What is Gout?

Gout is a form of arthritis that causes sudden, severe episodes of pain, tenderness, redness, warmth and swelling of the joints. It is the most common type of inflammatory arthritis in men over age of 40. Women are usually protected from gout until after menopause.

Gout is a disease that results from an overload of uric acid in the body. This overload of uric acid leads to the formation of tiny crystals of urate that deposit in tissues of the body, especially the joints. When crystals form in the joints, it causes recurring attacks of joint inflammation (arthritis). Gout is considered a chronic and progressive disease. Chronic gout can also lead to deposits of hard lumps of uric acid in the tissues, particularly in and around the joints and may cause joint destruction, decreased kidney function, and kidney stones(nephrolithiasis)

 What are the causes?

• Intake of alcholic beverages
• Hereditary
• Increase in level of uric acid
• Starvation and dehydration
• Trauma

Gout is the result of deposits of needle like crystals of uric acid in the joint spaces. Uric acid, a substance that results from the breakdown of purines in the body, usually dissolves in the blood and passes through the kidneys into the urine. In people with gout, the uric acid level in the blood becomes elevated.

This is called hyperuricaemia and can be due either to the increased production of uric acid eg. due to consumption of food rich in purines or decreased excretion of uric acid from the kidney eg. renal impairment.

Symptoms

An attack often occurs very suddenly with the maximum intensity of pain reached within a few hours. The joint involved can be extremely painful and is often swollen, warm and red. This rapid development of joint pain is a feature that differentiates it from most other forms of arthritis.

The most common joint affected is the first joint of the big toe. Other joints that may be affected are the knee, ankle, foot, hand, wrist and elbow joints. The shoulder, hip joints and the spine are rarely affected.

Why does uric acid build up?

Normally, there is a fine balance between the amount of uric acid (urate) that you make and the amount that you pass out in the urine and faeces. This keeps the level of uric acid in the blood in check. However, in most people with gout, their kidneys do not pass out enough uric acid and the blood level may rise. They are said to be under-excreters of uric acid. Their kidneys usually work otherwise normally.

In some people, the build-up of uric acid may due to other factors. For example:

• Drinking too much alcohol can cause uric acid to build up.
• If you do not have enough vitamin C in your diet.
• If you drink sugar-sweetened soft drinks high in fructose it can cause uric acid to build up. A recent research study found that having two drinks a day of a sugar-sweetened soft drink increased the risk of developing gout by 85%. (Drinks labelled as ‘diet’ or drinks containing artificial sweeteners were not found to increase the risk.) Fructose-rich fruits and fruit juices may also increase the risk.
• Certain foods may ‘tip the balance’ to raise your uric acid higher than normal. In particular, eating a lot of heart, herring, sardines, yeast extracts, or mussels may increase the level of uric acid. However, eating a normal balanced diet should not have much effect on the uric acid level.
• Some medicines may raise the level of uric acid. For example, ‘water’ tablets (diuretics) such as bendroflumethiazide, aspirin (at full painkiller dose – not low-dose aspirin used to prevent blood clots), and some chemotherapy medicines.
• More uric acid is made than usual in illnesses where the cells of the body have a rapid turnover. For example, severe psoriasis and some blood disorders.

People with certain other conditions have an increased risk of developing gout. These include:

• Obesity.
• High blood pressure.
• Kidney damage.
• Diabetes mellitus.
• Bone marrow disorders.
• Lipid disorders (especially hypertriglyceridaemia).
• Vascular disease.
• Enzyme defects such as hypoxanthine guanine phosphoribosyltransferase (HGPRT) deficiency and glucose-6-phosphate dehydrogenase (G6PD) deficiency.

What are the treatments?

The treatment of gout depends on the stage of disease. For an acute attack, the crucial step is to provide pain relief and shorten the duration of inflammation. The goal in the management of gout is to prevent recurrent or future gouty attacks with the ultimate objective of preventing joint damage.

