Gout: The Painful Arthritis Caused by Uric Acid 

最後更新日期 九月 15, 2021.

Gout is a common and painful form of inflammatory arthritis. It usually affects one or more joints (especially the first metatarsophalangeal joint of the big toe), causing intense pain and swelling. There is no cure for gout, but medications can manage the symptoms and prevent gout flares. 

Gout meaning: What is Gout?

Gout, or gouty arthritis, typically presents with acute severe joint inflammation in one or more joints. It often affects the first metatarsophalangeal joint at the base of the big toe, known as podagra. Other joints commonly affected by gout are the ankle, foot, small joints of the hand, wrist, elbow and knee. Signs and symptoms of gout can become worse suddenly and quickly, known as the progress of gout attack or gout flare. 

Gout Causes

Gout happens when there is too much uric acid in the blood (hyperuricemia). Normally, the human body obtains uric acid by breaking down purines, which are natural substances found in the body and certain foods. Uric acid then passes through the kidneys and is excreted in urine. However, when there is excessive uric acid produced or too little uric acid excreted, sharp and needle-like urate crystals could build up in the joints, causing inflammation and pain in the joints and surrounding tissue.

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Risk factors of Gout

The risk of developing gout increases with the amount of uric acid in the blood. The following factors contribute to a higher risk of gout.

  • Age and sex: The risk of gout is higher in males aged 30-50 years and postmenopausal women. 
  • Genetics: Having a family history of gout increases the risk of gout development. 
  • Medical conditions: Certain conditions increase the risk of gout, including hypertension, diabetes, renal diseases, metabolic syndrome, etc. 
  • Medications: Certain drugs increase the risk of gout, including diuretics, low-dose aspirin, and immunosuppressants.
  • Diet: Some foods, such as alcohol, sweeteners, red meat and seafood can promote uric acid production and hence the risk of gout. Gout used to be known as the “disease of kings” because of the overindulgence in diets of these foods by wealthy people in the past. 
  • Weight: Obesity or being overweight has been found to be associated with both increased production and decreased renal excretion of urate. 
  • Physical trauma or surgery: Recent trauma or surgery increases the risk of triggering a gout attack. 

Signs and Symptoms of Gout

Not everyone with hyperuricemia would develop signs and symptoms of gout. This condition is called asymptomatic hyperuricemia, which in general does not require treatment. 

Gout attacks mostly happen in only one joint at a time suddenly (especially at midnight) and last for days or weeks. These attacks are followed by long periods of remission without symptoms before another attack begins (intercritical period). Typically, the patient would experience the following signs and symptoms during a gout attack: 

  • Intense pain at the affected joint
  • Swelling at the joint
  • Redness around the joint
  • Heat or warmth in the joint area
  • Joint stiffness 

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Complications of Gout

Although gout attacks are recurrent, they can be treated and prevented. If left untreated, not only do they cause pain and discomfort, but they may also lead to the following serious complications: 

  • Joint destruction: Untreated gout may cause deposition of urate crystals under your skin (tophi). It can build up in the tendons and joints, causing severe pain and inflammation during a gout attack. It may eventually lead to joint destruction and disability which require surgical joint replacement by orthopedic surgeons.
  • Kidney stones: Urate crystals can also build up in the kidney, causing kidney stones. Kidney stones may eventually damage the kidney and lead to chronic renal disease and urologic problems.

Diagnosis of Gout

In most cases, doctors could make the diagnosis of gout based on medical history and typical signs and symptoms of gout, such as intense pain and swelling of the joint. Other tests may also help to confirm the diagnosis, such as:

  • Blood test: Your blood uric acid level may be measured and monitored after a gout attack, but it is not a diagnostic tool. Some people who experience gout symptoms may have normal levels of uric acid in the blood (especially during a gout attack), while some others can have hyperuricemia but do not experience gout. 
  • Synovial fluid analysis (joint aspiration): A sample of fluid from the affected joint is drawn by a needle by your doctor. It is used to be examined under a microscope for urate crystals.  
  • X-rays: An x-ray can be useful to check for lesions or damage of the joints caused by suspected chronic gout. 
  • Dual-energy computed tomography (DECT): DECT scan is a relatively new technology that can be used to detect urate crystals in the joints. 

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Treatments of Gout

There are 2 types of gout medicines that focus on 2 different treatment purposes. The first type of gout medicine is used to relieve acute pain and inflammation of gout, while the other type lowers blood uric acid levels to prevent future gout attacks. 

