Gout | NHS inform

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   About gout
   
2. 
   2.
   
   Symptoms of gout
   
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   3.
   
   Causes of gout
   
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   Diagnosing gout
   
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   Treating gout
   
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   Complications of gout
   

About gout

Gout is a type of arthritis in which small crystals form inside and around the joints. It causes sudden attacks of severe pain and swelling.

It’s estimated that between one and two in every 100 people in the UK are affected by gout.

The condition mainly affects men over 30 and women after the menopause. Overall, gout is more common in men than women.

Gout can be extremely painful and debilitating, but treatments are available to help relieve the symptoms and prevent further attacks.

Signs and symptoms of gout

Any joint can be affected by gout, but it usually affects joints towards the ends of the limbs, such as the toes, ankles, knees and fingers.

Signs and symptoms of gout include:

• severe pain in one or more joints
• the joint feeling hot and very tender
• swelling in and around the affected joint
• red, shiny skin over the affected joint  

Symptoms develop rapidly over a few hours and typically last three to 10 days. After this time the pain should pass and the joint should return to normal.

Almost everyone with gout will experience further attacks at some point, usually within a year.

Read more about the symptoms of gout.

When to see your GP

See your GP if you suspect you have gout and it hasn’t been previously diagnosed, particularly if the pain keeps getting worse and you also have a high temperature (fever).

It’s important that a diagnosis is confirmed because other conditions that require urgent treatment, such as an infected joint, can sometimes cause similar symptoms.

If you’ve already been diagnosed with gout and you have an attack, see your GP if any medication you’ve been prescribed (see below) doesn’t start working within a couple of days.

Read more about diagnosing gout.

What causes gout?

Gout is caused by a build-up of a substance called uric acid in the blood.

If you produce too much uric acid or your kidneys don’t filter enough out, it can build up and cause tiny sharp crystals to form in and around joints. These crystals can cause the joint to become inflamed (red and swollen) and painful.

Things that may increase your chances of getting gout include:

• obesity, high blood pressure and/or diabetes
• having a close relative with gout
• kidney problems
• eating foods that cause a build-up of uric acid, such as red meat, offal and seafood
• drinking too much beer or spirits

Read more about the causes of gout.

Treatments for gout

If you have gout, treatment is available from your GP to:

• relieve symptoms during an attack – this can be done using ice packs and by taking medications such as non-steroidal anti-inflammatory drugs (NSAIDs), colchicine or corticosteroids
• prevent further attacks – through a combination of lifestyle changes, such as losing weight or changing your diet, and taking medication that lowers uric acid levels, such as allopurinol 

With treatment, many people are able to reduce their uric acid levels sufficiently to dissolve the crystals that cause gout – and as a result have no further attacks. However, lifelong treatment is usually required.

Read more about treating gout.

Can gout cause further problems?

Sometimes gout can lead to further problems, particularly if it’s left untreated.

These can include:

• kidney stones
• small firm lumps of uric acid crystals under the skin called tophi
• permanent joint damage

Read more about the complications of gout.

What’s pseudogout?

Pseudogout is a similar condition to gout, but usually affects the knee joint first. It’s a form of arthritis that causes pain, stiffness, tenderness, redness, warmth and swelling in one or more of your joints – commonly the knee or wrist. 

Symptoms of gout

The main symptom of gout is a sudden attack of severe pain in one or more joints, typically your big toe.

Other symptoms can include:

• the joint feeling hot and very tender, to the point of being unable to bear anything touching it
• swelling in and around the affected joint
• red, shiny skin over the affected joint
• peeling, itchy and flaky skin as the swelling goes down

The intense pain can make getting around difficult. Even the light pressure of a bed cover or blanket can be unbearable.

Which joints can be affected?

Gout can affect almost any joint and can occur in more than one joint at the same time.

The joints towards the ends of the limbs tend to be affected more often, including the:

• toes – particularly the big toe joint
• midfoot (where your shoelaces sit)
• ankles 
• knees
• fingers
• wrists
• elbows

If gout is left untreated, it’s likely to affect more joints over time.

Pattern of symptoms

Attacks of gout tend to:

• occur at night, although they can happen at any time
• develop quickly over a few hours
• last between three and 10 days – after this time, the affected joint should start to return to normal, but the problem can persist if treatment isn’t started early
• come back – you may experience attacks every few months or years
• become more frequent over time if not treated

It’s difficult to predict how often attacks will occur and when exactly they will happen.

When to seek medical advice

See your GP if you suspect you have gout and it hasn’t been previously diagnosed.

Contact your GP immediately or call the 111 service if you have both:

• severe, worsening joint pain and swelling
• a high temperature (fever) of 38C (100.4F) or above

This could mean you have an infection inside the joint (septic arthritis).

If you’ve already been diagnosed with gout and you have an attack, see your GP if any medication you’ve been prescribed doesn’t start working within a couple of days.

Read more about diagnosing gout and treating gout.

Causes of gout

Gout is caused by small crystals forming in the joints, resulting in severe pain, tenderness and swelling.

These crystals can grow when a waste product called uric acid starts to build up to high levels in the body.

Uric acid

Uric acid is created when the body breaks down chemicals known as purines.

If your kidneys don’t filter out enough uric acid, or your body is producing unusually high levels of it, it can build up in the body and turn into microscopic crystals.

These crystals usually form in and around the joints, possibly because the temperature in these areas is slightly lower than the rest of the body. If they get into the space between joints, the crystals can cause painful inflammation (redness and swelling).

