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Gouty arthritis

Gout

Gout is one of the oldest types of arthritis that affects mankind. It has been known since before the days of Christ. Gout is also one of the commonest types of arthritis. It causes inflammation of the joint, with swelling, warmth, redness and pain.
Nowadays, due to advances in medical research, gout can be well controlled. If the correct treatment program is followed, gout becomes an easily manageable illness.

What is Gout?

Gout is a disease in which there is a build-up of uric acid in the body. A relatively small amount comes directly from the food we eat. Uric acid forms in the blood of healthy people as a breakdown product of various chemical processes. Normally, the body rids itself of any excess through the kidneys into the urine, so levels tend to be higher in people with kidney disease.

If the body cannot get rid of enough uric acid, there is a build-up of uric acid, some will be deposited in joints. This may cause acute inflammation of the affected joints (acute gouty arthritis).

The first attack of gout usually involves the big toe or “bunion” joint. The ankle, foot and knee may also be affected. It can also occur in the upper limbs, such as over the point of the elbow, occasionally in the hand and rarely in the other joints.

Attacks usually occur very quickly, often overnight, unlike most other forms of arthritis, which usually start more gradually. The affected joint rapidly becomes very painful, often to the point that even the weight of a bed sheet is unbearable. Untreated, each attack lasts approximately 1-2 weeks. After the first attack, which almost always involves only one joint, it is usually months or years before the next one occurs. But without the right management, attacks become more frequent, last longer and may involve other joints. Repeated attacks can lead to progressive joint damage, disability and crippling (chronic gout).

Attacks often occur for no obvious reason but can be triggered by:
• Drinking alcohol especially during a binge
• Over-eating especially if on a high-purine diet
• Minor injury to a joint
• Drinking insufficient fluids
• Fluid depletion due to certain drugs such as diuretics
• Attempting a “crash diet”
• Fasting, e.g. before surgery
Uric acid can also be deposited in other tissues. This usually occurs near the affected joints or around the elbow, toes, fingers and even the outer edge of the ear. These deposits look like little white pimples on the skin and are called tophi (Fig 2). Tophi usually take many years to be easily seen.

In some people, excess uric acid can be deposited in the kidney as stones, or less commonly in the bladder as gravel or multiple stones. This can cause problems with kidney functions and sometimes, severe pain.

Remember

• Acute gout is a very painful condition
• Always suspect an acute attack of gout if a joint is unduly painful after a minor injury
• Occasional aches and pains with raised uric acid is not gout
• Repeated attacks of gout will lead to joint damage and chronic arthritis

Who gets Gout?

Uric acid in the blood stream travels in the clear part of the blood – the plasma- in the form of a salt called urate. The plasma urate is measurable and normally tends to be higher in men than women.

Almost all people with gout have too much urate in their blood, a condition called hyperuricaemia. It usually occurs when (1) the kidneys cannot get rid of enough uric acid; (2) the body overproduces uric acid. These two defects are usually inherited from a parent or grandparent. Gout runs in families. The old adage that simply eating and drinking too much causes gout has been proven wrong, though it is true if you over-indulge in alcohol – especially beer and wine – or high purine content food.

Being overweight or not drinking enough fluids can also aggravate gout.

About 90% of people with gout are men. The first attack generally occurs between 40 and 50 years of age, but can occur at any age. Women with gout usually develop it after menopause.
It is not, as was once thought a disease of the wealthy, although too much alcohol and overeating are often associated with its development. Gout affects people from all walks of life.

Remember
• Gout is inherited (though by no means every member of a family gets attacked), but environmental factors can play a part
• It is due to too much uric acid in the body

How is gout diagnosed?

A sudden attack in one joint (usually the big toe) suggests a diagnosis of gout, but some other forms of arthritis can also act like gout, especially pseudogout and septic arthritis. It is important for a doctor to make an accurate diagnosis. The plasma urate can be measured by a blood test. It is usually raised during an attack but it can also be normal sometimes. On the other hand, a raised blood uric acid level can also happen in normal subjects who do not have gout; therefore a raised blood uric acid level does not necessarily indicate gout.