Management of acute gout attack:

During an acute gout attack, patients would experience extreme pain and inflammation, which can be alleviated by the following drugs: 

  • Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs are used as the first-line treatment of acute gout attack given that there are no contraindications (e.g. renal or gastrointestinal disease). They should be initiated at maximum doses at the onset of symptoms. Examples include ibuprofen, indomethacin, naproxen, and celecoxib. Keep in mind that aspirin should NOT be used because it can compete with uric acid excretion in the kidneys, which worsens the condition. 
  • Colchicine: Colchicine is also recommended as it is comparably effective to other agents when taken within 24 hours of the onset of a gout attack. However, colchicine is less tolerated by patients due to its side effects such as nausea, vomiting, and diarrhea
  • Corticosteroids: Corticosteroids, such as prednisone, are a very effective treatment option for patients who do not tolerate NSAIDs and colchicine. It can be taken orally or injected into muscles or joints. 

Prevention of recurrent gout:

Long-term medications are indicated for patients with frequent gout attacks, abnormally high levels of uric acid, or developed complications such as tophi and kidney stones. These medications aim to reduce blood uric acid levels so as to reduce the frequency of gout attacks and prevent damage caused by crystal deposition. Exampels of urate-lowering drugs include:

  • Xanthine oxidase inhibitors: Allopurinol and febuxostat are the first-line options to effectively lower uric acid levels by reducing its synthesis. If you experience skin rash after taking allopurinol, you should seek medical attention immediately because it may cause a severe skin reaction (Stevens-Johnson syndrome), particularly if you are a carrier of the HLA-B*5801 allele. Febuxostat is an alternative if allopurinol is contraindicated or intolerant, it is more effective at reducing serum urate than allopurinol.
  • Uricosuric agent: Probenecid is a second-line option that can promote uric acid excretion, it is not recommended for patients with moderate-to-severe renal impairment. 

After the initiation of urate-lowering therapy, there is a chance to trigger a gout attack so it is recommended to use after the gout flare subsides (~2 weeks), and cover with regular prophylactic drugs, such as NSAIDs or low-dose colchicine.

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Prevention and Lifestyle Modification for Gout

In addition to medications, lifestyle modifications are also important to relieve gout symptoms and prevent future gout attacks. Suggested self-management strategies to prevent gout attacks include: 

  • Loss weight: For people who are obese or overweight, losing weight can reduce the risk of gout by reducing pressure on joints. 
  • Regular exercise: Physical activity can lower uric acid levels and lose weight, which is beneficial for gout. Generally, exercising 150 minutes per week is recommended for all adults. Not only can it reduce the risk of gout, but also the risk of other diseases, such as heart diseases, diabetes, and stroke. Choose low-impact activities that are easy on joints, such as walking, bicycling and swimming. 
  • Self-management during a gout attack: You should take your gout medicines for an acute attack as soon as the symptoms show up. Also, you may apply an ice pack to the joint which may help relieve pain and inflammation. Try to relax your body and limit any stress on the joints as well, such as stress from socks or shoes. Consult your doctor or physical therapist for tailored measures. 
  • Drink plenty of water: Increased water intake can help the excretion of uric acid from the body. It is recommended to take around 3 liters of water per day
  • Gout diet: Avoid foods and drinks containing high purine levels that can trigger gout attacks, such as alcohol, red meat, organ meat, seafood (e.g. sardines, anchovies, tuna, trout), certain fruit juices, and drinks sweetened with fruit sugar. On the other hand, you should try to eat more vegetables, fruits, nuts, whole grains, and low-fat dairy products to lower uric acid levels.

 

This article is medically reviewed by Dr. Eric Sze Tsun Yeung. Dr. Yeung is a specialist in Orthopaedics and Traumatology both in UK and HK who graduated from the University College London Medical School, University of London. Before his return to HK in 2011, Dr. Yeung was an Orthopaedic Consultant in a London teaching hospital. Dr. Yeung worked for the HK Hospital Authority at the Prince of Wales Hospital, Yan Chai Hospital and Queen Elizabeth Hospital. He is now the Honorary Clinical Associate Professor of the Department of Orthopaedics and Traumatology at both the University of Hong Kong and the Chinese University of Hong Kong. Dr. Yeung has been practicing at the SINCERUS Orthopaedics & Rehabilitation Centre since 2018.

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