Gout

Gout is a painful and surprisingly common form of arthritis which causes swelling and inflammation in the joints. It usually develops in the joint of the big toe which is the image many people form when someone mentions gout to them. But it can develop in any joint in the body.

Gout can be a seriously debilitating disease although it can be successfully treated. There is no cure for gout but there are a range of treatments available which can ease the symptoms.

Many people assume that gout is something which affects wealthy people: in past times only rich people could afford to eat the types of foods which are known to cause gout –hence the name ‘King’s disease’.

But people from all different backgrounds and income levels develop gout so it is much more egalitarian than before.

Gout is discussed as follows in this section of the guide:

• Who is likely to develop gout?
• How does gout occur?
• Causes of gout
• Are some people more prone to gout?
• Symptoms of gout
• Diagnosis of gout
• Follow up appointment with your GP
• Treatment for gout
• Managing gout
• Are there any long term problems with gout?

Who is likely to develop gout?

One in every hundred adults develops gout and these are usually men. Women can get gout but men are three times more likely to develop this disease.

(Source: UK Gout Society)

Men between the ages of 40 to 60 develop gout. If women do develop this disease then they are usually older, around 60 to 80 years of age.

(Source: NHS Choices/Gout)

How does gout occur?

Before we look at the development of this disease, let us have a look at the role of uric acid.

Uric acid

This is a waste product which builds up in the body before being expelled from the body via the kidneys. It occurs as a by-product of the metabolism when the body breaks down food to use as energy.

We all produce uric acid. It is formed from a substance called ‘purines’ which are found in every cell in the body and certain types of foods.

Normally this acid is excreted from the kidneys and passed out of the body during urination. But if the kidneys fail to excrete this acid or too much is produced during the metabolic breakdown of food then problems occur.

Excess uric acid is transported in the bloodstream by plasma –a straw coloured component of your blood which carries proteins and other substances.

But this plasma cools down which causes the uric acid to separate from it and form into crystals. These crystals develop in the tissues around the joints which initiates a response from the immune system. This response takes the form of pain and inflammation in the joints. Some people process uric acid better than others. Their kidneys are more efficient at excreting uric acid which removes the risk of conditions such as gout.

But there are other people who are not as fortunate. They may have a family history of gout; or a blood disease in which too many blood cells produce too much uric acid which overwhelms the kidneys.

Causes of gout

The two main risk factors for gout are medical conditions such as high blood pressure or lifestyle, e.g. diet. These all increase the levels of uric acid in the blood which then leads to gout.

But there are in fact, several causes of gout which include:

• Gender
• Age
• Diet
• Lifestyle, e.g. alcohol
• Genetics
• Medication, e.g. certain types of cancer drugs
• Medical conditions, e.g. diabetes, kidney disease
• Joint injury

Gender

Usually women are more affected by arthritis than men but gout occurs in three times as many men than women. Plus it usually affects men aged between 30 and 60.

The one exception to this is women who have gone through the menopause. But statistically, they are less likely to develop gout than men.

Age

This type of arthritis affects older people. It usually occurs in people aged 30 and above which may be due to certain medical conditions such as high blood pressure which develop around middle age.

Diet

A diet high in substances called ‘purines’ is a known risk factor for gout. Foods which contain purines include seafood, red meat, pork, bacon, lamb and offal.

Lifestyle

There are a few lifestyle factors which contribute to gout. For example, alcohol tends to raise uric acid levels in the blood whilst reducing the amount excreted in the urine.

Excess alcohol intake increases this risk and the likelihood of developing gout.

Being overweight or obese is also a trigger for gout. This excess weight puts a strain on the kidneys and raises levels of uric acid - both of which are known causes of gout.

Genetics

Family history plays a part. If a close member of your family has gout then there is a strong chance you will do the same. There is evidence to show that gout runs in families.

Medication

Certain types of medication increase uric acid levels and the risk of getting gout. These include cancer drugs such as those used in chemotherapy (e.g. cyclosporine), niacin (used to lower cholesterol) and low dosage aspirin.

Diuretics are another cause. These are more commonly known as ‘water tablets’as they increase the frequency of urination and used to treat water retention. But they can also increase the amount of uric acid absorbed by the body which then leads to gout.

Medical conditions

There are conditions such as high blood pressure, diabetes, psoriasis, vascular disease and kidney failure which increase the risk of gout.

These diseases force the body to produce too much uric acid although the exact reasons are often unknown. However, we can assume that if someone has failing kidneys or has undergone a transplant then their kidneys will be less efficient at removing uric acid from the body.

This means that they are more likely to develop gout and any other similar disease.

Joint injury

If you injure a joint or joints as a result of an accident then this can predispose you to arthritis. There are joint injury cases which have resulted in osteoarthritis or another type of arthritis due to the damage incurred.

But even a mild injury can trigger an episode of gout.

Are there any other risk factors for gout?

Surgery is another possible cause. People who have undergone surgery will have stopping their fluid intake prior to their operation. But this alters the delicate balance of fluids in the body which can increase uric acid levels and gout.

