Watch out for gout

What you can do to keep this painful condition at bay

Knee sore with gout.

Winnipeg Health Region
Wave, January / February 2017

What is gout?

Gout is a form of inflammatory arthritis caused by a buildup of uric acid in the body. People with gout can expect to experience sharp pain in the joints, usually a toe, knee or ankle.

Although gout is easily treated, it can lead to more serious problems if left unchecked, including destructive joint disease and renal disease. 

Who does it affect?

Generally speaking, gout is most common in middle-aged men and in people older than 65, regardless of gender.

Is gout the same as pseudogout?

No. Pseudogout also causes joint pain and swelling, but is caused by a buildup of calcium pyrophosphate crystals instead of uric acid. The treatment of pseudogout is different from gout.

What is uric acid?

Uric acid is a waste product your body makes when it breaks down certain chemicals called purines. Normally, uric acid dissolves in the blood and passes through your kidneys and out of the body in your urine. High uric acid levels in the blood occasionally result from over-production of uric acid, but are typically the result of inadequate excretion of uric acid by the kidneys.

How does a buildup of uric acid cause joint pain?

If the level of uric acid builds up in the blood, it can form sharp needle-like crystals that build up under the skin and in the joints, causing pain and inflammation. These crystals can also cause kidney stones (or urinary tract stones) that lead to pain, problems with the flow of urine, and/or kidney damage.

The characteristic pain and inflammation of gout develop when white blood cells and cells in the joint linings attempt to surround and digest uric acid crystals. These cells recognize the crystals as foreign material and release chemical signals that contribute to the pain, swelling, and redness associated with an inflammatory gout “attack.”

Does everyone with high uric acid levels get gout?

No. Up to two-thirds of individuals with high uric acid levels never develop symptoms. It is unclear why some people with high blood uric acid levels develop gout while others do not.

It’s also worth noting that the uric acid levels generally have to be high for many years before you start having symptoms of gout. Uric acid levels in men start to go up after puberty. Women’s uric acid levels usually do not go up until after menopause. 

How does gout affect the body?

At first, gout usually affects one joint, frequently a big toe. Later attacks may affect other joints. The pain, redness, and swelling are usually the worst at the beginning of a gout attack. The pain and inflammation tend to reach their peak intensity within 12 to 24 hours and generally improve completely within a few days to several weeks, even if untreated. It is not clear how the body “turns off” a gout attack.

Why do some people have high uric acid levels?

The reason is not always clear. Some people have an inherited tendency to make too much uric acid. The problem can also be exacerbated by eating a lot of purine-rich beverages and foods.

Some meats and seafood are high in purine and can increase uric acid levels: purines found in plant foods, however, do not tend to increase uric acid levels. Drinking alcohol, particularly beer, increases your uric acid levels.

Certain conditions, such as dehydration, fasting, overeating, and/or lead exposure can cause excess levels of uric acid.

People who have recently had a serious illness, injury, or surgery have an increased chance of having an attack of gout.

Other factors that increase a person’s risk of developing gout include chronic medical conditions such as high blood pressure, high blood cholesterol, Type 2 diabetes, heart disease, genitourinary diseases, and/or chronic kidney disease. Some people have gouty arthritis even though they have normal blood uric acid levels.

Some “water pills” (or diuretics) can increase levels of uric acid. Other medications can also affect uric acid levels. It is important to make sure your health-care provider knows about all of the medications that you are taking, including all prescription and non-prescription medications.

What are the symptoms of gout?

In addition to causing joint soreness, often in the toe, ankle or knee, uric acid crystals can form stones, which may lead to severe abdominal, side, and/or back pain; nausea and vomiting; fever and chills; and/or blood in the urine.

People who have repeated attacks of gout or persistent high blood uric acid levels for many years can develop tophi. Tophi are lumpy deposits of uric acid crystals just under the skin. Common places for tophi to develop are in the outer edge of the ear, on or near the elbow, over the fingers and toes, and around the Achilles tendon in the ankle. Tophi are not painful and do not cause any symptoms unless they open and drain or become infected. However, tophi can develop in cartilage, bones, joints, bursae (i.e., the fluid-filled sacs that cushion/protect tissues), and/or under the skin. Depending on their location, tophi may limit the movement of joints, and may cause erosion of bones, joint damage, and joint deformities.  

How is gout diagnosed?