What can increase your risk?

A high level of uric acid in the blood is the main factor that increases your risk of developing gout. However, it’s still uncertain why some people with a high level of uric acid in the blood develop gout, while others with an equally high level don’t.

Other factors that may increase your risk of developing gout are outlined below.

Medical conditions

Some underlying medical conditions can increase your risk of developing gout, including:

• high blood pressure
• diabetes
• kidney disease
• high levels of fat and cholesterol in your blood
• obesity
• metabolic syndrome (a combination of diabetes, high blood pressure and obesity)
• psoriasis (a skin condition that causes red, flaky, crusty patches of skin covered with silvery scales)
• osteoarthritis

Medication

Certain medications can increase your uric acid levels and your risk of developing gout. These include:

• diuretics (water tablets) – used to treat high blood pressure or an abnormal build-up of fluid in your body
• certain medicines used to treat high blood pressure – including beta-blockers and ACE inhibitors
• low-dose aspirin – used to reduce the risk of blood clots
• niacin – used to treat high cholesterol
• ciclosporin – used to treat conditions such as psoriasis
• some chemotherapy medicines

Diet

Uric acid is created when the body breaks down purines. Eating foods that contain a high level of purines can increase your risk of gout.

Foods naturally high in purines include:

• red meat – such as beef, lamb and pork 
• seafood – especially shellfish and oily fish
• offal – such as liver, kidneys and heart

Alcohol

Alcoholic drinks can raise the level of uric acid in the blood.

Beer, fortified wines like port, and spirits do this more than wine. Moderate consumption of wine – one or two glasses a day – shouldn’t significantly increase your risk of gout.

Sugary drinks

Certain sugary drinks may also increase your risk of gout.

Some research has found that drinking sugar-sweetened soft drinks and drinks with high levels of fructose (a naturally occurring sugar found in many fruits) had an increased risk of gout.

Family history

Studies have shown that gout often runs in families. Around one in five people with gout have a close family member with the condition.

Diagnosing gout

Your GP may suspect gout based on your symptoms. Sometimes further tests will be needed to confirm the diagnosis and rule out other possible causes.

Seeing your GP

See your GP if you experience symptoms of gout for the first time.

Your GP will ask about your symptoms and medical history, and examine the affected area, to help make a diagnosis.

They may also ask you about your diet, particularly your intake of beer, spirits and foods high in purines, such as red meat and seafood.

Further tests

Many conditions can cause gout-like symptoms.

Your GP may be unable to make a firm diagnosis straight away and you may be referred for further tests. These will either confirm the diagnosis of gout or rule out other conditions.

Joint fluid test

A sample of fluid may be taken from the affected joint. The fluid can be checked for the small crystals that cause gout, and it can be tested for infection to rule out septic arthritis.

Blood test

A blood test known as a serum uric acid test may be used to measure the amount of uric acid in your blood. A high level or uric acid is often associated with gout.

It’s sometimes best to wait until two to four weeks after an attack of gout before this test is carried out, as the level of uric acid in your blood is often not raised at the time of an attack. This is because the level of uric acid in your blood can drop when uric acid crystals form in the joints.

X-ray

An X-ray is rarely used to diagnose gout because the condition isn’t usually detectable using this method.

However, an X-ray is sometimes used to help rule out similar conditions that affect the joints, such as chondrocalcinosis (a build-up of calcium crystals in the joints) or to assess whether there has been any joint damage due to repeated or persistent attacks of gout.

Ultrasound scan

An ultrasound scan of an affected joint is a simple and safe investigation that’s increasingly used to detect crystals in the joints. It can also detect crystals deep in the skin that aren’t obvious during a physical examination.

Treating gout

Treatment for gout includes pain relief to help you cope with a gout attack, as well as medication and lifestyle changes to prevent further attacks.

Pain relief for a gout attack

What to do during an attack

You should:

• take any medication you’ve been prescribed as early as possible after you notice an attack (see below) – this should start to have an effect within two or three days
• rest and raise the limb
• avoid knocking or damaging the affected joint
• keep the joint cool – remove surrounding clothing and apply an ice pack, such as a bag of frozen peas wrapped in a towel
• ensure you’re well hydrated

Apply the ice pack to your joint for around 20 minutes. Don’t apply ice directly to your skin and don’t apply it for more than 20 minutes at a time because this could damage the skin.

If necessary, you can keep reapplying an ice pack to your skin during an attack, but you should wait until your skin has returned to a normal temperature first.

NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs) are usually recommended as the first treatment for gout. They work by reducing pain and inflammation during an attack.

NSAIDs used to treat gout include naproxen, diclofenac and etoricoxib.

If you’ve been prescribed NSAIDs, it’s a good idea to have them with you at all times so you can use them at the first sign of a gout attack. Continue to take your medication throughout the attack and for 48 hours afterwards.

Your GP may also prescribe a medication called a proton pump inhibitor (PPI), to take alongside your NSAID. This reduces the risk of the NSAID causing indigestion, stomach ulcers and bleeding from the stomach.

Colchicine

If you’re unable to take NSAIDs or if NSAIDs are ineffective, a medicine called colchicine can be used instead.

Colchicine reduces some of the swelling and pain associated with a gout attack.

It’s best to have it with you at all times so you can use it at the first sign of a gout attack. Your GP will tell you how long to take it for and how often.

