“So Painful It Hurts If You Even Look At It!”
That’s what my patients with gout have often told me when I am about to examine them. A cloud of apprehension would envelop their face if my hand got anywhere near their swollen, painful great toe, the most common area affected by gout. Many also told me they could not even tolerate the weight of a sheet over their toe! While gout has been recognized as a medical condition for more than 4,000 years, it has become increasingly prevalent in the United States during the last two decades until now it affects 8.3 million Americans or 4% of the population.
The incidence of gout increases with age (it generally occurs after the age of 45) and men are affected more frequently than women. Some studies suggest a connection between the increasing prevalence of gout and the increase in obesity and high blood pressure. Some patients with gout have a genetic predisposition to this condition. The significant disability caused by this painful form of arthritis makes it an important health issue. Fortunately, with treatment, the symptoms of gout can be controlled and patients can lead a normal lifestyle.
What is Gout?
Gout is a type of arthritis characterized by inflammation in the joints and is caused by crystallization of uric acid within the joints. Nearly 43.3 million Americans (21% of adults) have an increased amount of uric acid in the blood, defined as a level greater than 6.7 mg/dL. When levels exceed this amount, uric acid can precipitate into tissues. Small amounts of uric acid are normal in the blood, resulting from the metabolism or breakdown of purines. Purines are a natural substance found in all of the cells of the body and provide part of the chemical structure of our genes. The uric acid produced when purines are metabolized is normally excreted by the kidneys, unless the level exceeds the kidney’s ability to keep up.
While most patients with elevated uric acid levels do not experience clinical gout, an attack can be precipitated by eating foods high in purines, certain medications, trauma and surgery. As you can see, there are a number of factors that can lead to the development of gout, including genetic factors, diet, high blood pressure, diabetes, obesity and kidney disease.
Clinical Manifestations
Gout occurs as acute intermittent attacks of joint pain, with redness, swelling and pain, often accompanied by fever and chills. Attacks of gout often occur during the night and symptoms generally reach a crescendo during the first 12 hours from the time of onset. The first attacks of gout usually affect only one joint and half of the initial episodes involve the joint of the great toe.
An attack usually lasts from 5 to 7 days and resolves spontaneously, but an attack can last up to 2 weeks. There may be a long period of time between the first attacks of gout and subsequent episodes, but eventually they can become more frequent and begin to involve more than one joint and the upper extremities. Some patients develop deposits of urate crystals in the soft tissue, known as tophi.
Diagnosis and Screening
Measuring uric acid levels as a screening mechanism is not recommended for asymptomatic individuals. Since most patients with elevated uric acid levels do not develop gout, treatment of elevated levels is not indicated in the absence of clinical manifestations. An elevated uric acid level is not diagnostic for gout and normal or low levels do not rule out gout. All of this can make the diagnosis of gout somewhat difficult.
While your health care provider can make a presumptive diagnosis based on the overall clinical picture, a definitive diagnosis requires specific identification of the urate crystals which can be aspirated from the joint or tophi with a needle. It is important to rule out an infectious cause for the inflammation, such as septic arthritis (infection within the joint requiring urgent treatment) and cellulitis (infection of the skin).
Treatment and Prevention
Non-steroidal anti-inflammatory drugs (NSAIDs) are effective in treating acute attacks of gout when used in maximum doses. They should not be used in patients with kidney disease. Corticosteroids, again in high doses, can also be effective and can be given orally, intravenously or injected directly into the affected joint. Another drug called colchicine can be effective when only one joint is involved if is used within the first 24 hours of the onset of symptoms. Beginning treatment soon after the onset of symptoms can reduce the severity of the attack.
Patients with mild hyperuricemia and symptomatic gout may be able to decrease their uric acid level by restricting dietary purines, losing weight and abstaining from alcohol. Patients who experience frequent attacks of gout and have tophi or renal stones are candidates for therapy with a uric acid lowering agent such as allopurinol. The goals of treatment are to ease the pain of acute attacks, reduce the number of attacks, prevent tophi and kidney stones and reduce the risk of long-term damage to affected joints. Your health care provider can answer any questions you might have about gout and provide you with further information about this common condition.
Dietary Guidelines
The following dietary guidelines may help lower the uric acid level and are recommended for patients with symptomatic gout and elevated uric acid levels:
High Purine Foods to Avoid:
-alcohol
-red meat
-seafood, especially shellfish
-food and drinks sweetened with high-fructose corn syrup
Low Purine Foods to Include in a Balanced Diet:
-low fat dairy products
-fresh vegetables and fruit
-nuts and grains