Gout is caused by too much uric acid in the bloodstream. Over time, deposits of uric acid crystals collect around bone or cartilage. The build-up of uric acid may cause no symptoms at first. If the area becomes inflamed, a gout attack occurs, with swelling, redness, and intense pain.
Acute gout attacks can be treated with over-the-counter anti-inflammatory drugs, such as ibuprofen, or more powerful prescription medicines. But after a first attack, there is about an 80% chance of another flare-up within the next two years.
Several medications are approved to lower uric acid levels and reduce the risk of flare-ups. But in patients with serious medical conditions in addition to gout, effective treatment can be difficult. Some of the most common co-existing conditions that complicate treatment are:
- High blood pressure
- Elevated cholesterol
- Kidney or liver disease
When Gout Becomes a Chronic Problem
When uric acid levels in the bloodstream remain too high, more and more crystals are deposited. Gout becomes a chronic condition, leading to painful and disfiguring damage to joints.
The course of gout varies considerably from person to person. Signs that chronic gout may be getting worse include:
- More frequent and longer-lasting flare-ups of gouty arthritis: As chronic gout gets worse, flare-ups occur more often and last longer. Over time, the inflammation causes permanent damage to bone and cartilage.
- Flare-ups in other parts of the body: In about half of all patients with gout, the first attack occurs in the joint at the base of the big toe. When chronic gout occurs, other joints may be affected, including the ankle and knee.
- Nodules forming under the skin: Uric acid crystals may begin to be deposited in soft tissue, forming nodules called tophi. Tophi commonly appear on the hands, fingers, elbows, and ears, but they can appear almost anywhere on the body. Tophi can be very disfiguring. Chronic gout is sometimes referred to as tophaceous gout, because of the presence of tophi.
- Kidney problems: Uric acid is normally eliminated by the kidneys. Kidney disease can cause uric acid build-up and gout. But excess uric acid can also damage kidneys. Kidney problems associated with chronic gout -- and signs that chronic gout is getting worse -- include gouty kidney, kidney stones, and kidney failure.
New Treatment Options
Several drugs have long been used to treat chronic gout by lowering uric acid levels in the blood, including allopurinol (Lopurin, Zyloprim) and probenecid (Benemid). It is important that these drugs be taken lifelong and that uric acid levels in the blood are maintained at a target level.
In recent years, two new drugs have been approved for chronic gouty arthritis. The first, febuxostat (Uloric), works by reducing the body's production of uric acid. The latest drug to win FDA approval, pegloticase (Krystexxa), is given intravenously. It breaks down uric acid into a substance that can be eliminated by the body. The drug is used only for very severe cases that do not improve with usual treatments.
Promising new therapies are also being tested that may offer new hope to people with chronic gouty arthritis. Several monoclonal antibodies are being tested that target steps in the production of uric acid, for example. At the same time, researchers continue to gain a better understanding of the complex biochemistry involved in the production and breakdown of uric acid in the body. Insights from basic research are likely to lead to new treatment options in the future.