When taken in high doses, side effects of colchicine include feeling sick, abdominal (tummy) pain and diarrhoea.

Corticosteroids

Corticosteroids are sometimes used to treat severe cases of gout if other treatments don’t work or you’re unable to take an NSAID or colchicine.

A short course of steroid tablets often provides relief, but they can’t be used long-term in high doses as they cause side effects, including: 

• weight gain
• thinning of the bones (osteoporosis)
• easy bruising
• muscle weakness

Corticosteroids can also be given by injection to provide rapid pain relief. This can be either into a muscle, a vein or directly into the affected joint. 

Medication and lifestyle changes to prevent further attacks

You can reduce your chances of having further gout attacks by taking medication and making lifestyle changes to reduce the level of uric acid in your body.

Medication

Medication to reduce uric acid levels – known as urate-lowering therapy (ULT) – is usually recommended if you have recurrent attacks of gout or you have complications of gout.

Most people with gout will eventually need to have ULT, so you may want to discuss the advantages and disadvantages of this treatment with your doctor as soon as you’ve been diagnosed with gout.

They should explain that while ULT can significantly reduce your risk of having further attacks, the medication needs to be taken on a daily basis for the rest of your life and there’s a small risk of side effects.

If you decide to start ULT, a medicine called allopurinol is usually tried first. If this isn’t suitable or doesn’t work, other medications may be used instead. These medications are described below.

Allopurinol

Allopurinol helps reduce the production of uric acid. It can help prevent gout attacks, although it won’t help relieve symptoms during an attack.

Allopurinol is a tablet taken once a day. When you first start taking it, your dose will be adjusted to make sure the level of uric acid in your blood is low enough. Regular blood tests will be needed to monitor this until the most effective dose is found.

Allopurinol can sometimes cause a gout attack soon after you start taking it and it can take up to a year or two before no further attacks occur. It’s important to persevere with treatment even if you do have attacks during this time.

To help relieve attacks, your doctor will prescribe one of the pain relieving medications described above to take alongside your allopurinol at first.

Most people taking allopurinol won’t experience any significant side effects. However, side effects can include:

• a rash – this is usually mild and goes away on its own, but it can be a sign of an allergy; if you develop a rash, stop taking the medication immediately and contact your GP for advice
• indigestion
• headaches
• diarrhoea

Febuxostat

Like allopurinol, febuxostat is a medication taken once a day that reduces the body’s production of uric acid. It’s often used if allopurinol isn’t suitable or causes troublesome side effects.

As with allopurinol, febuxostat can make your symptoms worse when you first start taking it. Your doctor will initially prescribe one of the pain relieving medications described in case you experience attacks.

Side effects of febuxostat can include:

• diarrhoea
• feeling sick
• headaches
• a rash

Other medications

Less commonly used ULT medications include benzbromarone and sulfinpyrazone.

These types of medication tend to only be used if people are unable to take allopurinol or febuxostat. They need to be prescribed under the supervision of a specialist.

Lifestyle changes

Certain lifestyle changes can also help reduce your risk of experiencing further attacks of gout, including:

• avoiding foods containing high levels of purine (the chemical involved in the production of uric acid), such as red meat, offal, oily fish, seafood and foods containing yeast extract.
• avoiding sugary drinks and snacks – these are associated with an increased risk of gout
• maintaining a healthy weight – follow a balanced diet; don’t crash diet or try high-protein, low-carbohydrate diets
• taking regular exercise – try activities that don’t put too much strain on your joints, such as swimming
• drinking plenty of water – keeping yourself well hydrated will reduce the risk of crystals forming in your joints
• cutting down on alcohol – avoid beer and spirits in particular and don’t binge drink

There’s some evidence to suggest that taking regular vitamin C supplements can reduce gout attacks, although the effect may only be small. Talk to your GP first if you’re thinking about taking vitamin C supplements, as they aren’t suitable or safe for everyone.

Complications of gout

Complications of gout can include small lumps forming under the skin (tophi), joint damage and kidney stones. These are more likely to occur if gout is left untreated.

Tophi

Gout is caused by a chemical called uric acid forming small crystals in and around the joints. These crystals also often build up under the skin and form small white or yellow lumps known as tophi.

Tophi are usually painless, but they can form in awkward places, such as at the ends of your fingers and around your toes. Sometimes they can make everyday tasks such as preparing food or getting dressed difficult.

They can also can become inflamed and produce a toothpaste-like discharge.

Tophi can develop anywhere in the body, but usually form on the:

• toes
• heels
• knees
• fingers
• ears
• forearms
• elbows

It normally takes several years after the first attack of gout for tophi to develop, but some people develop them even before experiencing an attack. They’re usually a sign of severe gout and a good reason to start treatment to reduce the level or uric acid in your body.

Successful treatment will prevent the tophi from getting any bigger, and long term treatment often gradually shrinks them.

If you have very large or painful tophi, they may have to be surgically removed.

Joint damage

Without treatment, gout attacks may become more frequent and prolonged, and your likelihood of developing permanent joint damage will increase.

In the most serious cases, surgery may be required to repair or replace a damaged joint.

Kidney stones

Occasionally, high levels of uric acid can lead to the formation of kidney stones.

Some kidney stones interfere with the flow of urine, resulting in pain when you pass urine, and can make you feel that you need to pass urine more often.

Some kidney stones interfere with the flow of urine, resulting in pain when you pee, and can make you feel that you need to pee more often.

