GOUT

What is Gout?

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Gout is an inflammatory arthritis which is due to the accumulation of excess Uric Acid in the body.

 

In excess this chemical precipitates as crystals in the joints which triggers a very strong localised immune response. This results in affected joints becoming extremely red, swollen and exquisitely painful.

 

It can result in swelling of a whole area, such as a hand, and foot even if only 1 or 2 joints are affected.

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What are the symptoms of Gout?

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A typical episode of Gout is known as an attack, because that it exactly what it feels like! It comes on suddenly with no warning and causes an exquisite amount of pain in the affected joints.

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It is very common for Gout to affect the big toes, but it can affect any joint. It usually affects joints that are subject to weight bearing and a lot of strain.

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Gout can also affect many joints at the same time, and if Gout becomes chronic and long term, it can mimic Rheumatoid Arthritis.

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When joints are involved they are usually exquisitely painful, to the extent it even hurts having the bedsheets on them, very red, shiny and swollen. Sometimes people can feel very unwell with these episodes, with high fevers.

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Sometimes the elbow can be involved with gout with the bursa on the outside of the elbow getting very swollen and sore. This is called 'Olecranon Bursitis' (with the Olecranon being the medical term for the tip of the elbow, known colloquially as the (not so) funny bone.

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In some people with long term gout, the Uric Acid crystals can accumulate together in clumps under the skin. These become quite white and sometimes they can burst and chalky white substance can ooze out through the skin. These are known as 'TOPHI'. They are common on the  bony border of the forearm near the elbow, as well as the ear, and on fingers and toes.

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What causes Gout?

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Gout is due to excess accumulation of Uric Acid in the body. This usually happens when there is an enzyme deficiency. Uric Acid is ingested as part of the food that we eat. If we are unable to process the Uric Acid it accumulates in our body.

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Episodes of Gout occur for reason that we are not entirely clear of. People can high levels of Uric Acid but still not get Gout!!

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Obesity, chronic kidney disease and hypertension are risk factors for Gout.

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Episodes of Gout can be precipitated by things such as:

• Drinking alcohol

• Eating high protein meals 

• High fructose dietary intake can also be an issue as the metabolism of fructose actually produces Uric Acid

• Dietary indulgence

• Drugs such as diuretics, aspirin and Cyclosporin

• Trauma such as surgery

• Dehydration

• Starvation

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Who gets Gout?

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Gout affects more men than women. Women don't tend to get Gout until after the menopause. Gout does not occur in children.

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In men Gout is typically diagnosed when they are in their 30 or their 40s.

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3% of the American population have Gout. This far exceeds the prevalence of Rheumatoid Arthritis, which occurs in 1% of the population. Interestingly the rate of Gout has been increasing since the 1970s. Its also interesting to note that the number of people in the USA with Gout are estimated to range from 3million to 8 million people!

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How do we diagnose Gout?

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Gout is usually a diagnosis made clinically, with the experience of the Rheumatologist. If there are typical symptoms such as red hot shiny and exquisitely painful big toe and a blood testing showing a high level of Uric Acid the diagnosis is simple.

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However, sometimes it is not clear what is happening, particularly if the symptoms don't respond as well as expected to usual treatment. In that case, more investigations are required to rule out other causes of arthritis.

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To see if you have Gout, your Rheumatologist will order blood testings, for ESR, CRP and Uric Acid, and some other blood tests to rule out other conditions. They may also take a fluid sample of an affected joint if it is not obviously Gout. The fluid will be analysed for Uric Acid.

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How do we treat Gout?

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Treating Gout is always personalised for each person. It involves a stepwise approach:

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1. Treat the acute attack

2. Long term treatment to prevent further episodes

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Treating the acute attack:

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Treatment here depends on the nature of the attack and how severe it is. Some people respond well and quickly to anti inflammatories such as Voltaren and other people require Prednisolone to settle down an attack. This will be determined in conjunction with your Rheumatologist. Usually episodes of Gout settle down within 48 hours, but if they don't they will need supervised treatment and further investigation to understand what is going on.

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The key thing is that if you get an acute attack DO NOT stop your gout preventing drug as it will prolong the attack and bring it on again when you restart it.

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Treating Gout Long term:

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If a person has 2 episodes of Gout a year, and has high Uric Acid we recommend starting a Gout preventing agent, in addition to making appropriate dietary and lifestyle changes. Starting a Gout preventing drug is best done under supervision by your Rheumatologist as they can work with you to tailor the appropriate dose that is right for you.

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If you have Gout and are getting many episodes it is always important to address any lifestyle factors that could be contributing to Gout, and/or making it worse.

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Obesity is an important thing to address, and dietary factors are also important to address: high protein and high fructose diets contribute to the accumulation of Uric Acid in the body. Alcohol is also not healthy for Gout.

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Its also important to review your medication list to see which ones are needed and which ones could be contributing to Gout. Also do this in conjunction with your doctor.

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If you are looking to make changes to your diet it may be a good idea to get support from someone qualified to give you guidance to make sure you are still getting the appropriate nutrition in your diet. Please note here that alcohol is not a health food ;)

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What drugs do we use to treat Gout:

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Common drugs we use to treat an acute attack are anti inflammatories such as Voltaren, or Naprosyn,as well as colchicine and Prednisolone

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Drugs we use to prevent Gout are Allopurinol, Probenecid and Febuxostat.