Gout is a type of arthritis that occurs when deposits of uric acid crystals form in a joint – usually the big toe – causing painful inflammation of the joint1. It is the most common inflammatory joint disease2,3.

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What is Gout?

Uric acid crystals are formed from uric acid – a natural byproduct that enters your bloodstream when your body breaks down food chemicals called purines4. Uric acid is usually absorbed out of your blood by your kidneys and then excreted when you urinate5. When you have a higher-than-normal concentration of uric acid in your bloodstream, this is called hyperuricaemia5. It’s not unusual and, in many cases, you would have no symptoms5.

But in some instances, as the blood becomes more saturated with uric acid, crystals begin to form around hard joint tissues, such as cartilage7. This is known as gout.

Currently there is no cure for gout. The good news, however, is that gout is one of the most treatable forms of arthritis9. This can be achieved with a combination of medical and lifestyle interventions9,10.

The Four Clinical Phases of Gout 11

Asymptomatic hyperuricemia11

Is when you have a level of serum urate in your blood that’s abnormally high without having gouty arthritis or kidney stones11. While hyperuricemia predisposes a person to gout, you should not assume that having hyperuricemia means you will definitely get gout and there’s no need to treat it if you don’t have any symptoms.

Acute gouty arthritis

An acute gout attack is when a person experiences sudden and severe pain in a joint, usually the big toe, as a result of uric acid crystal deposits in the joint4. These attacks are often called “flares” and can last for several days or even weeks9. Between flares, acute gout sufferers will have periods of no symptoms9.

Intercritical gout11

Is the asymptomatic phase of the disease that occurs between gout attacks. During this phase, your medical provider should work with you to address the causes of hyperuricemia – such as relooking medication (like diuretics) that can aggravate the condition, limiting high-purine foods and alcohol and starting a weight-loss programme if necessary.

Chronic tophaceous gout

Once you’ve had one gout attack, you’re likely to have subsequent attacks, which become more frequent over time11. Only a very small percentage of people with gout don’t have a second attack within ten years and most will have their second attack within a year11.

A tophus is a uric acid deposit that develops into a stone-like protrusion and is typically associated with gout11. That said, it rarely occurs with the first gout attack11. Tophi can occur anywhere in the body but are most often found around the joints of the hands and feet and, to a lesser extent, on the cartilage of the ear, Achilles tendon and elbow11. Tophi in the joints can damage the joints and lead to chronic secondary arthritis11. The rate of tophi formation tends to match the duration and severity of hyperuricemia11.

Secondary Types of Gout

Polyarticular gout

Is when gout flares occur in multiple joints at the same time11.

Did you know?

Pseudogout is a condition is commonly mistaken for gout as the symptoms can be similar. Like gout, pseudogout is the result of crystallised deposits causing painful inflammation in a joint. However, in the case of pseudogout, these are calcium deposits rather than uric acid deposits and it occurs more often in the knee than the big toe12.

Know the Signs

Gout attacks tend to happen suddenly and are very painful13. They often occur at night but can strike at any time13.

Extreme pain in a single joint – often the big toe – but it can occur in more than one joint at the same time and can affect any joint1.
Swelling and heat in affected joint1.

Shiny and red skin over the joint may appear13.

Peeling, itchy and flaky skin as swelling goes down.

Stone-like protrusion called a tophus in some cases – they can be big or small and may be located near a joint, on the cartilage of the ear or on the elbow. Tophi are usually painless and unlikely to occur with first gout attack14.

Attack peaks within 12-24 hours after it began and then slowly start to subside over several days with or without treatment. Untreated, it can take up to 14 days for the gout attack to subside entirely10.
Recurrent attacks: Once you’ve had one gout attack, you will most likely have subsequent attacks, but frequency varies – some patients may have an attack every few months; others may go several years between attacks13.
Increasing frequency: Attacks can become more frequent if the gout is not treated13.

Gout Triggers

Since ancient times, gout has been thought of as a disease of excess due to its association with a diet rich in meat and alcohol consumption – in fact, it goes by the nickname “the disease of kings”15. However, more recent research suggests that genetic predisposition may play as big a role as diet in determining an individual’s likelihood of developing gout16.

The following may trigger an attack9:

Drinking alcohol
Eating foods that are high in purines
Drugs or Medication – such as diuretics (water tablets)

In addition, other common risk factors include:

Age: Gout is usually more prevalent in men over 30 and post-menopausal women10.
Sex: Men seem to have a much higher risk of developing gout than women10.
Body weight: Obese people have a higher chance of developing gout10.
Underlying health condition(s): Hypertension, diabetes, insulin resistance, metabolic syndrome, congestive heart failure and poor kidney function have all been associated with increased risk of gout9.

