joints). Your GP may therefore be unable to make a firm diagnosis straight away, and you may have to be referred for further tests. These will either help to confirm the diagnosis of gout, or rule out other conditions.

Serum uric acid

A serum uric acid test is normally carried out four to six weeks after an attack of gout. During the test, a sample of your blood will be taken from a vein in your arm. This will then be analysed to measure the amount of uric acid in your blood. A raised urate level is often a strong indication that you have developed gout. However, this test cannot definitively diagnose the condition. Some healthy people without gout have high urate levels in their blood. And, those who are experiencing an attack of gout may have a normal level of urate.

Synovial fluid

If there is doubt as to what is causing your joint pain, you may have a sample of synovial fluid taken from the affected joint. Synovial fluid helps keep the joint lubricated, and stops the bones and cartilage from rubbing against one another. The sample of fluid will be taken using a needle and syringe. It will then be looked at underneath a microscope. If you have gout, there will usually be crystals of uric acid present in the sample. This sort of test will also help to rule out any infection that may be causing your symptoms, such as septic arthritis (when a join becomes infected with bacteria).

X-ray

X-ray is rarely used to diagnose gout because the inflammation gout causes will not normally be detected using this method. However, an X-ray may be used to help rule out other conditions which affect the joints, such as chondrocalcinosis (build up of calcium crystals in the joints).

Follow up

Around four to six weeks after your gout attack has subsided, your GP may ask you to return for a follow up appointment. During this appointment, your GP will check your serum uric acid level to see if it has returned to a more normal level. They may also measure your blood pressure and check the status of any other conditions you may have. You will also be offered advice on lifestyle changes that will help minimise the risk of gout recurring.

Your GP can also provide you with an advance prescription of painkiller medication, so that you can deal with attacks of gout promptly, and without having to wait to visit your GP.

There are a number of treatments and medicines that can be used to treat gout. Most treatments for gout aim to reduce the symptoms of pain and swelling. During an attack of gout, it is best to try and rest the affected joint as much as possible. You should also try to keep the joint elevated. Make sure that you drink plenty of fluids, such as water, squash or juice, to ensure that you stay well hydrated. Avoid drinking any alcohol during a gout attack.

Other treatments and medicines that may be used are outlined below.

Ice

If you are suffering from an attack of gout, the pain can be intense and severe. One of the most immediate ways you can treat the pain is to apply ice to the affected joint.

You can do this by applying ice to the affected, either using a bag of frozen peas, or some ice wrapped in a towel. Apply the ice to your joint, and leave it there for approximately 20 minutes. However, do not apply ice directly to your skin and never apply ice for more than 20 minutes at a time. If you want to apply ice to your joint more than once, you need to wait until your joint has returned to a normal temperature before reapplying it.

After using ice, it is best to try and keep the joint cool. If it is your big toe which is affected, try not to wear socks. If possible, you should avoid covering up, or clothing, any other joints which may be affected. Even a duvet or bed cover can be painful when resting on a joint affected by gout so, if possible, avoid using one during a gout attack.

Medication

Your GP will ensure that any medication you are prescribed is tailored to your individual needs. In order to work out what treatment will be best for you, they will consider your age, general health and any conditions you may already have. If your symptoms of gout are mild, and you experience severe side effects of medication, you may wish to consider treating your condition without the use of prescribed medication. For some people, the downsides of medication can outweigh the benefits. However, this is something you will have to discuss carefully with your GP. You should never stop taking any prescribed medication before speaking to your GP first.

If you are taking any of the medication listed below, you should always return to your GP if your medicine has failed to ease your symptoms after three to four days. It may be that you have to be prescribed a different type of medicine in order for your gout to be treated effectively. You should also see your GP immediately if your symptoms start to worsen after taking medication.

Non-steriodal anti-inflammatory drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs (NSAIDs) aim to reduce the pain and inflammation experienced with gout. If you have been prescribed NSAIDs, then it is best to keep them to hand so that they can be used at the first sign of a gout attack. You should continue to take your NSAID throughout the duration of your attack, and for 48 hours after the attack has finished. Some of the more commonly prescribed NSAIDs include diclofenac, indometacin and naproxen

Used on a short term basis, there are usually few side effects when taking NSAIDs. However, when taken in high doses, or over a long period of time, NSAIDs can cause complications, such as digestive problems, stomach bleeding, stomach ulcers, kidney and liver damage, tinnitus (ringing in your ears) and high blood pressure.

Cox-2 selective inhibitors are a newer type of NSAID which are designed to be less harmful to the stomach. However, research has linked use of Cox-2 inhibitors to an increased risk of strokes, raised blood pressure, heart disease and heart attacks. It is therefore important to tell your GP if you have a history of high blood pressure, or high cholesterol, or if you smoke. Etoricoxib is the Cox-2 selective inhibitor normally prescribed to treat gout.

Colchicine

Colchicine works by helping to reduce the build up of urate in your bloodstream. It is usually only used when NSAIDs fail to work, or if you develop severe side effects after taking NSAIDs. Colchicine is available in tablet form and is usually taken every two to six hours. However, it is not widely used because it frequently causes nausea, vomiting, and diarrhoea.

You should not take colchicine if you have :

• bone marrow disease,
• impaired kidney function,
• impaired liver function,
• heart failure, or
• if you are pregnant or breastfeeding.

Corticosteroids

Corticosteroids are a type of steroid, and they sometimes are used in severe cases of gout. Corticosteroids are usually only prescribed when NSAIDs and colcicine do not work. In some cases, a corticosteroid can be injected directly into the affected joint. The type of corticosteroid you receive will depend on the size of your affected joint.