You may be prescribed medication to make your urine less acidic, which should help dissolve any kidney stones that have developed. Read more about treating kidney stones.

Psychological and emotional effects

Gout can also affect your mood, work and home life. The severe pain that gout causes can make it difficult to do everyday tasks and to get around, which in turn can lead to feelings of depression or anxiety.

If gout is affecting your mood or making everyday life difficult, talk to your GP. They will be able to offer treatment and support.

There are also a number of organisations that offer information and advice for people who have gout, including Versus Arthritis.

How to identify, causes, and treatment

Gout is a form of arthritis that affects the joints and often begins at the big toe. Gout in the toes can lead to inflammation, pain, and joint stiffness.

According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), flares of gout often begin in the big toe.

Gout attacks can occur unexpectedly and without warning, often in the middle of the night, initially causing intense pain. A gout flare can last for a few days or weeks. Some people have frequent gout flares, while others may go several years before having another flare.

Gout occurs due to an excess buildup of uric acid crystals in the joints and soft tissue, causing inflammation and intense pain.

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Share on PinterestPeople with gout in the big toe may notice swelling and discoloration around the base of their toe.
Image credit: www.scientificanimations.com, 2019.

Gout attacks involve intense throbbing or burning joint pain, which occurs suddenly, followed by swelling, tenderness, warmth, and redness or discoloration.

It can affect a person’s hands, elbows, knees, feet, ankles, spine, and toes.

One 2018 article states that for some people, the pain may be so severe that they cannot tolerate the weight of a blanket. The symptoms are typically at their worst within 6–12 hours. The affected joint, or big toe, will recover in 1–2 weeks.

The following are indications that a person is experiencing a gout attack in the big toe:

• intense joint pain in the big toe
• rapid onset
• swelling and redness or discoloration
• tenderness
• difficulty moving

Due to severe pain and swelling, people who experience gout attacks may find it challenging to walk or stand.

How long does gout last?

Gout occurs due to an excess buildup of uric acid, or hyperuricemia.

According to the National Institutes of Health (NIH), hyperuricemia is the main risk factor for developing gout. However, a quarter of people with hyperuricemia do not develop gout.

When the body breaks down purines, it produces uric acid. Typically, the kidneys remove a certain amount of uric acid through urine. However, when they are unable to remove enough uric acid, crystals can form in the joints and soft tissues, causing swelling and pain.

Gout typically affects males more than females. However, females have higher levels of uric acid after menopause, which increases the risk of gout attacks. NIAMS states that being older also increases the chance of developing gout.

Genetics can also increase the chance of developing gout.

According to the Centers for Disease Control and Prevention (CDC), other factors that may increase the likelihood of gout include:

• Diet: Food can play a role in the development of gout symptoms. Seafood, red meat, and alcohol can raise uric acid levels. A low-purine diet may help avoid gout.
• Weight: Being overweight increases the chance of developing gout.
• Medications: Certain medications, including diuretics and low-dose aspirin, have an association with gout risk because they increase uric acid levels.
• Other medical conditions: High blood pressure, diabetes, and kidney disease can increase gout risk.

What is the link between gout and diabetes?

NIAMS recommends avoiding foods high in purine, such as:

• seafood, including cod, salmon, and mussels
• organ meat
• red meat
• pork
• sweetened foods, such as baked goods
• alcohol, and in particular, beer and distilled liquor
• beverages that are high in sugar

Conversely, certain foods may lower uric acid levels. They include:

• Cherries: A study has shown that cherries may help lower uric acid levels and reduce gout attacks. More studies are necessary, though.
• Vitamin C: According to a review from 2017, vitamin C may increase uric acid excretion. Eating foods that contain vitamin C may be beneficial.
• Coffee: One study suggests that people who regularly drink coffee are less likely to develop gout. However, more research is necessary to confirm these findings.

Which foods should people eat and avoid with gout?

A doctor has to carry out several examinations to diagnose gout.

Blood tests can assess uric acid levels in the body. However, the NIH states that some people with high uric acid may never develop gout symptoms, while those with low uric acid may experience gout attacks.

For this reason, a uric acid blood test cannot diagnose gout. However, it will help guide treatment and the doses of medication to use.

Joint fluid aspiration is the most helpful test to diagnose or confirm gout. In this test, urate crystals are visible. It is most useful soon after gout symptoms begin. It becomes more difficult for doctors to find the crystals over time because they dissolve and the body excretes them. A doctor may use ultrasound to guide this procedure.

An X-ray can detect bone erosion and calcifications, but these will only become visible as the disease progresses.

An experienced musculoskeletal radiologist may use a dual-energy CT scan to look for urate crystal deposits.

Gout happens when the body produces too much uric acid or does not excrete enough. Foods high in purines can trigger an attack. It commonly affects the joints of the lower extremities, such as the big toe, foot, ankle, or knee.

Pseudogout — also known as calcium pyrophosphate deposition disease — has similar symptoms, namely a painful and swollen joint, usually of the wrist or knee. It also involves a buildup of crystals, but not uric acid crystals.

Foods do not trigger pseudogout. It usually happens with older age, and genetic factors can play a role. It may also stem from metabolic causes, such as thyroid disease, iron overload, high calcium, and low magnesium levels.

Learn more about the difference between gout and pseudogout here.

A person can try the following to treat gout in the big toe:

Home remedies

According to the Arthritis Foundation, if a person experiences a gout flare in a big toe, they should call a doctor to make an appointment.

