The Facts about Gout

Gout, which accounts for approximately 5% percent of all cases of arthritis, is considered one of the most painful of the rheumatic diseases.

Gout results from deposits of needle-like crystals of uric acid in connective tissue, in the joint space between two bones, or in both. These deposits lead to inflammatory arthritis, which causes swelling, redness, heat, pain, and stiffness in the joints. Uric acid results from the breakdown of purines, which are part of all human tissue and are found in many foods.

For many people, gout initially affects the joints in the big toe. It also can affect the instep, ankles, heels, knees, wrists, fingers, and elbows.

Risk Factors
Gout is rare in children and young adults. Adult men, particularly those between the ages of 40 and 50, are more likely to develop gout than women, who rarely develop the disorder before menopause. People who have had an organ transplant are more susceptible to gout.

A number of risk factors are related to the development of high levels of uric acid, or hyperuricemia, and gout:

• Genetics may play a role in determining a person's risk, since up to 18% of people with gout have a family history of the disease.
• Gout is more common in men than in women and more common in adults than in children.
• Being overweight increases the risk of developing hyperuricemia and gout because there is more tissue available for turnover or breakdown, which leads to excess uric acid production.
• Drinking too much alcohol can lead to hyperuricemia because it interferes with the removal of uric acid from the body.
• Eating too many foods rich in purines can cause or aggravate gout in some people.
• An enzyme defect that interferes with the way the body breaks down purines causes gout in a small number of people, many of whom have a family history of gout.
• Exposure to lead in the environment can cause gout.

Some people who take certain medicines or have certain conditions are at risk for having high levels of uric acid in their body fluids. For example, the following types of medicines can lead to hyperuricemia because they reduce the body's ability to remove uric acid:

• Diuretics, which are taken to eliminate excess fluid from the body in conditions like hypertension, edema, and heart disease, and which decrease the amount of uric acid passed in the urine;
• Salicylates, or anti-inflammatory medicines made from salicylic acid, such as aspirin;
• The vitamin niacin, also called nicotinic acid;
• Cyclosporine, a medicine used to suppress the body's immune system and control the body's rejection of transplanted organs; and
• Levodopa, a medicine used to support communication along nerve pathways in the treatment of Parkinson's disease.

Signs and Symptoms
Once hyperuricemia has caused the deposit of uric acid crystals in joint spaces, an acute attack of gout occurs, with a sudden onset of intense pain and swelling in the joints, which also may be warm and very tender. "The skin over affected joints may feel warm, tight, and appear slightly reddened or purple," says David Severance, MD. "It is normal for the skin to peel as swelling decreases."

An acute attack commonly occurs at night and can be triggered by stressful events, alcohol or drugs, or the presence of another illness. Early attacks usually subside within 3 to 10 days, even without treatment, and the next attack may not occur for months or even years. Over time, however, attacks can last longer and occur more frequently.

The initial signs and symptoms of gout are:

• Hyperuricemia
• Presence of uric acid crystals in joint fluid
• More than one attack of acute arthritis
• Arthritis that develops in 1 day, producing a swollen, red, and warm joint
• Attack of arthritis in only one joint, usually the toe, ankle, or knee

Diagnosis
Gout can be difficult for doctors to diagnose because the symptoms may be vague. To confirm a diagnosis of gout, a doctor might insert a needle into an inflamed joint and draw a sample of synovial fluid, the substance that lubricates a joint, to see if it contains monosodium urate crystals.

Treatment
Gout symptoms can be controlled with treatment, says Dr. Severance. "You should get treatment to help relieve acute attacks," he recommends, "since regular treatment can help prevent future attacks."

Gout can be treated with one or a combination of therapies. The most common treatments for an acute attack of gout are high doses of nonsteroidal anti-inflammatory drugs (NSAIDs) taken orally or corticosteroids, which are taken orally or injected into the affected joint.

"During a flare-up, you may be more comfortable if you rest," Dr. Severance notes. "Complete rest and medication can help relieve the discomfort."

When NSAIDs or corticosteroids do not control symptoms, the doctor may consider using the drug colchicine, which is most effective when taken within the first 12 hours of an acute attack.

Prevention
People with gout can reduce their chances of future acute attacks by avoiding foods that are high in purines (such as liver, kidney and sardines) and drinking plenty of fluids, especially water, to help remove uric acid from the body.

It also helps to exercise regularly and maintain a healthy body weight. Lose weight if you are overweight, but do not go on diets designed for quick or extreme loss of weight because they increase uric acid levels in the blood.

Dr. Severance says people with gout should try to avoid injury to joints like sprains and strains, since They can bring on gout pain." He also recommends using "either warm or cold compresses (a washcloth soaked with either warm or cool water) on painful joints - whichever gives you the most relief."

for more information on this topic, see the HealthLink article Arthritis and Other Rheumatic Diseases.

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.