How Uric Acid Crystals Form
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The build-up of uric acid crystals begins with purines, a chemical compound found in many foods.
- When the body metabolizes purines, it produces a substance called uric acid.
- The uric acid enters the bloodstream.
- The kidneys filter the blood and normally filter out excess uric acid. This uric acid is then excreted via urine or stool .10
- If the kidneys cannot adequately filter out excess uric acid, or if the body produces too much uric acid, there will be too much uric acid in the bloodstream.
- Too much uric acid in the bloodstream is called hyperuricemia.
- In some people, hyperuricemia leads to the formation of uric acid crystals that collect in joint tissue, leading to painful symptoms.
An inability to adequately process and excrete uric acid accounts for an estimated 90% of gout cases.9 Other cases occur because a body produces too much uric acid.
What Is The Latest Research On Gout
Research is being done on using medications that block a chemical signal known as interleukin-1 to treat gout flares in patients who do not respond to other therapies. Anakinra and canakinumab are two medications that block interleukin-1. They are currently used for other conditions and are under investigation for use in gout flare-ups.
There is ongoing research in using a specialized CT scan known as a dual energy CT scan to diagnose gout. There is also a great deal of research investigating the various uric acid transporter genes that are responsible for uric acid metabolism.
Chronic Gout Signs And Symptoms
- Compared with the dramatic nature of acute gout pain, chronic gout pain is more of a soreness or persistent ache.
- Pain that tends to be a more continuous feeling of dull aching or soreness in the joints
- Hard white deposits or lumps under the skin, called tophi, found on the elbows, ears, or fingers.
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Intense Big Toe Pain From Gout: A Classic Symptom Of An Attack
While the big toe is the most common place for a gout attack to happen, gout can also affect surrounding joints in the foot, ankle, and knee.
People with gout typically experience flare-ups, or attacks, of symptoms followed by periods with no symptoms. The attacks typically last 3 to 10 days. Some people go months or even years without a gout attack after having one. In other people, attacks may become more frequent over time.
Gout can be difficult to diagnose. Once its diagnosed, it can be treated with medication and lifestyle changes.
How Can I Self
The methods of managing an acute attack of gout differ from the ongoing methods for managing gout. If youve been diagnosed with gout, youll benefit in the long term from making healthy changes to your lifestyle, such as:
- maintaining a healthy body weight. If you do need to lose weight, make sure your weight loss is gradual as crash diets can increase uric acid levels
- drinking alcohol in moderation and avoiding binge drinking
- drinking plenty of water, and staying hydrated
- avoiding, or eating in moderation, foods that are high in purines. Talk with a dietitian for tips and advice
- exercising regularly aim to complete at least 30 minutes of physical activity most days of the week
- working closely with your GP to prevent further attacks and actively manage your condition.
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Alternative And Complementary Therapies
Many complementary and alternative medicine approaches for managing gout focus on diet, weight loss, and exercise.
Your risk of gout goes up when your diet is high in naturally occurring compounds called purines. When purines break down in the body, they cause uric acid to form. In most cases, people who have gout will still need medication even when they follow a diet for gout. That said, tweaking your diet can be a powerful way to help manage gout and gout symptoms. Some research suggests that food changes alone can lower your uric acid levels by up to 15 percent, according to the Institute for Quality and Efficiency in Health Care.
The main principles of a gout diet are basically the same as those of any healthy diet: Reduce calorie consumption if you are overweight opt for unrefined carbohydrates like fruits, vegetables, and whole grains limit your intake of sugar, organ meats , and saturated fats.
What Is The Main Cause Of Gout
When it comes to what causes gout, higher levels of uric acid in your body may be caused due to various reasons including obesity, diet pattern, genetic reasons etc. Higher levels of uric acid are also termed as Hyperuricaemia. If you are more than the normal weight, then the fatty tissues in your body also enhance the production of uric acid in your body.
We also get lots of purines through our diet and it has been proven that around 15% of purine is sourced from our diets. Foods that are rich in purines, main gout causing chemicals include red meat, sugary beverages, asparagus, spinach, turkey, beer, herring and scallops.
Our body also produces its own uric acid and normally most of the excess ones are eliminated from our body, but in certain conditions, it is not able to eliminate the uric acid content thus increasing the levels of uric acid in the body. The reason why your body couldnt remove the uric acid may vary including obesity, being diabetic, alcoholic and consuming certain kind of diuretics.
Major factors that cause higher levels of uric acid in your blood include:
- Drinking too much alcohol
- Hypothyroidism
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How Will Gout Affect Me
Attacks can vary from person to person. Some people only have an attack every few years, while others have attacks every few months.
Without medication attacks tend to happen more often and other joints can become affected.
Having high urate levels and gout for a long time can lead to other health problems, including:
- narrowing of the arteries – which can lead to an increased risk of stroke or heart attacks or other heart problems
- osteoarthritis, which occurs when the urate crystals and hard tophi cause joint damage.
- an increased risk of developing kidney disease or worsening of the condition if you already have it
- kidney stones
- an increased risk of some cancers, especially prostate cancer
- mental health problems, including depression
- underactive thyroid
- erectile dysfunction in men.
If you take medication to lower your urate levels, and have a healthy diet and lifestyle, most of the damage and complications caused by gout can be stopped.
Treatments for gout are incredibly successful. There are two main parts to treating gout, which are:
- treating the acute attack
- treatments to prevent future attacks.
Can Gout Be Prevented
Some people with gout experience recurrent attacks, which may be prevented by using prescription medications. These medicines work by lowering uric acid levels in the blood. The most commonly used is allopurinol. This helps to lower uric acid levels by reducing the body’s production of uric acid.
