Gout

Specialty of Rheumatology

What is it?    

Gout is a type of arthritis that appears when there is a build-up of uric acid in the blood which causes joint swelling. If urate serum levels exceeds the physiological zone of saturation (around 7.6 mg/dl), monosodium urate crystals form and are stored in the cartilage and periarticular tissues of the peripheral joints. From a clinical perspective, the continued deposit is silent and almost 10% of patients have hyperuricemia, which will more than likely lead to clinical gout. Acute gout is a very painful condition that affects just one joint. Chronic gout involves multiple attacks and quite often more than one joint is affected.   

Disease prognosis

If the disease is diagnosed at the onset of symptoms then the affected person can lead a normal life if they follow the prescribed treatment correctly. For older people affected by gout, reducing uric acid levels in the blood could help the tophi disappear and improve joint movement. Broadly speaking gout has more complications when symptoms develop before the age of 30. Metabolic syndrome and heart disease contribute to early death in people with gout. Some treatments are less effective for patients, sometimes the reason is due to lack of monitoring the treatment, low doses of medications, or alcoholism.

What are the symptoms?

Acute gout symptoms include:

  • Only some joints are affected. The joints that tend to be affected are the big toe, the knee, or the ankle. 
  • In many cases the pain come on suddenly at night. It is an intense pain and has been described as throbbing and unbearable.
  • The joint is hot and red. It tends to be quite sensitive and swollen (pain can be felt even by putting a bed sheet or cushion on it).
  • A fever may develop.
  • The attack may subside after a few days, but it can intermittently return. Additional attacks tend to last longer.
  • After the first attack, gout patients don’t normally have any symptoms. However, many people will have another attack in the following 6 to 12 months. Some patients may develop chronic gout, also known as gouty arthritis. This type of gout can cause joint damage and loss of joint movement. People with this kind of gout quite often have joint pain and other symptoms most of the time.

Tests for gout

There are several medical tests to diagnose gout, including:

  • Synovial fluid analysis
  • Uric acid in the blood
  • Joint X-ray
  • Synovial biopsy
  • Tetsing for uric acid in the urine   

A level of uric acid higher than 7ml/dl in the blood is deemed high.  However, not everyone with high levels of uric acid has gout.  

What causes it?

Gout is caused by higher than normal levels of uric acid. This happened when the body produces too much uric acid or when the body is unable to get rid of the uric acid. When there is too much uric acid in the fluid around the joints, that’s when uric acid crystals form. These cause joint swelling and pain as well as an increase in temperature in the surrounding area.  The cause of gout remains unknown. The disease is thought to be hereditary and men, postmenopausal women, and alcoholics are more susceptible to it. As a person ages, their chances of developing gout increases.

People with the following diseases have a higher chance of developing gout:

  • Diabetes
  • Kidney disease
  • Obesity
  • Sickle cell anaemia and other types of anaemia
  • Leukaemia and other blood cancers.  

Gout may also develop after taking medications that prevent the elimination of uric acid. People who take medications such as hydrochlorothiazide and other diuretics are more likely to have higher levels of uric acid in the blood.

How can it be prevented?

It is thought that gout can’t be prevented, however there are certain risk factors that can make symptoms appear. Taking medications to reduce levels of uric acid can prevent gout from progressing.

What is the treatment?  

It is recommended that the patient see a specialist and start taking the medication for gout as soon as possible to lessen symptoms if having an attack. Anti-inflammatory medications such as ibuprofen and indometacin are also recommended. If symptoms worsen, the dose should be increased.

The patient will need different types of medication if they have:

  • Several attacks the same year or high intensity attacks
  • Joint damage
  • Tophi
  • Kidney disease or kidney stones

Another effective treatment is to make diet and lifestyle changes to avoid gout attacks:

  • Reduce alcohol consumption, especially beer
  • Lose weight
  • Exercise regularly
  • Reduce consumption of red meat and sugary drinks
  • Eat healthily, for example dairy products, vegetables, nuts, pulses, fruits, and whole grains (ones with less sugar) 

Drinking coffee and taking vitamin supplements can help some people.

What specialist should I see?

The specialist who treats gout is a rheumatologist. They are often also the specialist responsible for correctly diagnosing the patient and starting them on a treatment which could reduce uric acid levels in the blood so that the urate crystals dissolve. Rheumatologists believe that gout can be cured, and to achieve this the levels of uric acid in your blood should be enough to dissolve the crystals. The symptoms should disappear and there shouldn’t be any long term damage to joints.       

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