Get Diagnosed

See your healthcare provider if you have symptoms of gout for the first time – you don’t need to see a rheumatologist unless your healthcare provider refers you13. After the initial diagnosis, you can usually treat subsequent gout attacks with over-the-counter medication from your pharmacist9.

During the consultation, your healthcare provider will ask about your medical history and likely ask about your diet – particularly your intake of high-purine food and beverages such as meat, seafood, and alcohol10. Your healthcare provider will examine the inflamed joint and may take your blood pressure and measure your weight and waist circumference10.

Because the symptoms of gout can be similar to other conditions, your healthcare provider may send you for additional tests13. These may include:

Joint fluid test: The nurse will extract a fluid sample from the affected joint that will be tested for the presence of uric crystals13.
Blood test: This is to check the level of uric acid in your blood. A high concentration of uric acid – hyperuricaemia – is typically associated with gou13
X-ray: This is not commonly used to diagnose gout, but it may be used to rule out other conditions, such as pseudogout, or to check whether the joint is damaged13.
Ultrasound: An ultrasound scan may detect crystals in the joint that weren’t visible during the physical exam13.

Treating Gout

The treatment of gout requires a multi-factored approach that includes medication to alleviate the pain that you’re experiencing during an acute attack, medication to treat the underlying cause, and lifestyle interventions to help prevent recurring attacks in the long term9.

There are three types of medication to relieve the pain and symptoms of gout.

NSAIDs9,17

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, diclofenac or piroxicam have an anti-inflammatory effect that reduces pain and swelling. Be sure to tell your doctor or pharmacist if you have ulcers, other gastrointestinal conditions, a history of kidney problems or if you’ve ever had an allergic reaction to NSAIDs.

Corticosteriods9,17

If you have a history of kidney problems or are allergic to NSAIDs, your healthcare provider may give you a steroid injection or prescribe a course of corticosteroids, such as prednisolone. Tell the healthcare provider if you have diabetes or a history of high blood pressure, thyroid problems or tuberculosis.

Colchicine9,17,18

Has anti-inflammatory properties and helps to break down the uric crystals that are causing the gout attack. It’s especially effective in the first 36 hours after your attack starts. If this is not your first gout attack, you can get colchicine over the counter from your pharmacist. If you have tophi, you may have to continue a maintenance dose for up to six months, until the tophi have disappeared. Mention to the  healthcare provider  if you’re currently taking – or have recently taken – antibiotics. If you develop diarrhoea while taking colchicine, contact your healthcare provider immediately as the dosage may be too high.

Combination therapy17

If the gout is present in more than one joint or the attack is severe and you have extreme pain, you may be given a combination of the above treatment options.

ULT17,18

Urate lowering therapy (ULT) involves taking chronic medication, such as allopurinol, to lower the concentration of uric acid in the bloodstream. This may be recommended if you have two or more gout attacks a year, develop tophi, develop kidney stones, or an X-ray reveals joint damage resulting from a gout attack.

Lifestyle interventions9,17

Managing your lifestyle plays a key role in lowering your risk of future gout attacks. Reducing alcohol consumption, eating less meat and seafood, drinking more water, and exercise will all contribute to managing your bouts of gout.

Adopting a healthy lifestyle can go a long way towards reducing the frequency and severity of gout attacks.

Eating less high-purine food (meat, seafood, white bread, refined cereals, milk, peanut butter, certain fruit and nuts, tomatoes).
Drinking less alcohol (especially beer and spirits) will help reduce the concentration of gout-causing uric acid in the blood.
Drinking at least two litres of water a day will help the body flush uric acid regularly.
Maintaining a healthy weight takes pressure off joints – gout attacks have been linked to joint trauma. Regular low-impact exercise, such as brisk walking, swimming and cycling, lower the risk of the chronic diseases that have been associated with gout – without putting undue strain on the joints.
Schedule regular check-ups with your doctor to assess your progress and gout-management regimen.

The better Gout diet

Avoid these high-purine foods and drinks11

Alcoholic beverages

Anchovies, sardines, herring, mussels, codfish, scallops, trout and haddock

Turkey, veal, venison and organ meat.

