August 2014

Gout

Gout

Gout is a medical condition caused by a congenital disorder of the metabolism involving a chemical called uric acid. In gout uric acid crystals are deposited in the joints, on tendons and within the tissues surrounding certain joints. This deposition of uric acid crystals is caused by an elevated concentrations of uric acid in the blood stream. The depositing of the uric acid crystals provokes an inflammatory reaction of these tissues. Over time and with recurring episodes of gout the amount of crystals deposited can increase until it deforms the joint. In its early stages the only symptoms may be pain but over time there is also swelling, and enlargement of the joint as more and more crystals are laid down and the joint or tissues are destroyed. Sometimes even during the early stages an x-ray of the affected area can show damage to the joints which is characteristic of gout.

When gout exists the individual may have reoccurring attacks of joint inflammation, commonly involving the big toe. Gout may however, also involve the foot, ankle, knee, elbow, hand, arm, or shoulder. It affects adults of both sexes but is more common in men than women, until after menopause.


The Signs and Symptoms of Gout

The classic picture of gout is an individual with a sudden onset of excruciating, unexpected burning pain, with swelling, redness, warmness and stiffness in one or more joints. The individual may also have a low-grade fever, but not always. Pain usually occurs for two reasons, 1) the crystals inside the joint cause intense pain whenever the affected area is moved and 2) the inflammation of the tissues around the joint may also causes the skin to become swollen, tender and sore, even if only lightly touched. In some cases even a blanket or the lightest sheet draping over the affected area can cause extreme pain.

Gout usually attacks the big toe about 75% of the time during the first few attacks, however it can affect other joints such as the ankle, heel, instep, knee, wrist, elbow, fingers, and spine. In some cases the condition may appear in the joints of the small toes which have become immobile due to impact injury earlier in life. Any injury that causes reduced blood circulation can leads to gout.

Individuals with longstanding elevated uric acid in their blood stream (usually referred to as hyperuricemia) can have uric acid crystal deposits called tophi (singular - tophus) in other tissues for example in the whorl part of the ear. Elevated uric acid can also lead to the formation of kidney stone in some people.

The goal for treatment of gout is to reduce the level of uric acid in the blood stream. There are two ways to do this. 1) take medications that lowers uric acid in the blood stream and 2) reduce the intake of purines, the amino acids that are broken down into uric acid. We will not discuss the medical treatment of gout only the dietary changes needed to prevent high uric acid levels.


Review of Signs and Symptoms

Sudden onset of severe pain (usually at night) in the inflamed joint.
This often involves one or the other big toe.
The involved joints may be hot, swollen, and very tender.
The skin over the joint is often red and shiny.
The individual may experience fever, chills, or fatigue (sometimes)


The Causes

A high level of uric acid in the blood. This may be due to increased production of uric acid or decreased elimination of uric acid by the kidneys.


Who Is At Highest Risk?

  • Generally men over 60
  • Individuals with a family history of gout
  • People who are over weight or obesity
  • People who use  alcohol to excess
  • People with thyroid disorders
  • After the use of certain drugs, such as diuretic drugs (water pills), high blood pressure drugs, aspirin, drugs that treat gout, and others
  • People with High blood pressure
  • People with who are starving themselves such as with strict weight loss diets or dehydration
  • People who eat large amounts foods that contain purines. These include anchovies, sardines, sweetbreads, kidney, liver, tongue, and large amounts of red meat, shellfish, peas, lentils, and beans. See below.



Preventive Measures

Avoid risk factors such as high purine foods, trauma and exhaustion, where possible.


Expected Outcomes

Generally the first attack lasts a few days and may require treatment to control symptoms pain, swelling and loss or range or motion. Recurrent attacks are common unless the uric acid level in the blood is reduced and brought under control. Symptoms are generally relieved with treatment.


Possible Complications

  • The long term problems with gout are crippling deformities of the affected joints
  • Uncontrolled uric acid can lead to kidney stones and pain from them
  • Continued gout attacks (if untreated)


Diagnosis & Treatment

Gout is handled in three ways prevention, acute treatment and diet (which is part of prevention for recurrent episodes).


General Measures

  • Your physician should perform a complete medical examination and take a full medical history. He or she should also exam all involved joints. Medical tests such as blood and urine levels of uric acid and studies of fluid removed from the joint may be performed to manage and control your gout. An X-ray or a bone scan is often done to determine level of damage and to obtain a baseline to determine where in the disease process you are.
  • The primary goals of treatment are to control the symptoms, prevent recurrence, and to lower uric acid levels. Treatment usually involves drugs, lifestyle changes, and rarely, surgery.
  • Lifestyle changes include diet changes, weight loss (if overweight), decrease level of fatigue, reduce joint trauma and determine what factors other than the above lead to triggering attacks.
  • Surgery, while rare, may be required if the disorder has been untreated or treated to late to cause serious joint injury and malformation.
  • At home you an use warm or cold compresses on painful joints. Keep the weight of bedclothing off any painful joint by making a frame that raises sheets off the feet.


Medications

Nonsteroidal anti-inflammatory (NSAIDs) medications (such as indomethacin, ibuprofen, naproxen and others) to control inflammation and pain are usually prescribed.
Specific medications to lower uric acid such as colchicine, allopurinal drugs for an attack of gout may be prescribed.
Lifelong treatment with drugs to decrease uric acid production or to increase the kidneys' excretion of uric acid may be needed. These drugs have side effects and adverse reactions. Obtain as much information as possible regarding their use.


Activity

  • During an attack, rest and elevate the foot. Take care to avoid joint injury. Wear shoes that fit properly.
  • Exercise daily, or when ever possible, to improve circulation.


Diet

  • Limit foods that contain purines (see Risk Factors and see Low Purine Diet). Avoid all protein foods which contain purines.
  • Drink plenty of water and other liquids daily. Fluids keep the urine diluted, which helps prevent kidney stones.
  • Don't drink alcoholic beverages, especially beer or red wine. They can worsen or trigger an attack.
  • If you are overweight, begin a medically approved weight-loss diet. Do not go on a crash diet, as rapid weight loss may bring on a gout attack.


See Your Doctor, If:

  • You or a family member has symptoms of gout
  • You are having joint pain with any of the above symptoms or signs
  • Your pain gets worse, if you have associated fever or chills
  • If you have any new or unexplained symptoms develop. They may indicate an adverse reaction of drugs, or interactions between drugs.



To read Gout: Eat A Low Purine Diet, click here.