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:
Ult And The Acr Versus Acp Guidelines Controversy
The American College of Physicians bases their clinical practice guidelines on randomized controlled trial evidence. The American College of Rheumatology uses the best available evidence to make their guidelines recommendations. This may include observational studies or expert opinion when available RCT data is absent. Recommendations are given a grade based on the level of available evidence.
At normal pH and body temperature the solubility of urate is 6.8 mg/dL : 400.). The ACP did not identify any RCTs showing improved clinical outcomes by targeting a uric acid level less than 6 mg/dL. The ACR has observational data to show that lower serum urate levels promote faster dissolution of tophi. The ACP literature review did not include studies of pegloticase showing improved outcomes within 6 months on ULT. Long term extension studies of RCTs using oral urate lowering therapies found a benefit from lowering uric acid levels, but these were also discounted . The 2012 ACR guidelines recommend a serum urate target of less than 6 mg/dL and often less than 5 mg/dL with a Grade C for expert consensus .
Dr Neogi recommends monitoring serum urate levels because blindly prescribing allopurinol makes it difficult to discern clinical failures from undertreatment or patient non-adherence. Here is the 2003 BMJ article discussing the lack of RCT evidence for the use of parachutes .
What Else Should I Ask My Healthcare Provider About Gout
Consider asking your healthcare provider:
- What is causing the gout?
- Do I have any joint damage?
- What can I do to prevent future attacks?
- Can any gout medications help me?
- How long will I need to take gout medications?
A note from Cleveland Clinic
Gout is a painful form of arthritis. Extra uric acid in your body creates sharp crystals in the joints, leading to swelling and extreme tenderness. Gout usually starts in the big toe but can affect other joints. Gout is a treatable condition, and the uric acid level can be decreased by medication and lifestyle changes. Talk to your healthcare provider about medications that can reduce uric acid levels. They can also discuss changes you can make to your diet and lifestyle to prevent and reduce gout attacks.
Last reviewed by a Cleveland Clinic medical professional on 11/15/2020.
References
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When To Start Taking Uric Acid
Despite the fact that uric acid accumulation causes Gout, now is not the time to begin taking a uric acid-lowering medication. (If youre currently on one of these drugs, such as allopurinol or febuxostat, you should keep taking it even if your gout flares.
Your Doctor might need to recommend a blood test to determine whether or not you should take a drug like Allopurinol.
What Causes Excessive Uric Acid In Thebody
I previously mentioned how much purine-rich food you should eat. Other factors, such as drinking large amounts of fruit juice or drinks containing high fructose corn syrup, might trigger it. This, coupled with a lot of alcohol, has been found to raise uric acid levels. Ive stated above that beer is high in purines, so when alcohol enters the bloodstream and is filtered by the kidneys before entering the filtrate, which is urine, alcohol and uric acid compete with one another.
The alcohol will be expelled via the kidneys and those nephrons, but the uric acid will be left behind. As a result of not being expelled properly, it builds up in the body.
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What Are Future Possible Treatments Of Gout
Fortunately, present medications are successful in the vast majority of gout patients. But some patients cannot tolerate our present arsenal of gout medications. For others, these agents are not sufficiently effective. Therefore, new treatments are continually being sought. Some of the more promising include anakinra, rilonacept, canakinumab, BCX4208 and arhalofenate.
How Can I Manage My Gout And Improve My Quality Of Life
Gout affects many aspects of daily living, including work and leisure activities. Fortunately, there are many low-cost self-management strategies that are proven to improve the quality of life of people with gout.
For gout in particular:
- Eat a healthy diet. Avoid foods that may trigger a gout flare, including foods high in purines , and limit alcohol intake .
CDCs Arthritis Program recommends five self-management strategies for managing arthritis and its symptoms. These can help with gout as well.
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Gout Flares And How To Treat Them
Gout can be treated with a variety of medicines, but the most important aim during a gout flare is pain control. Because the pain is so intense, its critical to attempt to get it under control as soon as possible, explains Dr. Saag.
The sort of medicine you take when you have a Gout flare-up is of extreme concern. My personal advise is to avoid taking aspirin when you have Gout and flare up symptoms? because even modest dosages of aspirin can raise uric acid levels in the blood.
Another drug is cyclosporine, which is an immune suppressant as well as a diuretic like loop and thiazide diuretics.
