Get a Grip on Gout

Gout has been the cause of pain, suffering and chronic arthritis in human beings for thousands of years. It is described as "the disease of kings" because of its frequent occurrence among royalty since the times of Hippocrates.

Gout makes up about 5 percent of all arthritis cases. About one in every 100 people have gout, including 6 to 7 percent of older men. The condition is most common in men over 50, women after menopause and people with kidney disease. Children have low levels of uric acid in their blood, and gout in children is uncommon unless there is a rare inherited genetic disorder that causes increased uric acid levels. You are more likely to get it if you are obese or have high blood pressure, diabetes, hyperlipidemia or a family history of the disease. Taking certain medications can also increase your risk of getting gout.

The picture some people have of gout and bloated kings, such as Henry VIII, famous for his broad girth as well as his many wives, has some basis in fact. Obesity is known to raise the risk of gout, particularly in men who by gender are at higher risk than women. Alcohol abuse also is another factor.

What is the cause?

Every living cell, including those in our own bodies, has DNA, which is made from a group of materials that include chemicals known as purines. Certain meats, seafood, dried peas and beans, along with alcoholic beverages, contain high levels of purines, and when our body digests purines, it converts those it doesn't use to uric acid. The kidneys usually eliminate uric acid.

If our kidneys can't keep up with the levels of uric acid in the blood either because of a kidney problem or a flood of uric acid from an increased consumption of these certain foods, the uric acid will collect in the body. Over time, the uric acid collects around joints and forms needle-shaped crystals inside the joint. The irritation by these crystals causes inflammation and pain, the hallmarks of an acute gout attack. Uric acid crystals also may clump together under the skin and form a bump called a tophus (TOE-fus). Multiple bumps are tophi (TOE-fye), and if they are in the kidney or urinary tract, they become stones.

Who is at risk?

• Family History - About 20 percent of people with gout have a family history of that condition.

• Obesity - It appears there is a clear relationship between elevated body weight and elevated uric acid levels, which lead to an increased chance of getting gout attacks if you are overweight.

• Hypertension - Doctors and scientists are unsure whether hypertension (high blood pressure) causes hyperuriciemia, but hypertension is found in 25 percent to 50 percent of patients with gout.

• Alcohol use - Alcohol consumption has been associated with gout for a long time. One study found it to be the only significant risk factor for women with gout.

• Hyperlipidemia and diabetes - These diseases are associated with an increased risk of gout.

• Diet - Eating too many foods rich in purine can cause or aggravate gout in some people.

• Lead exposure - Gout can be caused by exposure to lead in the environment.

• Renal insufficiency - The inability of kidneys to reduce waste can bring on gout.

• Taking certain medications - Diuretics and some other medicines can increase your risk for gout.

• Organ transplant - If you've had one, you're more likely to get gout.

What brings on a gout attack?

Gout attacks also can be set-off by:

• Stress

• Infection

• Joint injury

• Weight loss because of the breakdown of cells releasing purines

• Surgery also involves cell breakdown and the release of purines

• Overindulgence in alcohol or purine-rich food (e.g. asparagus, mushrooms, sardines, anchovies, gravy)

• Severe illnesses and drug treatments are probably the most significant triggers. In patients with a history of gout, approximately half will have a gout attack while hospitalized for another reason.

What are the symptoms?

Gout is often divided into four stages:

• Asymptomatic hyperuricemia. This is the period when your levels of uric acid slowly build up over a long time, an average of 30 years. The uric acid buildup doesn't always lead to gout, so this is considered the first stage of the disease. Less than 20 percent of hyperuricemic people develop the full arthritic course of the disease.

• Acute gouty arthritis. The first symptoms appear in this stage, usually in the cooler fingers and toes where the uric acid crystals first appear. You may experience brief hints of pain, petit (small) attacks, before a full blown, sudden, severe, single joint attack, usually in the big toe. This is called podagra. If more than one joint is affected, called polyarticular gout, you may have a more gradual onset of pain, low-grade fever, loss of appetite and a feeling of poor health for eight to 12 hours before severe, debilitating pain develops around the joint. Sometimes, the attack may wake you up at night or early in the morning with pain, swelling, and red, shiny and tense skin over the joint. Gradually, the pain, swelling and redness disappear between five to seven days.