In the meantime, they can:

• Take medication: A person can take nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen (Aleve), ibuprofen, and celecoxib (Celebrex). However, low-dose aspirin may exacerbate a flare.
• Elevate the foot and apply ice: This may ease inflammation and pain. A person should elevate the foot so that it is higher than the chest and apply a cool pack to the toe for 20–30 minutes several times a day.
• Drink fluids: A person should avoid alcohol and sugary drinks. They should aim for 8–16 cups of fluid per day, half of which should be water.

A person can also use a cane or other mobility aids when they walk to help relieve pressure on the toe. They can also cut the big toe out of a pair of socks, so there is no pressure on the toe. Open-toe shoes or sandals are an option.

Learn more

Find out more about some home remedies for gout.

• What are some natural and home remedies for gout?
• Can apple cider vinegar help with gout?
• Does cherry juice help with gout?
• Can baking soda treat a gout flare?
• What are some natural ways to lower uric acid?

Long-term management

A doctor may recommend lifestyle changes to prevent recurrent gout attacks along with prescribed medications.

The CDC recommend the following lifestyle changes:

• reducing alcohol intake and drinks with high sugars
• taking regular exercise and maintaining a moderate weight
• avoiding foods that may cause gout attacks, such as seafood, organ meat, and red meat

What are the complications and long-term treatment of gout?

Medical treatment

Gout treatment usually involves medications.

A doctor will choose medicines based on the condition. According to NIAMS, medication can treat gout attack symptoms, prevent future attacks, and lower the chance of gout complications, such as tophi development.

Tophi occur when the uric acid crystals build up and form small lumps. They can happen anywhere but commonly develop at pressure points, such as the elbows or around the hand or foot joints.

To treat a flare, a doctor may recommend:

• a short course of oral corticosteroids, such as prednisone
• corticosteroid injections
• colchicine, such as Colcrys or Mitigare, taken for several days

To prevent flares, a doctor may prescribe one or more of the following:

• Allopurinol (Zyloprim) or febuxostat (Uloric): These reduce uric acid.
• Colchicine or NSAIDs: In the early stages, when the crystals are starting to dissolve, there is a higher chance of flare-ups. These drugs can help reduce this risk until allopurinol or febuxostat lower uric acid levels.
• Intravenous pegloticase (Krystexxa): This can help dissolve tophi in severe cases of gout that do not respond to other treatments.

According to the National Health Service (NHS) in the United Kingdom, some people with gout may develop complications, such as:

• Kidney stones: These may develop if urate crystals accumulate in the urinary tract.
• Kidney failure: Without treatment, urate crystals can build up in the kidneys, leading to kidney failure.
• Tophi: These are typically painless but can appear in awkward places, such as the toes, and can drain white chalky material.
• Joint damage: Some people may experience gout attacks frequently, while others may never have flare-ups. Without treatment, attacks may occur more frequently and cause permanent joint damage.

What is tophaceous gout?

Gout can be debilitating, but many lifestyle and dietary changes can help prevent it, such as:

• Maintaining a healthy body weight: Exercise and diet may help reduce uric acid levels in the blood.
• Reducing alcohol intake: Alcohol, especially beer and hard liquor, increases the risk of a gout attack. Limiting or avoiding alcohol helps the body excrete excess uric acid in the urine.
• Drinking plenty of fluids: A person should stay hydrated and limit their intake of sugary drinks.
• Eating a low-fat and low-purine diet: People should avoid food rich in purine, such as seafood and red meat. Instead, they can eat vegetables, low-fat dairy products, and plant-based proteins.

Is it safe to walk with gout?

Gout can occur without warning. Anyone experiencing intense pain in a big toe, followed by warmth, tenderness, redness, or discoloration should immediately seek medical attention.

If a person does not receive treatment for gout, it can lead to joint damage over time, including bone erosions and arthritis.

Gout attacks typically begin in a big toe. They can be excruciating, and people typically need medication to lower their uric acid levels and prevent uric acid buildup and joint damage.

Lifestyle choices, dietary changes, and medication can help prevent future attacks.

To relieve pain, a person can use NSAIDs as well as elevating the foot and applying ice.

90,000 signs, symptoms, diagnosis. Treatment of gout in St. Petersburg

Gout is a disease characterized by metabolic disorders and the development of pathological accumulation of sodium monourate crystals. An increase in uric acid in the blood (hyperuricemia) is a precursor to a possible gouty attack. In case of exceeding the maximum permissible concentrations of uric acid in the blood (> 360 µmol / l for women before menopause and > 420 µmol / l for men and women in postmenopausal age), in combination with environmental and / or genetic factors, places appear in the human body deposits of uric acid salts (in soft tissues, joints, kidney stones, etc. ).

History

Gout is one of the oldest diseases, the symptoms of which were first described by the doctors of Ancient Egypt in 2600 BC. The subsequent most accurate description was given by Hippocrates in the 5th century BC, describing “gout” as a disease with acute pain in the foot (the term “gout” comes from the Greek words “under” – leg, “agra” – a trap). The first classical description of gout appears in literature only in the 17th century (in 1683) in the “Treatise on Gout and Dropsy” and belongs to the famous English physician, “the father of clinical medicine”, Thomas Sydenham.