Gout diagnosis may be made by a history of symptoms and their sudden onset, as well as by a physical exam. Uric acid crystals found in fluid aspirated from the affected joint can confirm the diagnosis, but the absence of these crystals does not rule out gout. Blood uric acid levels can be measured to confirm high blood uric acid levels. MRI, CT, and ultrasound scans may be utilized to visualize tophi. X-rays are not useful in diagnosis of tophi, but may be used to rule out other causes of pain. A 24-hour urine specimen may be used to determine the amounts of uric acid being excreted in the urine.

How is gout treated?

Usually, if you have high uric acid levels but no symptoms, you will not need treatment. If you have a family history of gout or kidney stones, you may be treated for gout even though you do not have any symptoms.

If you have symptoms of gout, management is focused on relieving acute symptoms such as pain and inflammation, as well as preventing recurrences and complications. Treatment of gout usually involves the use of anti-inflammatory medicines, such as indomethacin, ibuprofen or naproxen, corticosteroid drugs (such as prednisone), or colchicine. (Aspirin is not usually recommended because it may keep the urine from taking the uric acid out of the body.)

If gouty arthritis becomes a frequent problem, allopurinol and probenecid may also be prescribed to prevent damaging deposits of uric acid in the joints. Deciding which medication to use is based upon several factors, including a person’s risk of bleeding; current anticoagulant medication use; kidney and liver health, and whether there is a past history of an ulcer or bleeding in the gastrointestinal system. Your primary health-care provider will check your uric acid levels regularly to make sure the prescribed medicines are working and you are taking the right medications and doses. He or she will also usually recommend that you limit your alcohol intake, avoid eating certain purine-rich foods, and treat predisposing factors (such as obesity and hypertension) to prevent problems. A low-fat, moderate protein (ideally with more vegetable proteins) diet and increased fluid intake will help promote uric acid secretion.

If you do have a gout attack, it’s important to take your daily medicines as prescribed by your primary health-care provider. People with a history of gout should keep medication on hand to treat an attack because early treatment is an important factor in determining how long it takes to decrease the pain, severity, and duration of an attack. The sooner treatment is started, the sooner the symptoms stop, which may be within 24 to 48 hours.

If gout is not treated, it could last a few days to several weeks. A second attack may occur, but usually not for six months to two years. In other cases, another attack may not occur until many years later.

How can I take care of myself and prevent gout attacks?

Future gout attacks may be prevented by taking all medicines as prescribed by your primary health-care provider and by following his or her recommended changes in your diet, lifestyle, and alcohol consumption.

Try to keep a healthy weight. If you are overweight, choose a weight loss plan that encourages slow, steady weight loss (under the guidance of your primary health-care provider). This may reduce the stress on your joints and help relieve gout symptoms. (Fasting, losing weight too quickly, and/or following a diet high in animal protein, however, can increase blood uric acid levels and the chance of a gout attack.)

Try to stay fit doing the right kinds of exercises for you, determined in consultation with your health-care provider before you start an exercise program. If you smoke, try to quit smoking and talk to your health-care provider about ways to quit. Try to get at least seven to eight hours of sleep each night. To help lessen pain, you can apply a warm washcloth or heating pad (set on the lowest setting) to the painful joint for 15 to 20 minutes three to four times a day. (Be careful not to fall asleep with a heating pad on, as it could cause a burn.)

Try to keep portions of meat and seafood reasonably small, and avoid shrimp, anchovies, sardines, and mussels. (Fish, however, is a healthy choice.) Avoid organ meats (e.g., liver, kidney, sweetbreads, etc.) because they contain high levels of purine.

Try to eat whole grains, brown rice, oats, and at least four servings of vegetables per day. Choose vegetable protein sources more often (e.g., lentils, beans, tofu, and unsalted nuts and seeds). (Although some of these vegetable protein sources contain purines, they are not linked with increases in uric acid or a higher risk of gout symptoms.)

Also try to choose low-fat milk and milk products, as they have little to no purines and may help lower uric acid levels and the risk of a gout attack. Try to limit sugar and high-sugar foods and beverages such as pop, fruit drinks, candy, and sugary desserts like pastries, doughnuts, cake, and cookies.

Stay well hydrated, but limit your alcohol intake, particularly beer, whisky, gin, vodka, and rum. Even one or two drinks of alcohol can increase your risk of a gout attack. Avoid all alcohol if you have painful gout or you are having a gout attack. Alcohol increases uric acid in your body, and can make gout medicine less effective.

Your health-care provider and a registered dietitian can help develop a plan that is right for you. Contact your health-care provider promptly if you have any new, persistent, and/or worsening symptoms.

Sarah Jayas is a registered nurse and team leader with Health Links - Info Santé, a telephone health information service with the Provincial Health Contact Centre at Misericordia Health Centre.

Wave: January / February, 2017

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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