Arthritis and Gout

Gout is a form of arthritis -- an inflammation of the joints -- that causes sudden, severe attacks of pain, tenderness, redness, warmth, and swelling in some joints. It usually affects one joint at a time, although it can be in several joints at once.

The large toe is most often affected, but gout can also affect other joints in the leg -- such as the knee, ankle, and foot -- and less often, the hand, wrist, fingers, and elbow. The spine is almost never affected.

What Are the Symptoms of Gout?

The symptoms of gout include:

  • Sudden, intense joint pain, which often can wake a person from sleep
  • Swollen joint that is warm to touch
  • Red or purple skin around the joint

If someone has gout on and off for years, eventually uric acid crystals may accumulate in the body to form gritty nodules called "tophi." These nodules can appear as lumps under the skin near joints such as the elbows and fingers, at the rim of the ears, or in the kidneys.

Uric acid comes from purines, which are the natural breakdown products of the genetic material in cells, RNA (ribonucleic acid) and DNA (deoxyribonucleic acid). Some foods contain large amounts of purines, especially red meats and organ meats (such as liver and kidneys), as well as some shellfish, anchovies, and alcohol. Purines are broken down to uric acid in the body.

Uric acid at normal levels is dissolved in the blood and is processed through the kidneys, leaving the body through the urine as waste. However, if uric acid levels are too high to be processed, the acid may form into crystals, which act like ground glass in the joint, causing significant pain and joint destruction as well as possible kidney damage.

The amount of uric acid in your blood can change depending on what you eat and drink, how hydrated or dehydrated you are, your overall health, how much alcohol you drink, and the medicines you are taking. It can change in response to a sudden illness.

What Causes Gout?

Gout results from abnormal deposits of uric acid crystals in the joint cartilage. The crystals are later released into the joint fluid.

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Gout was once incorrectly thought to be a disease of only the rich and famous, caused by consuming too much rich food and fine wine. Although diet and excessive drinking contribute to gout, they are not the main cause of the condition. We now know that heredity plays a role in the development of gout, and it's often associated with other medical problems like high blood pressure.

Not everyone with high levels of uric acid will develop gout. The kidneys' ability to rid the body of uric acid is partly determined by heredity. And just because someone in the family suffers from gout does not mean everyone in that family will have the disease. This risk varies from person to person.

How Frequent Are Gout Attacks?

Gout attacks can recur from time to time in the same joint. The initial attack may last several days to two weeks unless treated.

Over time, gout attacks may occur more often, involve more joints, have more severe symptoms and last longer. Repeated attacks can damage the joint.

Some people will have only a single attack. However, most people who have one gout attack will have at least a second attack, although it may not occur for several years after the initial onset. Others may have attacks every few weeks.

Who Is Affected By Gout?

Gout affects more than two million Americans -- most commonly men between ages 40 and 50, people who are overweight, people who frequently drink alcohol, and people who use diuretics ("water pills") to lower blood pressure or treat heart failure.

When gout affects women, it usually is after menopause, especially in women who are taking certain medications. Less often, younger people may be affected by gout if they have been taking certain medications for long periods of time, frequently drink alcoholic beverages or have certain genetic disorders.

In addition to diuretics, there are some medications that reduce the body's ability to flush out uric acid, thus increasing the risk for developing gout. These medicines include:

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How Is Gout Diagnosed?

Gout cannot be diagnosed simply from a blood test, because many people have elevated blood uric acid levels but do not have gout. However, if a person has elevated uric acid levels but no other signs of infection, gout is typically diagnosed.

Another means of diagnosing gout is to remove fluid from the inflamed joint through a needle, called arthrocentesis. Extracting the fluid not only aids in diagnosing the condition, but it may also reduce pressure within the joint, thereby reducing pain.

If crystals are not found in the fluid, the diagnosis of gout cannot be made with certainty. Occasionally, crystals may not be seen the first time, but may be seen if additional fluid is removed during a subsequent attack.

Since gout can cause chronic joint pain and involve other joints, it is extremely important that an accurate diagnosis be made so your doctor can prescribe the appropriate treatment.

How Is Gout Treated?

There is no cure for gout, but it can be treated and controlled. Symptoms often are relieved within 24 hours after treatment has begun.

