Have you ever had a sudden onset of severe joint pain? Have you had an arthritis attack after a great weekend–where you enjoyed beer on tap and some awesome seafood? If you’ve experienced any of these, you may have a form of arthritis called gout. Gout causes a sudden onset of pain in a joint with significant swelling and redness over the joints. “Big toe arthritis” is a hallmark of gout (podagra). Other joints that gout attacks include knees, ankles, and wrists. So what is gout, and what are the best tests to diagnose it? Perhaps most importantly, what is the best treatment for gout?
All About Gout
Gout is the most common form of crystal-induced arthritis. It is the most common cause of inflammatory arthritis in men over the age of 40. It usually occurs after menopause in women. Gout is due to deposition of uric acid crystals( in the joints and the soft tissues (called “tophi”). The presence of crystals leads to inflammation in the joints causing severe arthritis and excruciating pain. If left untreated, gout leads to joint damage. Gout not only affects the joints but, if left untreated, can lead to kidney stones, chronic kidney disease, and increased cardiovascular disease.
Our body normally produces uric acid, as a by-product of the breakdown of cells. We consume foods that contain purines which are broken down into uric acid. Uric acid is normally excreted by the kidneys. You could experience gout if your kidneys cannot adequately excrete the uric acid–this is the most common cause–or your body makes excess uric acid. Genetics play a role on how well your kidneys excrete uric acid, leading to a family history of gout. Gout can also flare after surgery (day 3-5).
Risk Factors
Gout occurs due to abnormal increase in the uric acid level (hyperuricemia). The uric acid level could be high due to decreased excretion of uric acid from the kidney. Genetic play a role leading to such decreased excretion of uric acid from the kidneys and is the most common cause for gout. Rarely your body could make excessively high levels of uric acid that could lead to gout.
Not all of you who have a high uric acid level will develop gout. Many lifestyle and dietary factors and various diseases interact to increase the risk of gout. These risk factors includes:
- Overweight
- Older age
- Family history of gout
- Kidney disease
- Frequent red meat or seafood consumption
- Frequent alcohol consumption
- Consumption of beverages with high fructose corn syrup such as soda
- Male gender (rare in men less that 25, if it occurs in an early age, it can be due to inherited defect in purine metabolism)
- Diabetes
- Leukemia
- Selected medicines (Aspirin, diuretics, etc)
Diagnosis
Gout is diagnosed based on a physical examination by your primary care physician or a rheumatologist. The doctor might take fluid out of your joint (called joint aspiration) and study the fluid under a microscope to identify the uric acid crystals. Doctors may also perform blood tests to check your uric acid level. This helps to determine the risk of a gout.
The best time to check your uric acid level is a few weeks after an acute attack of gout–when you are actually experiencing an attack, the blood uric acid level could be falsely low.
Other tests can also help make a diagnosis of gout. An X-ray could show signs of joint damage. Ultrasound of the joint has become a new tool to help diagnose gout. A new type of imaging study called dual-energy computed tomography (DECT) helps identify uric acid crystals without the need for joint aspiration. This test is expensive and involves radiation exposure, so it may not be a first choice. Rarely MRI of the joint could help identify joint damage, and tophi.
Good Options, Usual Treatments
Treatment of gout involves two strategies: (1) Control the pain and (2) prevent recurrent attacks. This is done by lowering your uric acid level to <6 mg/dl and 5mg/dl if you have a tophi. For an acute gout attack, there are multiple medications that may help; you and your doctor will choose one based on any other medical conditions you may have, especially if you have chronic kidney disease.
Different kinds of nonsteroidal anti-inflammatories (NSAIDs) at higher doses can be effective to control pain and inflammation. Colchicine and glucocorticosteroids (prednisone) are other options to control such inflammation. These medications are typically used for up to 2 weeks. Occasionally, the doctor could also inject glucocorticosteroids into your joint, which could help with severe pain.
The long-term treatment of gout involves medications and lifestyle changes. Allopurinol and febuxostat are two commonly used medications to help reduce the uric acid level (to less than 6, or less than 5 if tophi are present) to reduce the risk of another attack. These are reasonably well-tolerated medications, but you will need close monitoring by your doctors if you take them. Krystexxa is another great option, especially if you have a lot of tophi.
Lifestyle changes are an essential component of the long-term treatment of gout. The basic strategy is to reduce your intake of purines. Patients with gout should reduce the consumption of purine-rich foods: Red meats (particularly organ meats such as liver or kidneys) and seafood (shellfish, sardines, and anchovies). Avoid excess fructose consumption (sodas, fruit juices, and energy drinks).
Some vegetables have purine (asparagus, cauliflower, spinach, and mushrooms) but are considered to be safe to eat. Consumption of fat-free dairy products (milk and yogurt) is good for gout. Coffee is also found to be beneficial. But one key aspect of gout is that, even with a strict diet, you can usually only lower the uric acid level by 1 mg/dl, so dietary restriction by itself is usually not enough to avoid future attacks. Adequate hydration helps the kidneys to excrete the uric acid and prevent dehydration, which can cause a gout attack.
Alcohol consumption is an important risk factor for gout. Beer consumption has the strongest risk; wine has the lowest. Liquor also reduces the uric acid excretion from the kidneys and thus increases the uric acid level in the body.
Some other lifestyle changes that are vital include regular exercise and weight management.
If you or a loved one has suffered one of more of these agonizing attacks, the first step is talking with your healthcare provider to timely and accurately diagnose gout. You and your doctor can then work together to find the treatment that works best for you.
Written by John Bankston