If there is a clearly defined cause of your gout then this is classed as ‘secondary gout’. But gout develops for a variety of reasons.

Are some people more prone to gout?

There are people who for whatever reason are more prone to gout. Conversely, there are others who have high levels of uric acid in their blood but never develop gout.

The reasons for this are still uncertain.

But if you are prone to gout then take extra care not to trigger an attack. An injury or illness; surgery or a dental extraction; exhaustion; an excessive consumption of food or alcohol or dehydration will set off an episode of gout.

Symptoms of gout

Characteristic symptoms of gout include:

• Mild temperature
• Acute pain in a joint
• Pain and inflammation (swelling) in a joint
• Skin becomes red and shiny around a joint
• Small white pimples (‘tophi’) develop under your skin

Gout starts with the formation of crystals in the joints. As these develop they cause an inflammation and pain in the affected joint. The skin around the joint becomes flaky/peeling and itchy.

The affected area looks similar to boil with red, itchy/flaking skin and is tender to the touch. White pimples or ‘tophi’ form under the skin, for example the ears and/or the fingers.

Pain is a distinct sign of this arthritis. This and other symptoms usually develop in the joint of the big toe although they can appear in any joint. You will find that the pressure of the bedclothes on your big toe is painful. Even the weight of a duvet can hurt.

Most people develop gout in their big toe. But it is possible to develop gout in two or more joints at the same time.

These symptoms develop over a few hours and last for up to 10-14 days before disappearing. This is usually the case with untreated gout but it eases much quicker with treatment.

It is possible to suffer just the one attack of gout during your lifetime but most people experience several.

Diagnosis of gout

Your first step is to see your GP. He or she will examine your affected joint (or joints) before asking you about the symptoms and your medical history.

There are numerous conditions which cause pain and inflammation in the joints so your GP will use a combination of techniques to reach a diagnosis.

These will include a range of tests.

These tests include:

• Blood test
• Examination of synovial fluid
• X-rays

These are the standard range of tests used to diagnose gout and many other forms of arthritis such as rheumatoid arthritis and osteoarthritis.

The blood test is performed to check the levels of uric acid in your blood. A high level of uric acid is an indicator of but not a confirmation of diagnosis. Other tests will be needed.

The examination of synovial fluid refers to the liquid which surrounds the joint. This fluid acts as a lubricant for the joint and prevents any friction between the cartilage and bones.

A measure of this fluid is extracted from the affected joint via a syringe and then sent to a laboratory for analysis. If there are any crystals of uric acid in this sample then this indicates the presence of gout.

This test is also useful at detecting septic arthritis which develops when a joint becomes infected by bacteria.

X-rays are rarely used to diagnose gout but they are helpful at spotting any other conditions which affect the joints.

When the results of these tests are known your GP will use these and a checklist to confirm or reject a diagnosis of gout. This checklist contains around 8 criteria.

If you fulfil 6 of these criteria then you are said to have gout.

Follow up appointment with your GP

You will be asked to return to your GP four to six weeks following your episode of gout. You will undergo a blood test and your blood pressure will be checked.

Your GP will ask you about your lifestyle and may suggest a few beneficial changes.

Painkillers will be prescribed.

Treatment for gout

Treatment for gout involves dealing with the current symptoms and preventing another attack.

This will include elevating the affected joint, e.g. leg during an attack and applying an ice pack to the inflamed area (e.g. big toe).

Your GP will prescribe medication such as anti-inflammatory drugs. Other medications include corticosteroids or colchicines. But colchicines are less widely used due to their side effects.

There is a medication called ‘allopurinal’ which helps prevent an attack of gout. This is usually prescribed for people who have experienced two attacks of gout in a year. It stops any further attacks but is not a painkiller and so is ineffective during an attack.

There are a few lifestyle changes which will reduce the risk of an attack. These include avoiding foods high in purines, maintaining a healthy weight, taking exercise (e.g. swimming) and drinking plenty of water.

Minimise your alcohol intake as excess alcohol is one of several causes of gout.

These treatments are discussed in greater detail in our treatment for arthritis section in this guide.

Managing gout

Your GP will advise you about various ways of controlling your gout and preventing further attacks.

Vitamin C supplements are seen as a preventative measure against gout but discuss this with your GP before purchasing these supplements. These supplements are not suitable for everyone and can cause side effects in people with conditions such as diabetes.

For more information about controlling your gout and arthritis in general visit our living with arthritis section.

Are there any long term problems with gout?

Recurring attacks of gout can lead to permanent damage to your joints. This is why it is important that you seek treatment after your first attack as additional attacks tend to worsen over time.

Kidney stones can develop in a few cases although these often pass out of the body during urination.

You may be given medication which reduces the acidity of your urine and dissolves any kidney stones.

Gout can affect you on an emotional level and in severe cases, interfere with your normal daily routine. But there is help and advice out there to make your life easier. This also includes counselling which many people find helpful especially if they become depressed by this condition.