For a long time, gout was considered a disease of exclusively wealthy segments of the population and was popularly called the “disease of kings”. Famous people such as Alexander the Great, Leonardo da Vinci, Charles Darwin, Isaac Newton, members of the Medici family from Florence, Leo Tolstoy, Peter I, and Thomas Sydenham himself suffered from gout.

Disease pathogenesis

Protein compounds, entering the human body, are metabolized to purine bases, and further broken down to uric acid. And then the kidneys are responsible for removing uric acid from the body. If the concentration of uric acid is too high, at a certain point, the body is forced to start depositing its salts in the joints, soft tissues and kidneys.

As a result, the occurrence of arthritis and neoplasms on the flexor surfaces of the joints or auricles (tophi), kidney damage (urate nephropathy) and the formation of stones in them.

Gout usually affects men aged 30-60 years (an earlier debut is not excluded). Women are less likely to suffer from this disease and more often in the postmenopausal period. However, every year the statistics on the occurrence of gout begins to deteriorate and the proportional ratio among the sexes begins to change. Moreover, the older the population of the country becomes, the higher the prevalence of this disease.

An important link in the pathogenesis of hyperuricemia is not only a change in the cycle of excretion of uric acid from the body, but also the occurrence of a pathological cascade of reactions that have a toxic effect on body tissues (especially on the myocardium). Patients with elevated levels of uric acid in the blood are more likely to develop myocardial infarction, due to a deterioration in the contractility of the heart muscle and an increase in oxygen consumption by myocytes (cardiac muscle cells).

Causes of gout

The causes of gout in humans are:

• Unbalanced diet : consumption of large amounts of fatty meat or fish, alcohol, carbonated drinks, eggs and legumes. All of these foods contain a large number of purine bases, which can both cause gout and aggravate its course.
• Taking medications : thiazide diuretics, cyclosporins, aspirin (from 2 g per day).
• The presence of the following diseases: psoriasis (especially with widespread lesions of the skin), chronic renal failure , certain blood diseases, obesity and other metabolic disorders. Gout can be caused by organ transplantation or by the introduction of a contrast agent into the body during x-ray studies.

Gout: classification

Gout is classified into primary and secondary. AT 9In 9% of cases, primary gout is idiopathic, i.e. the cause of hyperuricemia (high uric acid) is not known (most often associated with a genetic predisposition). Most often, the development of primary gout depends on a number of factors: hormonal, genetic and dietary. Secondary gout is the result of taking medications, due to which there was a metabolic disorder in the body.

Signs of gout. Symptoms of gout

The main symptom of gout is an acute attack of arthritis. In this case, most often one of the joints is affected: the knee, ankle, and most often the 1st metatarsophalangeal (first toe). Most often, before the onset of an attack, a person feels completely healthy. An attack of gout always occurs suddenly and is characterized by the formation of arthritis (inflammation in the joint), accompanied by severe pressing pain and unfolds in full force at night or in the early morning. Uric acid, being in the joint cavity, leads to swelling, the skin becomes red and may shine, the body temperature in the affected area increases.

Very often, patients describe gout as a non-abating throbbing pain, accompanied by severe inflammation of the soft tissues surrounding the joint. Usually, the joint area becomes sharply painful and often patients cannot walk in their usual shoes. From time to time, a gout attack can be provoked by minimal injuries (bruises) of the joint, which causes confusion and an initial appeal to orthopedic traumatologists .

Attacks of gout can last from several days to several weeks, and in some severe cases can last even longer. Often, even despite the spontaneous relief of the first attack, in the future, patients are faced with the recurrence of the inflammatory process. It is possible to spread the process to other joints, and with a prolonged course of gout, tophi are formed on the flexion surfaces of the joints, which can open with the release of uric acid crystals. During this period, a person experiences very severe pain. That is why it is important to appear at the first symptoms of the disease rheumatologist .

Criteria for the diagnosis of gout:

Verification of the diagnosis of gout by a rheumatologist is carried out according to two different classification and diagnostic criteria:

1. 1. 2015 American College of Rheumatology/European League for Rheumatic Diseases (ACR/EULAR) classification criteria;
2. 2. Oxford Diagnostic Criteria 2014.

The classification criteria of 2015 are the most used in wide clinical practice. To apply the classification criteria, one condition must be met: at least one episode of swelling, pain, or tenderness in a peripheral joint or bursa.

Subject to this condition, further diagnosis is possible, depending on the anamnesis data available to the doctor, instrumental and laboratory research methods:

Criterion	Joint	score
Clinical
Joint involvement during a typical gout attack	ankle/tarsus, 1st metatarsophalangeal joint	+ 1 point + 2 points
Typical acute attack of gout	erythema over the surface of the joint (reported by the patient or fixed by the doctor), inability to touch or press on the area of ​​the affected joint, significant difficulty walking or inability to perform.	one characteristic “+1 point” two characteristics “+2 points” three characteristics “+3 points”
Dynamics of a typical acute attack	The presence of 2 or more signs, regardless of anti-inflammatory therapy: duration of pain attack less than 24 hours, resolution of symptoms in less than 14 days complete regression of symptoms (to baseline) in the interictal period	one typical episode “+1 point” recurrent typical episodes “+2 points”
Clinical signs of tofus	Drained or plaster-like subcutaneous nodule, often vascularized, with typical localization: joints, ears, olecranon bursa, fingertips, tendons.	Presented “+4 points”
Laboratory methods
Uric acid level (determined during the period of time when the patient does not receive drugs that reduce uric acid levels)	< 4 mg/dL (240 µmol/L) 6- 8- >10 mg/dl (> 600 µmol/l)	“- 4 points” “+2 points” “+3 points” “+4 points”
Analysis of synovial fluid (polarizing microscopy)	Negative result.	“-2 points”
Diagnostic imaging techniques
Signs of the presence of urate deposition	Ultrasound phenomenon of “double contour” or evidence of urate deposition when using the CT method with two radiation sources.	“+4 points”
Signs of gout-related joint damage	Detection of at least 1 erosion during radiography of the hands and/or feet.	“+4 points”

Diagnosis is possible if the total score is equal to or greater than 4 points.