• Intercritical gout. Time periods in between acute attacks of gout are labeled by this name. Complete relief usually follows your first attack from symptoms; but if left untreated, you can expect gout attacks to recur. Sixty-two percent of people will have at least one additional attack within the next year. That number will increase to 78 percent after two years and 93 percent within 10 years, with the time between each attack becoming shorter and shorter. Sometimes, the attacks are less intense, but they can last longer.

• Chronic tophaceous gout. If you have gout attacks over the long-term, say 10 to 20 years, the shorter intercritical periods blend into a chronic condition, with constant low-level pain and mild or acute inflammation of more than one joint. Also, the tophi may destroy the bone and cartilage in the areas around the joint. Joint deformities and loss of motion result. Receiving a timely diagnosis and treatment will avoid this stage of gout altogether.

How is gout diagnosed?

Although a blood test can measure the amount of uric acid in the blood, it may not reflect the long-term presence of uric acid in the tissues because the blood levels change quickly, depending on diet, alcohol, medication and physical condition. Therefore, the definite diagnosis is made when your doctor takes a sample of fluid from the affected joint and finds uric acid crystals in the sample examined under a microscope.

How is gout treated?

An effective drug for gout is colchicine, and it has been used for more than 175 years. While it's very effective, if you take it by mouth, it frequently causes nausea, vomiting and diarrhea. Colchicine can also be used intravenously in cases of severe acute gout or when someone can't take medications by mouth. Serious side effects with intravenous colchicines include bone marrow suppression, renal failure and reported fatalities.

Non-steroidal anti-inflammatory drugs (NSAIDs), such as diclofenac and naproxen, are the treatment of choice for the pain and inflammation that accompanies most acute attacks of gout. The NSAID that is most widely used to treat acute gout is indomethacin. NSAIDs also may have serious side effects. But used for the short period of time during an acute attack, they are generally well-tolerated. Aspirin and aspirin-containing products should not be used during acute attacks because aspirin can raise uric acid levels in the blood.

Corticosteroids may also be prescribed to be taken orally or injected into the affected joint. Prednisone is the most common corticosteroid that is used for gout. Improvement is usually noticed within a few hours of treatment.

A note about NSAIDs

NSAIDs (nonsteroidal anti-inflammatory drugs) are commonly taken to reduce pain and swelling, although they are not for everyone. Ibuprofen, naproxen and aspirin are all NSAIDs. Talk to your doctor about whether taking NSAIDs is safe for you, especially if you:

• Have stomach bleeding or peptic ulcers.
• Have liver or kidney disease or a bleeding disorder.
• Drink more than three alcoholic drinks each day.
• Have high blood pressure or kidney, liver or heart disease.
• Take medicine for high blood pressure, aspirin to protect your heart or any sort of blood thinning drugs.
• Do not give aspirin to anyone younger than 20. It has been linked to Reye's syndrome, a serious illness. Do not give ibuprofen or naproxen to children without first talking to your health care provider.

Always read instruction labels carefully to understand all precautions.

If you've suffered from multiple gout attacks or have developed tophi or kidney stones, you may consider therapy with medications to regulate the levels of uric acid in your blood. Drugs to help the kidneys eliminate uric acid are typified by such drugs as probenecid. The drug allopurinol blocks the production of uric acid by the body. Your doctor will be able to distinguish which, if any, of these drugs you might take. With the right treatment, your gout should be well controlled.

Related Articles What Is Arthritis? The Benefits of Exercise

External Sources The Arthritis Foundation The American College of Rheumatology National Institute of Arthritis and Musculoskeletal and Skin Diseases

This article was reviewed and updated June 2007.

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