Gout

Gout is one of the most painful forms of arthritis and the most common form of inflammatory arthritis. It is associated with other metabolic problems (ie problems relating to the chemical reactions occurring in your body) and is often a warning sign to assess the healthiness of your lifestyle. It usually affects men in their 40s and attacks last from five to seven days on average before getting better. If you get immediate treatment, gout may not permanently damage your joints.

Gout develops if there is too much uric acid in your blood. Uric acid is a chemical produced by your body, but usually, it's flushed away in your urine. You may have high blood levels of uric acid because your body is making too much uric acid or because your kidneys aren't removing enough of it from your body.

If uric acid builds up in your blood, it causes sharp, needle-shaped urate crystals to form in and around your joints. This causes inflammation, pain and swelling. Crystals build up slowly but if they work loose into the space inside your joint (synovial cavity), they can trigger an acute attack of inflammation.

Treatment for gout includes:

• Diet changes
• Longer-term medication
• Pain relief for flare-ups

 If left untreated, gout can lead to joint damage and chronic arthritis.

• Asymptomatic hyperuricemia — high blood levels of uric acid without any symptoms; although treatment is not needed, urate crystals may form and slightly damage your joints, so it is recommended that you take action to reduce your uric acid levels
• Acute gout — urate crystals suddenly cause inflammation and intense pain; sudden attacks (flare-ups) take five to seven days before they get better and can be triggered by alcohol, cold weather, drugs and stressful events 
• Interval or intercritical gout — the time between flare-ups (acute gout), which can last months or years, when symptoms are reduced; urate crystals are still forming
• Chronic tophaceous gout — the most severe type of gout, which takes about 10 years to develop and usually only in people who do not get proper treatment; it can cause: 
  • Chronic arthritis
  • Permanent joint and kidney damage 
  • Tophi — large chunks of urate crystals in and around the joints, particularly in the finger joints 
• Pseudogout — a condition with similar symptoms to gout but less severe flare-ups; calcium pyrophosphate crystals form instead of urate crystals (as in gout) and the treatment is different

Most people only find out they have gout when they have their first acute attack. Gout symptoms may come on quickly, often at night, and cause extreme joint pain and inflammation — inflammation causes heat, redness, swelling and tenderness in a joint. The skin over your joint may be red and shiny or peel.

After the intense pain is over, you may experience lingering joint discomfort for a few days or weeks. Subsequent gout attacks may be longer and affect more joints. Over time, gout may reduce the range of movement of your affected joints.

Gout symptoms most often affect joints in your limbs, such as your:

• Big toe
• Elbow
• Finger
• Foot (pain)
• Knee (swollen)
• Wrist

You should see your GP if you have any of these symptoms. 

If your joint pain is getting worse or you also have no appetite, a fever or feel sick, you should see your GP urgently. These could be signs that you have a joint infection and need urgent treatment. 

Your GP will assess your symptoms and they may arrange:

• A blood test to check your uric acid levels — this is not a definitive test as you can have high uric acid levels and no gout symptoms or gout symptoms without high uric acid levels
• A dual-energy CT scan to detect urate crystals in your joints even if your joints aren’t very inflamed; this scan is not routinely performed or widely available due to its expense
• A joint fluid test, also called a synovial fluid examination — a sample of fluid from your joint is collected using a thin needle and examined under a microscope to check for urate crystals
• An ultrasound scan to detect urate crystals or tophi (large chunks of urate crystals) in your joints
• An X-ray to rule out other causes of joint inflammation

Your GP will also ask about your lifestyle, your diet and how much alcohol you drink. If they think you have gout, they may refer you to a rheumatologist (a specialist in arthritis and joints)

These factors may increase your risk of developing gout:

• Age — gout is most common in people aged 75 or over; men tend to develop it at a younger age than women, usually in their 40s whereas women tend to develop it after the menopause
• Certain medications — this includes diuretics or medication to treat high blood pressure eg ACE inhibitors
• Family history — people whose parents or grandparents have or had gout are more likely to develop it
• Gender — gout is more common in men than women; this is partly because women tend to have lower uric acid levels than men before menopause; after menopause women have higher levels of uric acid which increases their risk of gout
• Lifestyle — the following factors increase your risk:
• Being overweight or obese 
• Drinking alcohol
• Medical conditions — this includes: 
• Kidney disease — you may be less able to filter uric acid from your blood
• Metabolic conditions that affect your kidney function eg high blood pressure, high cholesterol or type 2 diabetes

If you have recently had an injury or surgery, you are also at greater risk of developing gout.

Gout is treated by managing lifestyle factors and also by treating acute and chronic gout symptoms. 

