Gout

What is gout?

Gout is a condition in which little crystals of monosodium urate, needle-shaped crystals, irritate the lining of the joint, and the body then produces a huge response against them which creates inflammation. These crystals may be present for years without the patient being aware they are there. It is an intensely painful form of arthritis and predominately affects the lower limb.

How is it diagnosed?

It is usually diagnosed on the basis of the history of the patient, a physical examination, and blood tests. The doctor would look for a high level of urate when conducting a blood test. The doctor may also look for other signs such as renal failure and kidney failure. Occasionally x-rays or ultrasound imaging scans are used. The doctor can now do special scans which allow them to see how much urate has been deposited within the joint. At the moment, this is predominately a research tool but it is likely it will come into practice for diagnosing diseases of the joints.

What are the symptoms?

It involves short-lived attacks of intense pain, affecting predominately the lower limbs and usually a single joint, such as the big toe. The affected joint becomes intensely painful, red, hot and swollen. The skin over the joint may appear shiny and might start to peel. As well as the big toe, other joints can be affected, including other areas of the feet, the ankles, knees, elbows, wrists and fingers.

Patients can find that even moving about excruciatingly painful. The pain in the joint can be so severe and involve such exquisite tenderness that patients cannot bear any light contact to the joint, including even the weight of a bedsheet or wearing clothes such as socks. An attack is usually short-lived and at its most painful 12-24 hours after it started, but can sometimes take place over the course of five to seven days, and occasionally longer.

What are the causes?

Gout is caused by either overproduction or under-excretion of urate. The patient may either produce too much urate in their blood, or they do not get rid of enough because their kidneys are not functioning properly. This leads to a rise in urate levels, and once it reaches a certain point, the urate starts to form crystals of sodium urate which mainly develop in and around joint tissues. The crystals build up in the cartilage and other joint tissues over a period of years. During this period, there will not be any noticeable signs anything is happening. Eventually, the hard, needle-shaped crystals touch the soft lining of the joint, leading to intense inflammation developing quickly.

There are a number of factors that can increase the chances of someone developing gout. A patient may inherit genes which make their kidneys less likely to effectively dispose of excessive urate in the body. If a patient has a number of relatives with gout, this increases their likelihood of developing the condition.

Another risk factor is being obese or overweight, as this can trigger the body to producing more urate than is needed. Furthermore, if a patient has certain underlying conditions, such as hyperlipidaemia (high cholesterol levels), high blood pressure, diabetes, or kidney disease, this can affect the kidney’s ability to process or dispose of urate properly.

Who gets gout?

It can be present in all ages but tends to be a condition affecting people over the age of 40. It is more common in men than women, but also with people with underlying health problems, such as diabetes, high blood pressure, kidney disease and hyperlipidaemia. People with bone marrow disorders, like leukaemia, lymphoma, and any condition associated with high cell turnovers, are also prone to developing gout.

What treatments are available?

This depends on whether the aim of treatment is to relieve acute attacks or to treat the condition in the long-term. The main two forms of medication for acute attacks of gout are anti-inflammatory drugs and colchicine.

If an acute attack does not improve through these medications, the doctor might prescribe steroid treatment, either through an intravenous injection into the joints or oral medication. Sometimes simply applying an ice pack to the affected area can reduce the pain, heat and swelling.

Then there are drugs which can lower urate levels and dispose of urate crystals in the body, which include allopurinol, febuxostat and uricosuric drugs. These are usually prescribed for people with severe cases of gout or to treat the condition early on to avoid any further consequences.

What are the benefits of treatment?

The benefits of treatment are to ease the pain and swelling and ultimately eliminate the gout entirely. The earlier the patient receives the treatment, the more effective it will be to reduce the frequency of gout attacks. Ongoing treatment to reduce urate levels will relieve the patient of further attacks of gout and avoid any long-term joint damage and other health implications associated with the condition.

Are there any side effects of the treatment?

Anti-inflammatory drugs have side effects like all drugs, but the doctor will monitor the patient closely to avoid these and may prescribe a low dosage for a short period of time. Side effects can include digestion problems, such as stomach upsets and indigestion. There is also the increased risk of heart attack, especially if the patient has any underlying health conditions, such as diabetes, high cholesterol, or high blood pressure.

Patients usually respond well to urate-lowering treatments, but they may have to stop using them if they experience side effects such as indigestion or a rash. With allopurinol, side effects can include headaches or nausea, but these can be avoided if the dose is gradually increased. Patients must also ensure they do not miss doses of the medication, as this can cause fluctuations in urate levels and trigger acute attacks.

Are there any self-help measures the patient can do in addition to receiving treatment?

A healthy lifestyle should be maintained, not just for general well-being but because it will also help ease attacks of gout. Patients should lose weight if they are obese or overweight, avoid excessive quantities of alcohol, and ensure they drink plenty of water to keep hydrated.

Diet is very important, and changes in the patient’s diet can often help with the condition. Patients should avoid foods containing high levels of purines, such as red meats, oily fish, and beer, which get broken down into urate. Research has suggested there is a significant advantage of eating lots of cherries, as they have been shown to reduce the frequency of gout.

Patients are encouraged to use an ice pack for the affected area to reduce the swelling and pain, alongside any treatment given by the doctor. They should also ensure they rest the painful joint as this can reduce the severity of the pain.

Have there been any recent research developments?

Ongoing studies have improved the understanding of the triggers of gout and the effectiveness of therapies and medications in treating the condition. A recent discovery found that lowering uric acid levels to below 300 micromoles per litre of blood can help prevent people from getting gout, or at the very least reduce the frequency and severity of attacks. Doctors are also now employing something called "treat-to-target," which is derived from the way rheumatoid arthritis is treated and involves prescribing a treatment and then using a combination of measures to monitor the patient’s progress.

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