The relief provided by corticosteroids is often rapid, but these medicines can rarely be used on a long term basis. Long term use can often cause the following side effects:

• weight gain,
• fluid retention,
• osteoporosis (thinning of the bones),
• bruising, muscle weakness, and
• thinning of the skin.

can also make diabetes and glaucoma (an eye disease caused by blocked fluid in the eye) worse.

Allopurinol

If you experience two or more gout attacks within a year, you may be prescribed medicine to help prevent further attacks. Allopurinol is the most commonly prescribed medicine and works by lowering the amount of urate in your blood. However, it is not a pain killer and will have no effect during a gout attack.

If you are prescribed allopurinol, you will have to take it once every day. It usually has to be taken for two to three months before you will start to see any effects. Once you are prescribed allopurinol, you will usually have to take it indefinitely. However, you may only be able to stop taking the medicine if you have a normal serum uric acid level for many years, with no attacks of gout during that time.

When you first start taking allopurinol it can sometimes cause a gout attack. This is because allopurinol usually raises the level of urate before lowering it. This type of treatment is therefore prescribed one to two weeks after an attack of gout has settled down. Side effects are very rare with this medicine, even when taken for long periods of time.

Although gout attacks rarely last for long periods of time, they can cause complications. As well as affecting you physically, gout can also affect your mood, and your work and home life. The severe pain gout causes can make it difficult for you to get around, which can sometimes lead to feelings of depression or anxiety. Your GP will discuss ways of making your day-to-day life easier during a gout attack, and will help you deal with any feelings of depression that you may be experiencing.

Joint damage

If you have frequent and recurring attacks of gout, it may eventually damage your joints permanently. If you do not treat an attack of gout, future attacks will often become more frequent and prolonged, and the likelihood of causing permanent joint damage will be increased.

Tophi

Sometimes, the crystals of uric acid in your blood can build up and cause small white lumps (tophi) to form underneath your skin. These white lumps are usually harmless and painless, but they can form in awkward places, such as at the ends of your fingers. It usually takes at least 10 years after your first attack of gout for tophi to develop. They commonly develop on the fingers, forearms, ears and toes, but can occur anywhere in the body, even in the spinal canal, or the vocal cords.

In rare cases, tophi can become inflamed, which can sometimes cause damage to the surrounding bone and tissue. If your tophi are large, or painful, you may have difficulty performing everyday tasks, such as preparing food or dressing yourself. If you are experiencing problems such as these, speak to your GP who will be able to advise you about ways in which these types of activities can be made easier. Very large or painful tophi may have to be surgically removed.

Kidney stones

Occasionally, the crystals of urate can collect in your urinary tract, causing kidney stones to develop. 10-25% of people with gout experience kidney stones. Some kidney stones can interfere with the flow of urine, causing you pain when passing urine and making you feel that you need to pass urine more often. Kidney stones can also cause infection to develop in your urinary system.

Most kidney stones are small and will pass out of your system naturally within a day or two. It is important to try and drink plenty of water, as this will help flush the stones out of your system naturally. You may be prescribed medication to make your urine an alkali instead of an acid, which should help to dissolve any kidney stones that may have developed.

Diet and lifestyle

Making some simple changes to your diet and lifestyle can significantly improve your chances of preventing gout from recurring. Some of these changes are outlined below.

Food

Some foods are high in purines and avoiding them can help reduce your risk of a gout attack. It is best to eat only moderate amounts of the following foods. If possible, you may want to try cutting these foods out altogether:

• Meats - kidney, liver, veal, turkey and venison.
• Fish - anchovies, herring, mackerel, sardines, fish roes, mussels and scallops.
• Vegetables - asparagus, kidney beans, lima beans, lentils and spinach.
• Other - foods containing yeast extract.

Weight

If you are overweight, the levels of urate in your blood often rise. Losing weight will significantly reduce your urate levels. If you need to lose weight, it is important to make sure you do so as part of a balanced, calorie-controlled diet. Do not try and crash diet. High protein and low carbohydrate diets should also be avoided.

Try and get plenty of exercise. Not only will this reduce your urate levels and decrease your risk of gout, it will also leave you feeling more energised and healthy. However, if you are suffering from a gout attack, make sure you keep the joint rested and elevated. You should also avoid exercise which puts strain on the muscles or joints. Swimming is a good way of staying fit, without putting pressure on your joints, as the water supports your weight.

Water

Try to drink plenty of water. You should be drinking approximately 1.2 litres (6-8 glasses) a day, or more when you are exercising, or when it is hot. Keeping yourself well hydrated will help reduce the risk of urate crystals forming.

Alcohol

Some types of alcohol are high in purines. Beer, stout and port contain the highest levels of purines. Spirits, such as vodka and whisky, also contain purines. Studies have shown that wine (but not including fortified wine), which is lower in purines, should not contribute to an attack of gout.

If your diet contains a lot of alcohol which is high in purines, you should consider cutting back or, ideally, cutting out these drinks all together. Getting drunk or 'binge drinking' on any type of alcohol can interfere with your body's ability to deal with uric acid. Men should be drinking no more than 3-4 units a day, and women no more than 2-3 units.

Other conditions

Some other conditions, such as psoriasis, can increase your risk of developing gout. If you have a condition such as this, it is important to manage and treat the condition as fully as possible. If you are able to manage a condition, such as psoriasis, effectively, then it will help to prevent gout from recurring.