The Difference Between Acute And Chronic Gout
The first step we should take is to differentiate acute and chronic gout. They are different manifestations of the same disease. Gout is not only diagnosed after blood tests with high levels of uric acid. This is called hyperuricemia. The diagnosis of gout requires a physical and functional examination to evidence that the articulations of the patient are being affected by such levels of uric acid in the blood. Otherwise, hyperuricemia is not diagnosed as gout.
Circled in Red is a Patient with Gout caused by Excessive Allopurinol
Acute gout is characterized by severe pain located in the toes or hands, but not limited to them. The symptoms appear suddenly, sometimes in the middle of the night, and become unbearable and very severe.
The area becomes swollen, red, tender, and very warm because theres a severe inflammatory process triggered by uric acid crystals. Pain in acute gout may last for hours, days, and sometimes a whole week. But after the attack has gone, the patient does not display any symptoms.
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My Recent Gout Attack
I had a Gout attack September 05, 2021. This attack was very disabling. I was bed bound for more than 2 weeks. Majority of the days I was not able to get off the bed to even open my room door, as the pain was in both of my knees and ankles.
I must assure you that this can be a very crippling and scary moment, especially if you are living alone. It was really difficult for me to move around and do anything whatsoever. There were days when I could not even have a shower because I just could not walk.
The intensity of the pain can be unbearable at times but what can You do. The medications do not seem to help ease the pain sometimes. This is the kind of pain that I would not wish on my worst enemy.
If youve had gout before or not, youll know somethings amiss when it flares up: Its difficult to ignore the intense pain and swelling that frequently develops in a single joint .
If youve never experienced Gout and think others who have it are exaggerating, then look at this study: 37% of patients with Gout would gladly give up a winning lottery ticket if they never had to endure another gout flare.
Of course, making such a compromise isnt an option. So, what are your real-life options? The greatest thing you can do is call your doctor right away. â As soon as you feel a twinge, you should seek medical attention,â advises Joseph Huffstutter, MD, of Arthritis Associates in Hixson, Tennessee. âThe simpler it is to treat a gout attack the sooner you treat it.â
Uric Acid Levels In Males And Females
Having some uric acid in the blood is normal. However, if uric acid levels go above or below a healthy range, this can result in health problems. High uric acid levels can increase the risk of gout.
It is unusual to have low uric acid levels, but it is possible if a person passes too much uric acid out of their body as waste.
The following table gives low, normal, and high levels of uric acid in the blood. All amounts are in milligrams per deciliter .
| Uric acid level |
Some medical conditions and treatments are also associated with high uric acid levels, particularly gout, cancer treatment, and kidney disease.
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Can Gout Be Cured
Cure is a very strong word, but we can certainly treat the gout and put it in remission by giving the treatment as mentioned, Dr. Meysami says.
Whether to use the word cure may be a matter of semantics: A patients gout tendency may never go away but can be well-controlled. Treatments for gout are extremely good, and the vast majority of gout patients can expect to be cured, Dr. Fields says. Cured is in quotes since it means that gout flares can completely disappear, but the person would need to stay on their medicine.
Gout progression, though, certainly isnt inevitable, which is close to the best news any gout patient can hear.
What Are Gout Treatments And Home Remedies
When gout is mild, infrequent, and uncomplicated, it can be treated with diet and lifestyle changes. However, studies have shown that even the most rigorous diet does not lower the serum uric acid enough to control severe gout, and therefore medications are generally necessary. When attacks are frequent, uric acid kidney stones have occurred, tophi are present, or there is evidence of joint damage from gout attacks, medications are typically used to lower the uric acid blood level.
Medications for the treatment of gout generally fall into one of three categories: uric-acid-lowering medications, prophylactic medications , and rescue medications to provide immediate relief from gout pain.
Urate-lowering medications are the primary treatment for gout. These medications decrease the total amount of uric acid in the body and lower the serum uric acid level. For most patients, the goal of uric-acid-lowering medication is to achieve a serum uric acid level of less than 6 mg/dl. These medications also are effective treatments to decrease the size of tophi, with the ultimate goal of eradicating them. Uric-acid-lowering medications include allopurinol , , probenecid, and pegloticase .
Gout home remedies
Home remedies for an acute gout attack include drinking plenty of water. Over-the-counter NSAIDs , such as ibuprofen and naproxen sodium , can be used when there are no contra-indications, such as decreased kidney function or stomach ulcers.
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What To Do When You Have A Gout Flare
While an individual Gout episode is conceivable, Dr. Saag adds that ânormally once Gout occurs, youll require ongoing medication to maintain it.â If you dont take frequent uric-acid-lowering medicine or find another means to decrease youruric acid levels, cutting back on alcohol, decreasing your bodyweight, and avoiding high purine meals may help.
