Diagnosis Treatment And Prevention Of Gout
BARRY L. HAINER, MD ERIC MATHESON, MD and R. TRAVIS WILKES, MD, Medical University of South Carolina, Charleston, South Carolina
Am Fam Physician. 2014 Dec 15 90:831-836.
Gout is the most common inflammatory arthropathy, affecting more than 8 million Americans.1 Gout accounts for approximately 7 million ambulatory visits in the United States annually at a cost of nearly $1 billion.2 Risk factors include genetics, age, sex, and diet.2,3 These factors may contribute to a high serum uric acid level, which is currently defined as a value of at least 6.8 mg per dL .4,5
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Oral corticosteroids and nonsteroidal anti-inflammatory drugs are equally effective in the treatment of acute gout.
To prevent recurrent gout, patients should reduce their consumption of high-fructose corn syrupsweetened soft drinks, fruit juices, and fructose-rich vegetables and fruits . Reducing consumption of meat and seafood, and increasing consumption of dairy products help reduce the frequency of gouty symptoms. Consumption of low-fat or nonfat dairy products may help reduce the frequency of flares.
A = consistent, good-quality patient-oriented evidence B = inconsistent or limited-quality patient-oriented evidence C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to .
What Happens At Your Appointment
The GP may ask about your diet and if you drink alcohol.
They may refer you to see a specialist and arrange a blood test and scan. Sometimes a thin needle is used to take a sample of fluid from inside the affected joint, to test it.
The blood test will find out how much of a chemical called uric acid there is in your blood.
Having too much uric acid in your blood can lead to crystals forming around your joints, which causes pain.
What Could Be My Problem
Gout is a form of arthritis caused by a buildup of uric acid crystals in the joints. Acute gout attacks are characterized by a rapid onset of pain in the affected joint followed by warmth, swelling, reddish discoloration and marked tenderness.
The small joint at the base of the big toe is the most common site for an attack. These painful attacks usually subside in hours to days with or without medication. In rare instances, an attack can last for weeks.
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What Are Symptoms Of Gout
The large joint at the base of the big toe is the most common site for a gout attack, however, any other joint can be affected. Most commonly, other joints affected are the ankles, knees, wrists, fingers, and elbows.
Patients with gout attacks suffer a rapid onset of pain in the affected joint followed by swelling, redness, and severe tenderness. Some experience pain so intense that even the light touch of a bed sheet on the joint is excruciating. These painful attacks can last from hours to several days. In cases of chronic inflammation, the attack may last for weeks. Unfortunately, patients with gout are at risk for repeated attacks of gouty arthritis.
Who Is Affected By Gout
Gout can affect anyone. It usually occurs earlier in men than women. It generally occurs after menopause in women. Men can be three times more likely than women to get it because they have higher levels of uric acid most of their lives. Women reach these uric acid levels after menopause.
People are more likely to get gout if they have:
- Obesity, or a lot of extra weight.
You are also more likely to develop gout if you:
- Consume a diet high in animal proteins
- Consume a significant amount of alcohol
- Are on water pills .
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Arthritis In The Heel And Ankle
Several types of arthritis, including OA, RA, AS, and PsA, can affect the heels and the ankles.
Symptoms of arthritis in the heel might include:
- Stiffness upon awakening in the morning
- Recurring pain in the heel
- Swelling of the heel
- Limited movement
- Skin changes, including rashes and growths
Inflammation at the heel from RA, AS, or PsA can lead to conditions that cause heel pain. This might include Achilles tendonitis, plantar fasciitis, or retrocalcaneal bursitis, a condition in which the bursa becomes inflamed, causing pain and swelling.
The ankle is not affected by arthritis as often as other joints, but it can be a source of severe pain and instability when it is affected. Additional symptoms of ankle arthritis include swelling and stiffness of the ankle and problems with mobility. Ankle arthritis will eventually affect gaitthe way a person walks.
How Are Gout Attacks Prevented
Maintaining adequate fluid intake helps prevent acute gout attacks and decreases the risk of kidney stone formation in people with gout. Alcohol is known to have diuretic effects that can contribute to dehydration and precipitate acute gout attacks. Alcohol can also affect uric acid metabolism and cause hyperuricemia. It causes gout by slowing down the excretion of uric acid from the kidneys as well as by causing dehydration, which precipitates the crystals in the joints.
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Arthritis / Acute Gout Attack
Gout is a form of arthritis, hence it causes pain and discomfort in the joints. A typical gout attack is characterized by the sudden onset of severe pain, swelling, warmth, and redness of a joint. The clinical presentation of acute gouty arthritis is not subtle with very few mimics other than a bacterial infection.
The joint most commonly involved in gout is the first metatarsophalangeal joint , and is called podagra. Any joint may be involved in a gout attack with the most frequent sites being in the feet, ankles, knees, and elbows.
An acute gout attack will generally reach its peak 12-24 hours after onset, and then will slowly begin to resolve even without treatment. Full recovery from a gout attack takes approximately 7-14 days.