Diagnosis criteria example:

• Attack of arthritis of the I metatarsophalangeal joint – +2 points
• Episode description: erythema over the joint, inability to tolerate touch/pressure, great difficulty walking/inability to use the affected joint +3 points
• More than 1 “typical episode of arthritis” – +2 points
• Hyperuricemia (548 µmol/l) – +3 points

Treatment of gout

Treatment of gout by rheumatologists of our clinic in St. Petersburg is carried out by pharmacological and non-pharmacological methods and takes into account the following factors:

• the concentration of uric acid in the blood of a person, as well as the number of previous manifestations of arthritis,
• stage of disease development (asymptomatic increase in uric acid, interictal period, acute or intermittent arthritis, chronic tophi gout, established chronic renal failure),
• the patient’s age, sex, presence of obesity, whether there was an intake of antihyperuricemic drugs, as well as concomitant and comorbid diseases.

It is important to note that asymptomatic hyperuricemia does not equate to gout. To date, there are conflicting data on the need to correct hyperuricemia. Some researchers agree on the position of reducing the pharmacological burden (there is no need to prescribe drug therapy in case of an asymptomatic increase in the level of uric acid), others prove the need for drug therapy to maintain normouricemia in such patients. The main thesis on which both domestic and foreign doctors and scientists agree is the mandatory prescription of drug therapy to patients at risk of developing fatal cardiovascular events and already formed cardiovascular diseases, published as part of the Resolution of the Council of Experts in 2023 (“B focus on hyperuricemia”; Cardiovascular Therapy and Prevention. 2023;22(4):3564. doi:10.15829/1728-8800-2023-3564).

Scheme of prescribing therapy for patients with an increase in the level of uric acid in the blood according to the results of the Resolution of the Council of Experts “Focus on hyperuricemia”; Cardiovascular therapy and prevention.

The combination of non-pharmacological and pharmacological methods in the treatment of gout is considered more effective than monotherapy. However, it is important to take into account the phase of the disease: acute attack of arthritis or its chronic form, or interictal period, tophi form, serum uric acid concentration, number of arthritis attacks, the presence of comorbid conditions such as diabetes mellitus (DM), arterial hypertension, coronary heart disease (IHD).

The most important thing in the treatment of gout is maintaining a proper lifestyle for patients, reducing alcohol intake (especially beer), smoking cessation, diet, and weight loss. If you limit the intake of purine-rich foods and reduce body weight, then the serum level of uric acid will decrease. Also, in the treatment of gout, it is important to control comorbid diseases – diabetes mellitus, dyslipidemia, alternative hypertension.

Treatment of an acute attack of gout

• One of the fastest-acting treatments in practice is removal of synovial fluid and intra-articular injection of long-acting steroids.
• Compliance with dietary recommendations . Without dieting, achieving relief from an attack is almost impossible. In the acute period, strict adherence to a diet is necessary with a mandatory decrease in the intake of protein products (especially from red meat) and a complete rejection of alcohol.
• Note that patients with gout are restricted from taking diuretics except when it is vital.
• In the treatment of an acute attack of gout, a doctor prescribes non-steroidal anti-inflammatory drugs (NSAIDs) and first-line antihyperuricemic drugs (colchicine) in combination or monotherapy. Non-steroidal anti-inflammatory drugs (NSAIDs) are prescribed to relieve pain and reduce the intensity of the inflammatory process.
• Glucocorticoids (GCs) are prescribed in short courses, but they do not show great efficacy compared to NSAIDs and have a greater number of delayed side effects.
• In patients with frequent attacks of arthritis and contraindications to the appointment of antihyperuremic drugs, NSAIDs and GCs (by mouth and by injection), consider using interleukin-1 inhibitors for the treatment of an attack: canakinumab (Ilaris) or anakinra (Kineret).

In our rheumatology center, it is possible to prescribe all options for the treatment of an acute attack of gouty arthritis, including with the help of innovative expensive drugs (a group of genetically engineered biological therapy: interleukin-1 inhibitors).

Purpose of therapy at the time of exacerbation:

1. 1. normalization of blood uric acid levels.

2. 
   2. Relief of an acute attack with a further decision on the appointment of maintenance therapy.

NB: Prescribing maintenance therapy is mandatory (!!!) to prevent the occurrence of gout attacks and prevent the development of chronic diseases associated with an increase in the level of uric acid. In particular, it is important to prescribe therapy for patients with cardiovascular diseases or an increased risk of their occurrence. Therapy is prescribed for a long period and is not canceled in the absence of seizures.

Recommendations for antihyperuricemic therapy in the asymptomatic period

Antihyperuricemic therapy is prescribed to prevent the formation of sodium monourate crystals, as well as the dissolution of existing crystals, by maintaining the level of uric acid at a level below 360 µmol / l.

