What is gout?

Gout is a condition that causes sudden, excruciating pain swelling in the affected joints particularly the big toe. It is a metabolic disorder that results in an excessive amount of uric acid in the blood. The uric acid deposits in the joints in the form of crystals, which cause swelling and pain.

Gout can also arise as a result of a diet that is too rich in proteins, fat and alcohol – a common diet in affluent societies and indulgent lifestyles. When the kidneys are unable to excrete the excess uric acid, it may end up getting deposited as solid crystals in the joints.

Other diseases such as diabetes, hypertension, leukemia and kidney disorders and certain medications can also cause gout. If left untreated, the joints may be damaged resulting in deformity and restricted mobility even after and acute attack has subsided.

Who gets affected by gout?

Most sufferers of gout have their first attack between the age of 30-40. The majority of gout sufferers are men, although women may develop the condition after menopause. Females in their reproductive age rarely suffer from gout as the female hormone oestrogen helps to excrete uric acid from the body. Gout often runs in families because of a genetic connection.

What happens to the joints in gout?

Purine, a chemical compound found in most foods, is metabolized and degraded in our bodies into uric acid which is then passed out in the urine. In some people, there is an abnormality in the metabolism, which leads to high levels of uric acid in the blood – far more than what the kidneys can excrete in the urine.

The excess uric acid in the blood is deposited as uric acid crystals in the joint cartilage, tendons and other tissues. The uric acid crystals irritate the synovial membrane that covers the joints, resulting in redness, pain and swelling. The joints commonly affected by gout are the big toe, foot, ankle, heel, instep and knee. Gout rarely affects joints of the upper limbs like the fingers or wrists.

What are the stages of gout?

Gout sufferers do not suffer from pain all the time. They experience sudden pains from ‘acute attacks' of gout. When the acute attacks subside, patients may be quite well for months or even years, but the attacks then begin again only this time they become more frequent. Eventually there is chronic pain and swelling of numerous joints all the time.

From a medical point of view, there are 4 stages of gout:

• Asymptomatic phase – Patients have elevated levels of uric acid in the blood, but do not experience pain or swelling. Not all patients with high uric acid will have an acute attack.
• Acute gout – At this stage, uric acid crystals are deposited around the joint, causing a sudden swelling and intense pain. This commonly referred to as an attack of gout.
• Interval gout – In between gout attacks, patients will not show symptoms and will have normal joint function. The uric acid level remains high.
• Chronic gout – If treatment is not sought, years of gout attacks will exact a toll on the affected joints, causing deformity, chronic pain and immobility.

Can uric acid crystals deposit anywhere else other than the joints?

Elevated levels of uric acid may be deposited as crystals in the kidney forming uric acid kidney stones. These uric acid kidney stones, like the regular ones, may cause pain, obstruction to the flow of urine and infection. Clumps of uric acid crystals called tophi can form around joints, tendon, ligaments and even in ear lobes in patients with chronic gout.

What are the risk factors for gout?

Gout is linked to obesity, hypertension and diabetes. A family history of gout is also a risk factor. Some drugs like diuretics (commonly known as water tablets) used in the treatment of hypertension and swelling can cause gout as a side effect.

What are the symptoms of gout?

The first sign of a gout attack is a sudden, warm throbbing of the affected joint. Within a few hours, this can rapidly escalate into excruciating pain, accompanied by swelling and redness of the joint.

During this period, the skin around the joint will also be very tender, sensitive and sore, setting off extreme pain at the slightest touch. Patients with an acute attack find walking very difficult and painful.

In the chronic stage patients may have chronic pain, reduced function of the involved joint and occasionally extreme large deposits of uric acid crystals or tophi in the joints or other tissues. Many patients with chronic gout have reduced kidney function or kidney failure and hypertension.

How is gout diagnosed?

If the patient exhibits the symptoms and signs of a gout attack, the doctor can confirm the diagnosis by physical examination and blood tests. X-rays can help in the assessment of amount of bone and joint damage.

The most definitive test is a joint aspiration, where a needle is inserted in a swollen joint and a sample of the fluid is taken and then examined for the presence of uric acid crystals.

What is the treatment for gout?

There is currently no cure for gout  but the symptoms and its progression can be controlled by a combination of medication and special diet.

Medication

NSAIDs  (non-steroidal anti-inflammatory drugs) like diclofenac acid (Voltaren) or the newer COX-2 inhibitors (Celebrex and Arcoxia) are often prescribed to reduce the pain, swelling and stiffness that result from the first hours of a gout attack. Colchicine is also very effective in relieving the acute pain and can be taken two or three times a day. Colchicine can also be used to prevent acute attacks. A short course of steroids like prednisolone is also very effective in an acute attack. Often a combination of drugs is used.

To control the condition in the long term, other medication may be prescribed. Allopurinol  which reduces the production of uric acid or probecenid which increases the excretion of uric acid in the urine are often used. Such drugs need to be taken for long term in order to control the uric acid level and prevent further acute attacks.

Diet

To further reduce the level of uric acid in the blood, a special low-purine diet is recommended. Avoid foods that are rich in purine such as alcohol, liver, kidneys, salmon, sardine, dry beans, bean curd, soya bean drink and limiting the daily intake of protein-rich food like red meat. It is essential to seek advice from a dietician for complete details.

Overweight and obese patients need to go on a supervised weight loss programme. However fasting and crash diets are not recommended as they aggravate the condition.

Surgery

Surgery is rarely used to treat gout. Occasionally surgery is required to remove infected tophi (or clumps of uric acid crystals), or tophi that interfere with joint movements. Tophi tend to recur unless hyperuricaemia (high uric acid in the blood) is corrected. In patients with extremely painful joints like the big toe and knee, injections of steroid, directly in the joints are often very helpful.