An accurate and colorful discription of a gout attack was elegantly written in 1683 by Dr. Thomas Sydenham who was himself a sufferer of gout:
The Role Of Physical Activity In Prevention Of Gout
Along with diet, physical activity can help with weight loss, and gout has been associated with being overweight.7 in patients with well-established gout, especially if X-rays have demonstrated joint damage in the foot, a low-impact exercise program is reasonable. An exercise program combined with diet in gout can reduce risk for attacks.7 If an attack seems to be coming on in the lower extremity, patients are well-advised to try to get off their feet, since impact seems to worsen gout attacks. Clues to an attack of gout coming on include local swelling, heat, redness, and tenderness in a joint, especially in the foot, ankle, or knee. Some patients have fever and chills as the first warning that an attack of gout is coming on.
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The Four Stages Of Gout
Gout is best understood by seeing it as having four phases or stages :
Stage 1: High uric acid
Elevated uric acid without gout or kidney stone, this stage has no symptoms and is generally not treated.
Stage 2: Acute flares
This stage is marked by acute gout attacks causing pain and inflammation in one or more joints.
Stage 3: Intercritical periods
These are periods of time between acute attacks, during which a person feels normal but is at risk for recurrence of acute attacks.
Stage 4: Advanced gout
This is a stage of chronic gouty arthritis, in which there are lumps of uric acid, or tophi , frequent attacks of acute gout, and often a degree of pain even between attacks .
Figure 1: Stages of Gout
Figure 2: Illustration of Toe Joint with Gouty Tophus. normal toe joint Urate crystals, shown in white, at the “bunion joint,” represent a gouty tophus.)
Figure 3: Progression of Gout
Treating Gout With Medications
Certain medications reduce the pain and inflammation of gout attacks, such as anti-inflammatory drugs , colchicine, and corticosteroids. Other medications decrease the level of uric acid in the blood and prevent the deposit of uric acid in joints , the kidneys , and in tissue , helping to prevent further attacks and complications. These drugs include allopurinol, febuxostat, lesinurad, and probenicid.
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Decreased Excretion Of Uric Acid
Two thirds of urate excretion occurs in the kidneys while the rest is excreted through the gastrointestinal tract . Reduced secretory function of the transporter ABCG2 leads to decreased excretion of uric acid through the GIT resulting in rise of serum levels of uric acid and enhanced renal excretion .
How Is Gout Treated
Gout can be effectively treated and managed with medical treatment and self-management strategies. Your health care provider may recommend a medical treatment plan to
- Manage the pain of a flare. Treatment for flares consists of nonsteroidal anti-inflammatory drugs like ibuprofen, steroids, and the anti-inflammatory drug colchicine.
- Prevent future flares. Making changes to your diet and lifestyle, such as losing weight, limiting alcohol, eating less purine-rich food , may help prevent future attacks. Changing or stopping medications associated with hyperuricemia may also help.
- Prevent tophi and kidney stones from forming as a result of chronic high levels of uric acid. Tophi are hard, uric acid deposits under the skin. For people with frequent acute flares or chronic gout, doctors may recommend preventive therapy to lower uric acid levels in the blood using drugs like allopurinol, febuxostat, and pegloticase.
In addition to medical treatment, you can manage your gout with self-management strategies. Self-management is what you do day to day to manage your condition and stay healthy, like making healthy lifestyle choices. The self-management strategies described below are proven to reduce pain and disability, so you can pursue the activities important to you.
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Warning Signs Of A Gout Flare
Gout flare-ups tend to come on suddenly.
A flare-up will usually occur in one localized areausually the big toe, but it can also affect other joints like the ankles, knees, elbows, wrists, or fingers.
Some symptoms you may experience include:
- Joint pain
- Loss of mobility
When it comes to gout prevention, get to know your familys general medical history.
Genetics plays a big role in your chances of developing gout, so its a good idea to get familiar with your family history of gout.
Other risk factors include:
- Sex: Men are three times more likely than women to develop gout.
- Age: Men over 40 and post-menopausal women are more likely to develop gout.
- Weight: People who are obese are at a greater risk of developing gout.
- Medical conditions: People with high blood pressure, diabetes, insulin resistance, or heart and kidney diseases are at a greater risk of developing gout.
- Alcohol consumption: Alcohol is dehydrating. The risk of developing gout increases as alcohol consumption goes up.
If you have a family history of gout or fall into multiple risk factor groups, discuss prevention with your doctor.
A low-purine diet is typically recommended to help keep uric acid levels in your body low.
Common Locations For Tophi
Gout results from uric acid buildup in your blood. Uric acid normally gets removed from your blood through your renal system in urine, but your diet or certain conditions can make it hard for your body to excrete uric acid. In this case, uric acid builds up around joints.