The type of treatment prescribed will depend on several factors, including the person's age, type of medications he or she is taking, overall health, medical history, and severity of gout attacks. Gout attacks are mainly treated with anti-inflammatory drugs. These include:

  • NSAIDs (nonsteroidal anti-inflammatory drugs), such as ibuprofen or naproxen, are generally prescribed to treat sudden and severe gout attacks. They usually reduce inflammation and pain within hours.
  • Corticosteroids (also called steroids), may be prescribed for people who cannot take NSAIDs. Steroids also work by decreasing inflammation. Steroids can be injected into the affected joint or given as pills.
  • Colchicine is often used to treat gout and usually begins working within a few hours of taking it. This drug is used less often due to concerns about its side effects and its high cost.

Long-term treatment of gout (to prevent attacks) involves medicine that lowers uric acid levels, such as Benemid, Uloric, or Zyloprim. Low doses of colchicine are also used to prevent attacks. These drugs are recommended for people who have had multiple attacks of gout, kidney stones due to uric acid, or tophi. The goal of lowering the blood uric acid is to slowly dissolve deposits of uric acid in the joint.

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Sudden lowering of the uric acid level may cause an attack of gout. To prevent attacks in people who are taking uric acid-lowering drugs, prednisone, colchicine, or an NSAID is temporarily prescribed.

In addition, uric acid-lowering therapy (with Benemid, Uloric or Zyloprim) is not started during a gout attack, since sudden lowering of the uric acid can cause a new attack or prolong an existing one.

The drug Krystexxa (pegloticase) has been approved for adults with long-standing chronic gout who do not improve with or cannot tolerate other treatments. Krystexxa does have some side effects. A quarter of the patients who participated in the clinical trials experienced a severe allergic reaction. The FDA recommends that health care providers provide patients a corticosteroid and an antihistamine to reduce the risk of an allergic reaction.

What Are the Side Effects of Gout Drugs?

Upset stomach, indigestion, and headaches are the most common side effects of anti-inflammatory NSAIDs. Taking these drugs with food can help reduce stomach upset. NSAIDs also can cause vomiting, constipation, ulcers, bleeding in the stomach, irritation of the liver, and kidney damage, although these side effects are less common. NSAIDs should be avoided in those with a history of bleeding stomach ulcers and weak kidneys.

Side effects of corticosteroids include weight gain, increased appetite, and mood swings. Corticosteroids can have serious side effects when taken for a long period of time. Possible serious side effects include osteoporosis (thinning of the bones), diabetes, high blood pressure, cataracts, and decreased resistance to infection.

Possible side effects from colchicine include diarrhea, nausea, and abdominal cramps. In high doses, colchicine can cause kidney failure, seizures, and failure of the bone marrow, which leads to low blood counts. High doses of colchicine should be used with caution, especially in patients with kidney or liver disease.

The most common side effects of Zyloprim or Benemid are upset stomach, diarrhea, headache or dizziness, and a skin rash. The development of a rash while taking Zyloprim should be reported to your doctor immediately; the drug will likely need to be stopped. The most commonly reported adverse events in Uloric's clinical trials include liver function abnormalities, nausea, rash, and joint pain.

Not everyone will develop side effects from gout medications. How often any side effect occurs varies from person to person. The occurrence of side effects depends on the dose, type of drug, concurrent illnesses, or other drugs the person may be taking.

Some side effects are more serious than others. Before any medication is prescribed, your doctor will discuss with you the potential benefits and risks of taking the medication.

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Should I Change My Diet to Help Gout?

Dietary changes for most people with gout do not play a major role in controlling their uric acid levels. However, limiting certain foods that cause an increased production of uric acid -- such as red meats and organ meats (for example, liver and kidneys), as well as some shellfish and anchovies -- and reducing alcohol intake is often helpful.

Also, stay very hydrated by drinking lots of water. This may help keep crystals from forming in the joint and also help flush the kidneys.

What Is the Outlook For People With Gout?

Although there is no cure for gout, it generally can be controlled with medication, diet, and hydration. Controlling gout can help prevent permanent damage to the joint and kidneys.



WebMD Medical Reference Reviewed by David Zelman, MD on September 01, 2016

Sources

SOURCES:

Arthritis Foundation.

National Institute of Arthritis and Musculoskeletal and Skin Diseases.

American College of Rheumatology.

WebMD Health News: "FDA Approves Krystexxa to Treat Gout."

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