Limit these moderate-purine foods to occasional consumption11

Meat, including beef, bouillon, chicken, duck, and ham

Shellfish, including crab, lobster, oysters and shrimp

Asparagus, kidney beans, lentils, lima beans, mushrooms, and spinach

Have as much of these low-purine foods and drinks as you want11:

Fizzy drinks, coffee, fruit

Bread, grains, macaroni, cheese, eggs, milk products, sugar

Green vegetables (excluding those listed, but including lettuce)

What it feels like to have a gout attack

The pain is excruciating – especially once it really sets in. It's a combination of throbbing and sharp nerve pain. It feels like the whole compromised joint is hot, you can just feel the heat. Added to that, there is also a crippling effect as you cannot even budge the toe. When it's at its worst, if I'm lying down and you were to flick a bed sheet out and have it float down and touch the toe – I would bite down or scream.

Generally you can feel it coming on a day or two away. The joint will just have an uncomfortable tingling sensation, with very minor discomfort, and that builds till it sets in fully. Generally I use that as my warning sign and then begin hydrating big time. This usually works. If not, then I quickly shoot to the pharmacy to get a pack of Colchicine and anti-inflammatories – these work like a charm, although it can result in an upset stomach for the next day.

Having a healthy plant-focused eating plan definitely helps. Also knowing what your triggers might be – for me I've linked it pretty much to tomatoes. I have noticed it’s more likely when I go 'off the wagon' during the holidays, when my routine is disrupted. I guess it's because I'm not getting my regular 1.5-2 litres of water, and not eating as 'clean' and plant-rich as I would normally be.

Manage The Pain

Colchicine is an over-the-counter medication specifically formulated for the treatment of gout. Get it from your pharmacy as soon as you feel an attack coming on and within 36 hours of the start of an acute attack for best results.

References

  1. Hainer, Barry et al. Diagnosis, Treatment, and Prevention of Gout. Am Fam Physician. 90, 12. 831-836. (2014)
  2. Schäffer, V.S. Systemic Inflammatory Polyarticular Gout Syndrome – Description of a Previously Neglected Entity. JSM Arthritis 2,2: 1024. (2017)
  3. Doherty, M., et al. Gout: Why Is This Curable Disease So Seldom Cured? Annals of The Rheumatic Diseases.71,11. (2012)
  4. Arthritis Foundation Staff. Which Foods Are Safe For Gout? Available at: https://www.arthritis.org/health-wellness/healthy-living/nutrition/healthy-eating/which-foods-are-safe-for-gout.
  5. Cleveland Clinic Staff. High Uric Acid Level. Available here: https://my.clevelandclinic.org/health/symptoms/17808-high-uric-acid-level
  6. InformedHealth.org [Internet]. Cologne, Germany: Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Gout: When Is Long-Term Treatment with Medication Suitable? 2015 Mar 11 [Updated 2018 May 17].
  7. Chhana A., et al.. Factors Influencing The Crystallization of Monosodium Urate: A Systematic Literature Review. BMC Musculoskeletal Disorders. 16, 205. (2015)
  8. Masseoud D, et al.. Overview of Hyperuricaemia and Gout. Curr Pharm Des. 11, 32:4117-4124. (2005)
  9. CDC Staff. Gout. Available here: https://www.cdc.gov/arthritis/basics/gout.html
  10. Fox, R. Management of Recurrent Gout. BMJ. 336,7639. (2008)
  11. Harris, Mark, et al. Gout and Hyperuricemia. Am Fam Physician. 59, 4. 925-934. (1999)
  12. MacMullan, P. & McCarthy, G. Treatment and Management of Pseudogout: Insights for the Clinician. Ther Adv Musculoskelet Dis 4,2. 121-131. (2012)
  13. NHS Staff. Symptoms of Gout. Available here: https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/conditions/gout#symptoms-of-gout
  14. Salama A. & Alweis R. Images In Clinical Medicine: Tophi. J. Community Hosp. Intern. Med. Perspect. 7,2. (2017)
  15. Tang SCW. Gout: A Disease of Kings. Contrib Nephrol. 192,77-81. (2018)
  16. Dalbeth N, Stamp LK, Merriman TR. The Genetics of Gout: Towards Personalised Medicine? BMC Med. 15,1:108. (2017)
  17. Haines A, et al., Pharmacists’ Assessment and Management of Acute and Chronic Gout. Can Pharm J.  151,2: 107-113. (2018)
  18. Latourte A, et al., Prophylaxis for acute gout flares after initiation of urate-lowering therapy. Rheumatology. 53,11: 1920-1926. (2014)
  19. Tikly, M & Makan, K.S.. Gouty Arthritis: An Approach For General Practice. Afr. Fam Pract. 55, 4. 307-312. (2013)

Learn more about other areas of pain.

Learn more about other areas of pain.