Tophi can form in any of the following body parts:
Types of tissues where uric acid most commonly builds up to form tophi include:
- tendons that connect joints to muscles
- cartilage around your joints
- synovial membranes that line your joint cartilage
- any soft tissues in your joints, such as fat or ligaments
- bursae, small sacs that create a cushion-like barrier between bones and other soft tissues
Tophi can also form in connective tissue that isnt found in a joint. Some of these locations include:
- sclerae, better known as the whites of your eyes
- renal pyramids, which are triangular-shaped parts of your kidneys made up of ducts and nephrons that help absorb nutrients before releasing waste as urine
- heart valves, such as the aorta
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The Role Of Medication In Prevention Of Gout
Table 3: Medications to pevent attacks of gout
Standard medications in preventing gout attacks
i. Colchicine : using the matches analogy discussed above1, using colchicine can be seen as dampening the uric acid matches. Colchicine does not lower the bodys store of uric acid, but it decreases the intensity of the bodys inflammatory reaction to these crystals. Recent studies have shown that at least one mechanism of colchicines action is by acting to prevent a cascade of reactions that lead to the production of interleukin 1-beta, which is an inflammatory protein , which is important in gouty inflammation.8
ii. Allopurinol: This agent is presently the most commonly used drug for the prevention of gout. Allopurinol blocks the enzyme xanthine oxidase, which blocks the breakdown of purines, thus decreasing the bodys total amount of uric acid. Allopurinol is effective in preventing gout no matter what the mechanism of the elevated uric acid was. Whether a person is making too much uric acid, or has difficulty excreting it via the kidney, allopurinols decrease in uric acid production leads to the same goal: a decreased total body uric acid.
Table 4: Reasons to use medication to lower uric acid
Lifestyle Changes Can Make Gout Attacks Less Likely
When you consider how much pain gout causes, it makes sense to try and prevent the problem flaring up. A key approach is to consume fewer foods and drinks containing high levels of purines, substances that lead to a uric acid build-up. A low-purine diet means avoiding beer, rich meats such as bacon, pork and liver, as well as many types of fish, seafood and shellfish.
The link between gout and over-indulgence is why the condition was known historically as the rich mans disease. Being a healthy weight, drinking plenty of water to flush out uric acid and exercising regularly can all help you to avoid gout attacks.
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Coping With Arthritic Feet
- Steroid medications to be injected into the affected joints
- Custom-made shoes, shoe inserts, or arch supports to support your ankles and feet
- Physical therapy that includes foot exercises and stretches
Your doctor might recommend surgery if other treatments dont work to manage foot and ankle arthritis. Surgical options might include:
- Arthrodesis: Also called fusion surgery, this involves fusing bones together with rods, pins, screws, or plates. When bones heal, the bones will stay joined.
- Joint replacement surgery: Also called arthroplasty, this surgery is used only in severe cases. The surgeon will take out damaged bones and cartilage and replace them with metal and plastic.
Home remedies you can try to help you cope with arthritic feet include:
- Creams containing capsaicin or menthol: These creams may stop the nerves from sending out pain signals.
- Hot or cold packs in the affected areas
- Gentle exercises, including yoga and tai chi
- Foot massage
Making changes to your lifestyle can also help you to feel better and keep arthritis in your feet from getting worse. Lifestyle changes might include choosing low-impact exercises like swimming rather than high-impact ones , maintaining a healthy weight to keep stress off joints, and reducing or avoiding activities that trigger symptoms in the feet and ankles.
What Procedure Is Used To Diagnose Gouty Arthritis
Gout is usually diagnosed by a doctor based on the location of the inflamed joint and a history of having similar non-traumatic attacks of pain and swelling. The most reliable test for confirming gout is an arthrocentesis. Arthrocentesis is a procedure where fluid is withdrawn from an inflamed joint with a needle and syringe, using a sterile technique and a local anesthetic such as lidocaine. The fluid is sent to a lab where it is analyzed for the presence of uric acid crystals.
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Who Should Diagnose And Treat Gout
The disease should be diagnosed and treated by a doctor or a team of doctors who specialize in care of gout patients. This is important because the signs and symptoms of gout are not specific and can look like signs and symptoms of other inflammatory diseases. Doctors who specialize in gout and other forms of arthritis are called rheumatologists. To find a provider near you, visit the database of rheumatologistsexternal icon on the American College of Rheumatology website. Once a rheumatologist has diagnosed and effectively treated your gout, a primary care provider can usually track your condition and help you manage your gout.
Now Its Your Turn To Understand How To Treat Gout In The Big Toe
Theres right now a large number of us who no more endure gout because we tackled it at its result in. Of simply tinkering with the outward symptoms Rather.
Im one of them.
Remember, I got gout for the same reasons you own it now.
An unhealthy gut microbiome intended that bacteria that should have been eliminating one third of my bodys uric acid easily wasnt.
That bacteria had diminished to the stage that my kidneys were trying to cope with the acid independently.
And they couldnt cope.
Nor can yours.
It wasnt that I was suddenly creating too much uric acid. Its that my gut seemed to be no longer in a position to help my kidneys take it off from my body.
And the transformation from gout to no gout felt like magic almost.
You can possibly imagine it yourself.. what it would be like to simply never have any gout ever again.
Take my word for it, its wonderful!
No flare-ups, no pain, no being laid-up in bed for days waiting for the pain to subside.
No thinking if some upcoming celebration shall be messed up because Im laid up in agony with another attack.
In the same way pleasing is that Ive also greatly lowered my hazards of enduring diabetes, kidney failure, cardiovascular disease and some cancers.
Shellys program lays it all out for us. No special knowledge is required. I found it easy.
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