• Compliance with dietary recommendations . Without dieting, achieving a long period of inaccessibility in most cases is impossible. When stable remission is achieved (no relapses), it is possible to gradually add moderate portions of high-protein foods to food. NB: the doctors of our center welcome the diet, but we are not inclined to insist on the complete rejection of the entire list of products indicated in the anti-gout diet.
• For long-term treatment in an attack-free period, rheumatologists use first-line anti-gout drugs (colchicine) , used in the treatment of gouty attacks, or allopurinol.
• In case of intolerance to the above drugs, including due to allergic reactions, as well as in patients with mild or moderate renal insufficiency, xanthine oxidase inhibitors are used, which are metabolized in the liver and almost not excreted by the kidneys.
• Also used are uricosurics – drugs that can be prescribed to patients with chronic forms of gouty arthritis in the form of monotherapy or combination therapy with other drugs. They block the reabsorption of uric acid in the renal tubules, resulting in a decrease in its level in the blood. But while the content of urates in the joints decreases, on the contrary, there are more of them in the urine, which is dangerous for kidney stones.

N.B. Therefore, it is clear that prescribing drugs and monitoring their use is the task of a doctor who assesses the current state of the patient, knows the mechanism of action, indications and contraindications for the use of the drug and the risks of prescribing it.

Goal of therapy in the absence of seizures:

1. 1. Continuous maintenance of normal blood uric acid levels (less than 360 µmol/l).

2. 
   2. Prevention of the occurrence of acute attacks and the formation of complications against the background of the course of hyperuricemia and chronic gout.

3. 
   3. Timely detection and correction of concomitant diseases that have arisen against the background of a long-term increase in the level of uric acid in the blood.

The basic principle of patient management in our clinic is that patients with gout should be fully informed and fully involved in the decision-making process regarding the administration of urate-lowering therapy.

In our rheumatology center in St. Petersburg on the basis of the KVMT named after. N.I. Pirogov, you can not only undergo a complete diagnosis of rheumatic diseases, including gout, but also do all the necessary laboratory and instrumental studies that the doctor will prescribe for you. You can make an appointment and consultation by phone +7(812) 676-25-25 or fill out an application on our website.

What you need to know about gout, the disease that killed Pierre Narcisse

• Health

A harmless inflammation of the big toe in a person can lead to a serious illness, which is often called the disease of kings. Ignoring an alarming symptom is extremely dangerous.

June 23, 2022

Pierre Narcisse was 45 years old.

Source:

social networks

In ancient times, the disease of kings was called gout. Perhaps because older people suffer from this disease more often, and as you know, only rich people lived to old age.

Now people are talking about gout again in social networks: the day before it became known that it was because of this disease that the famous singer, a member of the Star Factory, Pierre Narcisse, died. The artist suffered from several chronic diseases, including gout. At the time of his death, he was only 45 years old.

What can provoke gout, what indicators in the analyzes should be looked at especially carefully so as not to miss the disease, and what symptoms appear very first? We deal with experts.

What is gout

– This is a disease in which there is an excessive accumulation of uric acid salts. In general, this is a normal metabolic product, but with gout, the body produces more of it than it has time to excrete,” explains cardiologist Aleksey Zhito in his blog.

Therefore, it is very important to know and control the level of uric acid. If the indicators are high, then this may indicate that one or another pathology develops in the body, among which there may be gout.

See also

Symptoms of gout

A characteristic symptom of gout is an inflamed bump on the big toe, while the toe itself may become red and swollen.

– First of all, gout is manifested by inflammation on the big toe, which then spreads to other joints, – says Alexey Zhito. – During the transition to the chronic form of the disease, tophi (seals) are formed around the affected joints, the joints are deformed.

Among other signs of gout

• back pain,

• sometimes blood in the urine,

• inflammation of the periarticular tissues.

Why gout is dangerous

– The disease can be very painful. When the big toe is affected, the feeling is as if it is constantly being burned or being pierced with a red-hot poker. Hence the complications in the form of depression due to constant pain syndrome, high blood pressure and coronary heart disease,” says Alexey Zhito.

How gout is diagnosed

– During acute attacks, a complete blood count is performed. He can detect an increase in ESR, leukocytosis with a shift to the left – it means that young, “immature” neutrophils appear in the blood, which are normally present only in the bone marrow, but not in the blood, explains therapist Gito. Also, the diagnosis can be confirmed by these indicators:

• Increased uric acid in the blood serum.

• Increased C-reactive protein.

• Urates (salts of uric acid) were found in the general analysis of urine.

• Inflammation, deformity on x-ray and ultrasound of the joints.

Read also

Treatment of gout

– This is a multifactorial disease that can and should be fought, – says the doctor. – It is possible to prevent and prevent exacerbation. For this you need to see a doctor. The therapist will assess the general condition of the patient, give direction for research. Optimal treatment of gout should take into account the level of uric acid, the number of previous exacerbations, x-ray data, stage of the disease, age, gender of the patient, obesity, and other factors. Preparations for the treatment of gout are selected individually with the doctor.

The therapist notes that gout can be treated without the use of drugs.

– If you see a doctor and can control the process of exacerbation, then you can get by with non-drug methods of treatment – this is dieting, limiting alcohol consumption, reducing excess weight, says therapist Alexei Zhito.

Source:

IStockphoto

How gout appears due to diet

As endocrinologist Zukhra Pavlova notes, uric acid is formed in our body as a metabolic product and when it enters the body purines.