What is gout

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

Gout is one of the most common forms of arthritis.

It is a metabolic disease that presents as an acute attack often coming on overnight. Within 12-24 hours there is severe pain and swelling in the affected joint. The skin over the joint may become red and shiny.

Gout usually affects only one or two joints at a time - most often the feet and ankles. The big toe is the most common site.

Involvement of this site is termed "podagra."

Without treatment the attack goes away in a week or so and when patients first develop gout there may be intervals of many months or even years between attacks. As time goes by, these attacks tend to become more frequent and more severe and eventually many joints may be involved, sometimes all at the same time. At this stage a state of chronic or continuous joint disease may develop with progressive joint damage, disability and crippling (chronic gout). Gout affects mostly men and is very rare in women until after the menopause when it is quite often seen.

Uric acid is a chemical which is a byproduct of the break down of purines, a constituent of many foods. The term used to describe elevated blood uric acid is hyperuricemia. When this is present, the uric acid which is normally dissolved in the blood may form microscopic crystals in the joint. These crystals cause the inflammation which is called acute gouty arthritis or acute gout.

Gout may develop in persons whose uric acid is higher than normal. There are many causes of this. The following are some of the more common causes:

• Higher than normal levels of uric acid can be part of the inherited make-up of some families
• Obesity
• Excessive alcohol intake
• High intake of food containing purines
• Some of the drugs used to treat high blood pressure
• Less commonly, longstanding kidney disease may result in high blood levels of uric acid

The first step must be to correct those factors mentioned above which give rise to high uric acid levels. Purines are substances found in food, which, when broken down produce a lot of uric acid. Therefore the following foods which are high in purines should be restricted or avoided:

• Sweetbread foods such as liver, kidneys, tripe, sweetbreads and tongue. • Excessive amounts of red meat.
• Shellfish, fish roe and scallops.
• Peas, lentils and beans.
• Alcohol intake should be reduced. Two glasses of beer a day or less is sensible.
• Weight loss may be very important.
• Medication for high blood pressure may need to be altered.
Anti-inflammatory drugs (NSAIDs) can be effective but the dose should be high enough and the drug taken as soon as possible at the first sign of an attack. With effective treatment, the attack may be controlled within 12-24 hours and treatment need be discontinued after a few days. Rest and elevation of the affected limb and fluid intake increased by an extra 4 or 5 glasses of water a day are also important.

If in spite of all the measures above the uric acid remains high and attacks continue or become more frequent, other drugs can be used which directly lower the blood uric acid. However, these drugs have no effect on the actual attacks of acute gout and they must be taken on a long term basis. The dose must be adjusted by repeated checks on the blood uric acid before a maintenance dose can be decided on. Once the uric acid is within normal limits (<6.0 mgs/dl), the patient will remain free from gout provided the drug is continued. Some drugs work by increasing elimination via the kidneys and others by blocking uric acid formation.

It is also very important for patients beginning such drugs to realize that for the first few months of treatment, gouty attacks can become more severe and frequent. This is usually controlled by taking one or two tablets a day of an additional drug such as colchicine for at least six months and if any acute attacks do appear they must be treated in the usual way and the long term medicines continued.

Where elevated uric acid has been present for a long time and acute gout has been frequent and severe, deposits of uric acid may appear around the affected joint and even in tissues elsewhere such as the ears. These are seen as chalk colored nodules called tophi. Their presence indicates the need for treatment with one or other of the long term uric acid lowering drugs mentioned above.

High uric acid levels and recurrent gout are often associated with high blood pressure which your doctor will check and treat as necessary. This combination of hyperuricemia and high blood pressure can lead to kidney damage so it is important, not just because of the effects on the joints, to correct this problem of through the proper use of all the measures mentioned above under your doctor's supervision.

Gout is often associated with other conditions besides high blood pressure. It can occur along with elevated blood lipids, obesity, and diabetes. This collection of medical problems is termed the "metabolic syndrome."

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