You can also reduce your chance of having further attacks of gout by adopting some sensible lifestyle changes, such as:
- reducing alcohol intake avoid binge drinking, in particular
- gradually losing weight if you are overweight, while avoiding fad diets
- eating a healthy, balanced diet
- drinking plenty of water, especially when at risk of dehydration
There is no scientific evidence that particular foods cause gout, but some studies have shown that people who are prone to gout are more likely to eat foods rich in purines a substance that’s converted into uric acid within the body.
Foods with high levels of purines include:
- red meat and offal such as liver, kidneys and heart
- seafood, especially shellfish, scallops, mussels, herring, mackerel, sardines and anchovies
- foods containing yeast such as Vegemite and beer
It’s best to seek the advice of your doctor or an accredited practising dietitian before making any changes to your diet. Most people with gout find that a healthy, balanced diet along with medication is enough to reduce their uric acid levels.
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Most Common Gout Attack Sites
The most common site for a gout attack is what is known as the bunion joint on the big toe. It is typically the first joint affected by gout. As gout worsens, the ankle, mid-foot, knee, and elbow can become common sites of gout attacks. Uric acid crystals can also collect in soft tissues and form lumps called tophi, most typically on the hands, fingers, elbows, and ears.
When Is Surgery Considered For Gout
The question of surgery for gout most commonly comes up when a patient has a large clump of urate crystals , which is causing problems. This may be if the tophus is on the bottom of the foot, and the person has difficulty walking on it, or on the side of the foot making it hard to wear shoes. An especially difficult problem is when the urate crystals inside the tophus break out to the skin surface. This then can allow bacteria a point of entry, which can lead to infection, which could even track back to the bone. Whenever possible, however, we try to avoid surgery to remove tophi. The problem is that the crystals are often extensive, and track back to the bone, so there is not a good healing surface once the tophus is removed. In some rare cases, such as when a tophus is infected or when its location is causing major disability, surgical removal may be considered.
Since it is hard to heal the skin after a tophus is removed, a skin graft may be needed. For this reason, we often try hard to manage the tophus medically. If we give high doses of medication to lower the urate level, such as allopurinol, over time the tophus will gradually reabsorb. In severe cases, we may consider using the intravenous medication pegloticase , since it lowers the urate level the most dramatically, and can lead to the fastest shrinkage of the tophus.
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Myth: If You Stay Away From Liver And Alcohol You’ll Avoid Gout Attacks
Truth: Alcoholic drinks especially beer and organ meats such as liver and some fish, including anchovies and sardines, are very high in a class of natural substances known as purines. When the body breaks down purines it creates uric acid, so eating a lot of purine-rich foods does increase the risk of an attack. But while avoiding these foods may reduce attacks, it won’t halt them, says Reveille.
Gout can be life threatening if left untreated.
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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What Are The Symptoms Of Gout
The most common symptom of gout is pain in the affected joint, such as the big toe. Gout flares often start suddenly at night, and the intense pain may wake you up. In addition, your joint may feel swollen, red, warm, and stiff.
Gout flares usually occur in one joint. They can be triggered by:
- Certain foods.
- Physical trauma.
- Certain illnesses.
Flares typically get better over a week or two. In between flares, you usually dont have symptoms. Some people may have frequent flares, while others may not have another flare for years. However, over time, if left untreated, your flares may last longer and happen more often.
Some people with gout may be more likely to develop other conditions or complications, especially with the heart and kidneys.
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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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
What To Do During An Attack
You should:
- take any medication you’ve been prescribed as early as possible after you notice an attack this should start to have an effect within two or three days
- rest and raise the limb
- avoid knocking or damaging the affected joint
- keep the joint cool remove surrounding clothing and apply an ice pack, such as a bag of frozen peas wrapped in a towel
- ensure you’re well hydrated
Apply the ice pack to your joint for around 20 minutes. Don’t apply ice directly to your skin and don’t apply it for more than 20 minutes at a time because this could damage the skin.
If necessary, you can keep reapplying an ice pack to your skin during an attack, but you should wait until your skin has returned to a normal temperature first.
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To Treat An Acute Attack
To stop a gout attack, your doctor will give you medicines. These are usually pills like colchicine, NSAIDs , or a steroid medicine. Sometimes it’s treated with a steroid shot. The sooner you get started on medicines, the sooner your symptoms will start to get better.
To ease the pain during a gout attack, rest the joint that hurts. Taking ibuprofen or another anti-inflammatory medicine can also help you feel better. Using ice on the sore joint may also help.
Gout Myths And Misconceptions And The Facts
Gout was once called the disease of kings, because of its propensity to affect overweight, rich men throughout history. Famous gout sufferers have included Alexander the Great, Charlemagne, Henry VIII of England, and Benjamin Franklin.
While gout is no longer thought to be a disease of the wealthy, it is more common in men and people with weight-related health problems including high blood pressure and type 2 diabetes.
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Stage : Intercritical Gout
After a first gout flare, 75 percent of people will have a second within a year but some people can go years before another attack, says Dr. Fields. The in-between stage is where a person has already had a gout flare but is presently not having any joint pain or swelling, he says. Almost all gout patients will go through this phase, since it is the nature of gout to have flares and then quiet down for a period of time before the next flare.
Even though it may seem like nothing is happening, this is the point in which patients should begin long-term treatment. Lowering uric acid levels with medication can prevent future gout flares and long-term complications that go with them.
Joints Affected By Gout
Gout can affect any joint, but some joints are more likely to be affected than others. Joints commonly affected include the big toe, the foots instep, heel, ankle, and knee.2 Less often, gout affects the elbow, wrist, fingertips, or spine.2–7
Gout is acute, painful swelling in the joints from uric acid buildup. Common areas include the foot and big toe.
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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.
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