To confirm the diagnosis it is sometimes necessary to take fluid from the joint to see if there are gout crystals under microscopic examination. X-rays of the joint may also be done, but as they often appear normal, they may not help in the diagnosis.

How is gout treated?

a. For the acute attack
• Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to control both the pain and the swelling. They are usually taken in moderate to full doses over a short period of time and are generally efficacious within 2 days. COX II inhibitors are the newer anti-inflammatory drugs which are effective to treat an acute gouty attack. It has less adverse effects to the stomach as compared to the conventional NSAIDs.

• Colchicine has been used for more than 100 years to treat the inflammation caused by gout. Up to six tablets over a 24-hour period usually settle an attack. It is seldom used nowadays to treat acute gout as NSAIDs/COX II inhibitors are more efficacious to settle an attack. Lower doses over a longer period are sometimes prescribed as a preventive measure to reduce the frequency of gout attack when a patient is on uric acid lowering drug.

• Corticosteroids, usually injected directly into the inflamed joint, are used and can control an acute episode efficaciously.

• Each attack should be treated promptly to achieve the best results. If possible tablets should be taken at the very beginning of an attack – if attacks recur – the doctor may give you tablets to keep so you do not have to wait until he/she arrives, or the chemist opens. By following your doctor’s instructions carefully and promptly, your attack of gout can be controlled quickly and satisfactorily.

Remember
Always be on the look-out for the early signs of an attack, because the earlier you start the treatment, the better.

b. Long term
To remove contributing factors that raise uric acid level:
• Weight control. Being overweight interferes with the body’s ability to get rid of uric acid.

• Avoid excessive alcohol. More than one glass of wine or one can of beer a day can raise uric acid levels.

• Diets. Special diets used to be prescribed, but since the effective treatment has been found, most sufferers can eat or drink anything they like. However, certain foods can cause increased uric acid levels. It is sensible to avoid them or reduce the intake. These include liver, brains, kidneys, sweetbreads (pancreas), anchovies, leguminous vegetables, roe, yeast, broths, gravies and sardines. Avoid periods of sudden strict starvation because this can start an attack of gout. Increased consumption of low- fat dairy products can help to reduce uric acid levels.

Remember
• Help yourself by modifying your lifestyle to reduce uric acid
• Drink plenty of water

Uric acid lowering drugs

The drugs given to relieve an acute attack have little effect on uric acid levels in the blood. They can do little to prevent further attacks, or stop uric acid being laid down in the joints. Should your attacks become more frequent, or if blood tests show you are accumulating too much uric acid, your doctor may decide to prescribe one of the drugs that reduce the quantity of uric acid in the blood. These have to be taken everyday, whether you have an attack or not, as a preventive measure.

There are now several drugs available that will lower the uric acid level, but it must be appreciated that you may have to persist with the daily treatment for the rest of your life. Should you stop, uric acid will begin to accumulate again.

These tablets are prescribed to be taken regularly. Taken consistently over a period, the treatment ensures that you maintain a normal blood level of uric acid.

The most commonly prescribed tablet is Allopurinol. It reduces the amount of uric acid made by the body. It is well tolerated even when taken for years; the only side-effect that occurs frequently is a rash, which disappears when the tablets are stopped. Occasionally, people may be allergic and have more severe skin rashes.

Sometimes acute attacks of gout may become more common when Allopurinol is started, so it may be necessary to take Colchicine or an NSAID as well. Whichever drug proves right for you, drinking plenty of fluid will help to get rid of uric acid through the kidneys.

Remember
• Allopurinol is not a painkiller
• Allopurinol once prescribed means life-time treatment
• Do not stop or change the dose of Allopurinol yourself when you have an acute attack.

Conditions that are associated with Gout

Gout is commonly associated with high blood pressure, diabetes mellitus, coronary artery disease and high cholesterol. These conditions should be checked regularly and treated.

Gout is a treatable disease. Proper diagnosis and management, including weight and diet control, should mean gout can be totally controlled.

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