Treatment is tailored for each person and medications are used to:

1. Relieve the pain and swelling during an acute episode,
2. Prevent future episodes,
3. Prevent or treat tophi, which are nodules of crystallised uric acid formed under the skin that can become swollen and cause pain during gout attacks.

Medication for acute episodes
Non-steroidal anti-inflammatory drugs (NSAIDS) for example, Naproxen, Mefenamic acid, Indomethacin, or Diclofenac are commonly used to relieve pain and swelling during an acute gout episode. NSAIDS usually begin to work within 24 hours. Their side-effects include stomach upset, skin rashes, fluid retention or kidney problems and stomach ulcers. They should be used cautiously in patients with kidney impairment and stomach ulcers. Newer drugs called COX-2 inhibitors may be safer for the stomach.

Corticosteroids work quickly as well and can be taken by mouth or injected directly into an inflamed joint to relieve the pain and swelling of an acute episode of gout.

Colchicine gives prompt relief when taken at the first sign of an attack. Common side effects include abdominal cramps or diarrhea. Lower doses of colchicine can be taken daily to prevent future attacks.

Medications that control uric acid levels
Long term management of patients with gouty arthritis is to reduce blood uric acid levels so that future episodes of gouty attacks can be prevented. This is achieved by – medications such as Allopurinol or uricosuric agents (i.e. medications that result in increased urate excretion from the kidneys). These medications do not relieve the pain and inflammation of an acute episode and are usually started after the acute episode of gout is treated. They may occasionally cause you to have more gout episodes when first started, hence you may be prescribed colchicine or NSAIDS to be taken at the same time.

Allopurinol decreases the blood uric acid level and has to be taken daily. It can also reduce tophi size and prevent formation of crystal deposits in joints and other tissues. The most common side effect is skin rash and has to be discontinued if you develop any rashes or itch. Allopurinol is usually taken daily and for years. It should not be stopped during an acute episode of gout.

Uricosuric drugs such as probenecid lower the blood level of uric acid by increasing its excretion in the urine. They are not as effective as allopurinol and do not work as well in people with renal impairment. Patient should drink plenty of water as the excretion of uric acid in the urine may lead to formation of stones in the kidney.

Ultimately, your doctor will advise you regarding the types of medication(s) you need and monitor their side-effects.

Other problems in gout

Gout may be associated with high blood pressure, diabetes, kidney diseases and obesity. It may be important to screen for these diseases. Uric acid crystals can form deposits in the kidneys or the ureter leading to renal or ureteric stones. This can lead to renal impairment.

Dietary advice if you have gout

Diet plays an important role in the management of gout. Patients with gout should avoid food with high purine content. It is also important to drink lots of water (at least 2 litres per day) unless instructed by a doctor not to do so. Patient should also reduce the consumption of alcoholic beverages and reduce weight. However, crash dieting is not advised.

Food high in purine content (restrict your intake)

• Asparagus, Cauliflower, Mushroom, Oatmeal, Wholegrain, Wheat, Germ, Red Meat

Food highest in purine (abstain completely if possible)

• All Internal Organs of Animals and Birds, Liver, Kidney, Brain, Pancreas
• Rich Games – Venison, Gamebird Pigeon, Black Chicken
• Meat Extracts – Gravies, Chicken Essence, Bak Kut Teh
• Certain Fish/ShellFish – Salmon, Herring, Mackerel, Anchovies, Sardines, Cockles, Mussels,
  Scallops, Prawns
• Certain Vegetables – Spinach, Peas, Beans, Peanuts, Carrots
• Products of Beans – Beancurd, Soya Bean Drink, Bean Sprout, Bean Cake, Moon Cake,
  Legumes
• Fruits – Strawberries, Strawberry Jam, Durian, Tomato, Tomato Sauce
• Alcohol – Beer, Champagne, Brandy, Whisky, Port