Treatments to soothe a flare-up may include:

• An ice pack to cool your joint
• Avoiding putting pressure on your affected joints
• Keeping bedclothes off your affected joints at night
• Non-steroidal anti-inflammatory drugs (NSAIDs) — this includes: 
• Colchicine — an older drug that reduces gout pain but has side effects, particularly at higher doses, including diarrhoea, nausea and vomiting
• Ibuprofen — an over-the-counter NSAID
• Diclofenac or indomethacin — prescription NSAIDs that are more powerful than ibuprofen
• Protecting and resting your joint
• Steroid tablets or injections — if you can’t tolerate NSAIDs or they are not effective, you may be given steroids 

Medications to prevent gout complications

Your doctor may recommend medications to prevent gout complications if:

• You have chronic kidney disease, kidney stones or tophi
• You have joint damage due to gout
• You have several gout attacks every year
• Your gout attacks are intensely painful

You will need to wait until your gout attack is over before starting on medications to prevent gout complications. These medications reduce your uric acid levels but can initially trigger a gout attack. This is because when uric acid levels drop due to the medication, urate crystals in your joints may dislodge, which triggers an attack. However, continuing with treatment is the most effective way to reduce future gout attacks. 

Your doctor may prescribe a low, regular dose of colchicine alongside either a medication to block uric acid production or a medication to improve uric acid removal — both of these types of medication will reduce your uric acid levels and therefore reduce your risk of a future gout attack. 

Medications that block uric acid production

• Allopurinol — side effects include a rash and low blood count
• Febuxostat — side effects include: 
• A rash
• Increased risk of heart problems that may cause a heart attack
• Nausea 
• Reduced liver function
• Xanthine oxidase inhibitors (XOIs)

Medications that improve uric acid removal

These drugs are called uricosurics and help your kidney remove uric acid from your body via your urine. Side effects include a rash, kidney stones and stomach pain. Uricosurics include: 

• Pegloticase — this is only used when other medications to reduce uric acid levels have not worked; it quickly reduces uric acid levels to lower levels than other drugs; it is given directly into a vein (intravenous) every two weeks
• Probenecid — this is taken two times a day as a tablet and is sometimes combined with febuxostat
• Lesinurad — this can only be taken with an XOI

Lifestyle changes to prevent gout coming back

Try to avoid: 

• Drinking certain beverages — this includes
• Beer — beer is more likely to cause gout than wine
• Sugary drinks
• Drinking more than 14 units of alcohol per week — if you drink up to 14 units per week, spread this out over at least three days; do not binge drink
• Eating certain foods — this includes: 
• High-purine foods eg anchovies, bacon, haddock, scallops and trout
• Full-fat dairy foods
• Meat and shellfish — these are linked to high levels of uric acid after digestion
• Offal (eg liver and kidneys)
• Sugary snacks
• Intense exercise that puts pressure on your joints
• Smoking — if you are a smoker, quitting will reduce your risk of many diseases, including gout attacks

Make sure you: 

• Consider vitamin C supplements — talk to your GP before taking any supplements
• Drink plenty of water and eat low-fat dairy products — low-fat dairy products help protect you against gout
• Exercise regularly and lose weight if you're overweight
• Have at least two alcohol-free days a week
• Have regular checks of your blood pressure, and cholesterol and triglyceride levels
• Quit smoking

Alternative medicine

The risks of alternative medicines for gout are not clear. You should speak to your GP before starting on any alternative medicines so they can assess whether the risks outweigh any potential benefits. 

Studies have been carried out into whether certain foods, including cherries, coffee and vitamin C, can reduce uric acid levels. Before changing your diet, speak to your GP or a dietitian.

• Becoming dehydrated
• Drinking too much alcohol 
• Eating a large, fatty meal
• Having a fever
• Injuring a joint
• Taking certain medications — speak to your GP if you are concerned about any medications you are taking

If you feel a gout attack coming on, get treatment immediately.

• Advanced gout — chronic gout can cause painful tophi (large chunks of urate crystals) to appear under your skin, usually on your ears, elbows and fingers 
• Kidney stones — very high uric acid levels can cause kidney stones to develop 
• Recurrent gout — most people with gout do not get frequent attacks but if this does occur, your joints can become permanently damaged

Before you see your GP, consider making a list of your symptoms, medical history, and any medications and supplements you are taking. You may also want to list any questions you want to ask, such as: 

• What could be the cause of my symptoms?
• What tests will I need? 
• What can I do to improve my symptoms? 
• Are there any medications to improve my symptoms? 
• Do I need to see a specialist?

Your GP will discuss your symptoms and medical history with you and may ask you questions, such as: 

• What are your symptoms and when did they start? 
• Do your symptoms come and go or are they constant? 
• Does anything trigger your symptoms or make them worse? 
• Do you have any other medical conditions and are you being treated for them?
• What medications and supplements are you taking? 

They may also ask you questions about your family history and lifestyle, such as:

• Do your parents, siblings or children have a history of gout? 
• Do you drink alcohol and if so, how often and how much?
• What do you normally eat? 

Depending on your symptoms, your GP may refer you to a rheumatologist. Questions to consider asking your rheumatologist include: 

• What are the side effects of the drugs prescribed for my gout? 
• When can I expect my symptoms to improve? 
• Will I need to take medication for a long time? 
• Can I drink alcohol? 
• Should I change my diet and if so, how? 
• Where can I learn more about gout? 

If you have other health conditions, you may also want to ask how you can effectively manage them together.