Youll likely have shorter intervals between Gout flare-ups over time, he says. âGout develops into chronic arthritis, which may be very disabling.â
Common Medications Priscribed By Your Doctor For Gout Flare
Alternatively, your doctor would likely prescribe a larger dose of an NSAID, such as Naproxen, or a steroid, such as prednisone. According to Dr. Saag, your doctor may inject a steroid directly into the afflicted joint or put you on an intravenous steroid if the pain is severe enough.
Another drug that is occasionally used to treat Gout flares is Colchicine. This medication isnt a typical pain reliever because it doesnt appear to help with pain caused by other disorders.
According to a Cochrane Review, around 40 out of 100 persons who used colchicine during a Gout episode assessed their pain 50% lower than those who took a placebo. However, there is a significant chance of adverse effects such as vomiting, nausea, and diarrhoea, especially when taken at high dosages.
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Take High Fiber Foods And Vitamin C
High fiber foods may help absorb uric acid from the bloodstream, making it easy for the kidneys to filter it. Fruits, vegetables, and whole grains are some of the best sources of fiber.
Vitamin C may also help with uric acid excretion. Try to consume at least 500mg of vitamin C per day, preferably from natural sources like citrus fruits, bell peppers, kale, broccoli, and guavas. Cherry juice is also a great addition to your diet. Though it is low in vitamin C, it has strong anti-inflammatory properties that may help fight uric acid symptoms.
What Is The Prognosis Of Gout
Gout is a chronic condition. Left untreated, patients may suffer from recurrent painful and disabling acute attacks of gout. Joint damage and other complications of gout may occur. However, excellent treatments for gout are available, and most patients respond very well to gout treatment with a good prognosis.
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Overproduction Of Uric Acid
Purines, which are later metabolized to uric acid, enter a common metabolic pathway by which either nucleic acid or uric acid is produced. Normal production of uric acid is considered to be 600 mg per day in men with normal renal function on a purine-free diet.4 Overproduction of uric acid may occur because of an abnormality in the enzymes that regulate purine metabolism. Two such abnormalities have been documented. An increase in the activity of phosphoribosylpyrophosphate synthetase results in increased uric acid synthesis. A deficiency of hypoxanthine-guanine phosphoribosyltransferase also increases serum uric acid levels.9
A practical approach is to obtain a 24-hour uric acid determination without dietary restriction. A patient on a regular diet who excretes more than 800 mg of uric acid per 24 hours is considered an overproducer.4
What You Can Do
If you think your condition is getting worse, talk to your doctor. They will give you medicine to keep your uric acid levels low and to try to prevent future attacks and complications.
Allopurinol treats chronic gout by lowering the uric acid produced in your body.
also lowers uric acid production but would be used with caution if you are at risk for heart or blood vessel disease.
Once you start taking these medicines, youâll need to take them for life so that your uric acid stays at the right levels.
Probenecid and lesinurad help the body get rid of more uric acid in your urine. Pegloticase and rasburicase can break down uric acid into a substance that your body can get rid of. They are only for very severe gout that doesnât get better with usual treatments.
Scientists are also testing new treatments for chronic gout. At the same time, researchers are getting a better understanding of how the body makes and breaks down uric acid. Insights from this research could lead to new treatments in the future.
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How Can Your Uric Acid Be Normal And You Still Have Gout
Gout results from urate crystals lodging in joints and surrounding tissue, but it is possible for blood tests to show normal uric acid levels even after the body forms these crystals. Confirming gout requires testing fluid from the affected joint to see if the crystals are present, notes WebMD.
Diagnosis of gout involves demonstrating uric acid is elevated in the blood. However, when the urate crystals form, that uric acid is drawn out of the bloodstream, which is why levels may test low during a gout attack, states WebMD.
Regardless of a person’s uric acid levels during a gout attack, the first task of treatment involves pain alleviation. Patients who apply ice to the painful joint and take anti-inflammatory medicines to control swelling and pain find swift relief, according to WebMD. Within a few days, the intense pain from the attack should ease. Uric acid deposits can also form in the kidneys and elsewhere in the body, and the urate crystals can cause permanent damage without treatment.
After the initial pain goes away, long-term treatment of the problems leading to gout involves reducing uric acid levels in the blood so the urate crystals dissolve. The drugs allopurinol and febuxostat reduce uric acid production in the body, explains WebMD. Also, removing such foods as game meat, organ meat, gravy and certain types of seafood from the diet lowers uric acid levels over time.