Gout

            Gout is a common form of arthritis in which uric acid crystals become deposited within the joint, causing an inflammatory reaction.  Uric acid is a naturally occurring compound in the body that results from metabolizing food and production of body tissues.  Uric acid is secreted through the kidneys.  People who develop gout often have increased levels of circulating uric acid.  However, some people with gout have normal levels of uric acid in their blood and some people with increased uric acid levels do not develop gout.  Therefore, the relationship between circulating uric acid levels and gout is not completely clear. 

Gouty arthritis comes on quickly, is exquisitely painful, and generally occurs at the small joint at the base of the big toe.  Other joints that may be affected include the ankles, knees, wrists, and elbows.  Gout generally only affects one joint at a time.  If untreated, an attack of gouty arthritis will generally last a few hours to a few days.  Occasionally, it may last as long as a week.  After one attack, it is much more likely to experience another attack of gouty arthritis.  However, the next attack may not occur for years.  Chronic gouty arthritis may develop in a few patients in which hard deposits of uric acid crystals occur in various soft tissues in the body.   When they occur, they are most commonly found around the big toe, fingers, and tips of elbows.  However, they may occur in any body location.   

Gout affects approximately 1 million people every year in the United States alone.  Men are affected much more commonly than women.  It is rare for women to have gout until after menopause.   

How is gout diagnosed?

            Because women rarely are afflicted with gout before menopause, gout is not generally suspected in younger women.  The typical patient with gout will report sudden onset of excruciating pain at the small joint at the base of the big toe.  However, patients may report acute onset of severe pain in the ankle, knee, wrist, elbow, or other joint.  When multiple joints are involved in a symmetrical arrangement (e.g. both hands), gout is less likely.  A joint that is affected with gout will typically be red, warm to the touch, and extremely tender. 

            People who are obese, have recently gained weight, have high blood pressure, consume large amounts of alcohol, take certain medications such as thiazide diuretics, niacin, or low-dose aspirin, are dehydrated, or have a disease called hypothyroidism (low thyroid hormone) are at increased risk for developing gout and so a higher index of suspicion for diagnosing gout should be taken in people with these risk factors. 

            The gold standard diagnostic test for gout is an arthrocentesis.  In this test, a needle is inserted under sterile conditions into the affected joint and the joint fluid is aspirated.  The joint fluid is then analyzed for uric acid crystals, infection, and other possible causes of arthritis.  The uric acid crystals can be visualized with a polarizing microscope.  When seen they are diagnostic of gouty arthritis.  In addition to being diagnostic, removing the fluid can have a therapeutic effect.  If the crystals are not present, an alternative diagnosis must be sought.  Alternative diagnoses include pseudogout, psoriatic arthritis, rheumatoid arthritis, septic arthritis, as well as other potential causes.

            Laboratory blood tests may reveal an increased level of uric acid.  Radiographs (x-ray) may be obtained and may show crystal deposits and bone damage in patients with chronic gout.

How is gout treated?

            An acute attack of gouty arthritis is treated primarily by raising the affected joint, applying ice, relieving pressure from the joint, and giving oral medications.  Oral medications to treat an acute attack of gouty arthritis include non-steroidal anti‑inflammatory drugs (NSAIDs), colchicines, and prednisone.  NSAIDs such as indomethacin and naproxen are very effective first-line medications.  The most common risks include stomach problems, increased blood pressure, and kidney problems. 

            Colchicine inhibits the inflammatory response and is generally given by mouth but can also be given intravenously.  When given orally, it is given every 1-2 hours until symptoms significantly improve or the patient develops severe diarrhea.  The most common side effect of colchicines is stomach problems.

            Oral prednisone can also be given to treat an acute attack of gouty arthritis.  Side effects from a short course of prednisone include irritability, increased blood pressure, increased susceptibility to infection, puffy face, insomnia, euphoria, mood swings, personality changes, headache, and facial flushing. 

            As previously discussed, an arthrocentesis is often performed to diagnose gout.  Aspirating fluid from the joint can be therapeutic in and of itself. In addition, if the index of suspicion for an infected joint (called septic arthritis) is extremely low then cortisone can be injected after aspirating the fluid.  However, if septic arthritis cannot be ruled out by the appearance of the joint fluid and history and physical exam, then your doctor will have to wait to inject cortisone as injecting into a potentially infected joint can have a disastrous result.  Once joint fluid examination is performed and the diagnosis of gout is confirmed, an injection of cortisone can greatly reduce a painful attack of gouty arthritis.

            Once an acute attack of gout is treated, the focus should be on preventing subsequent attacks.  Probenecid and sulfinpyrazone are two medications that decrease blood uric acid levels by increasing urinary secretion of uric acid.  A potential side effect of these medications is the development of kidney stones so they should not be taken by people who have a history of kidney stones.  When taken, the patient should be advised to also drink plenty of fluids in order to facilitate the secretion of the uric acid and to prevent the uric acid from crystallizing into kidney stones. 

            Allopurinol is a medication that blocks the creation of uric acid from purine containing foods.  Patients with kidney problems may not be able to take this medication as kidney disease puts patients at increased risk for the potential side effects of developing a skin rash and/or liver damage.

            Patients undergoing an acute attack of gouty arthritis should not be given medications that are designed to decrease circulating uric acid levels.  Specifically, patients in the midst of an acute gouty arthritis attack should not be given probenecid, sulfinpyrazone, or allopurinol.  When given during an acute gouty attack, these medications tend to increase symptoms.  If you are already taking a uric acid lower medication and then you develop an acute gouty attack, you may continue to take the uric acid lowering medication at the same dose as you have been taking it. After the attack, your physician may want to change your dose.  

            Not all patients who suffer one gouty arthritic attack need to go on prolonged uric acid lowering drug therapy.  The decision to take these medications is one that should be individualized after a complete discussion is had between physician and patient weighing the potential risks and benefits of taking versus not taking the different medications.

            Other important methods for preventing gouty arthritis include losing weight if you are overweight, decreasing your amount of alcohol intake (particularly beer and wine), decreasing your intake of purine-rich foods such as organ meats (e.g. brain, liver, and kidneys), decreasing your shellfish consumption such as oysters  and muscles, and decreasing intake of sweetbread, peas, and beans.