Gout

Gout is a common painful form of arthritis (joint swelling or inflammation). It causes sudden bouts of severe joint pain and swelling, especially in your toes, knees, elbows, wrists and fingers. If left untreated, gout can cause serious damage to joints, kidneys and your quality of life.

Key points

  1. Gout is a painful form of arthritis that can be well managed and effectively treated. 
  2. Gout is caused by a build-up of uric acid in your blood, which forms sharp crystals in the joints. The key to effective gout management is getting uric acid levels below 0.36 mmol/L.
  3. Gout is caused more by your genes than your diet. While common in Maori and Pacific men, gout is not normal – see your doctor.
  4. If you have more than two attacks of gout per year, your doctor may prescribe a medication that will prevent further attacks by lowering uric acid levels.
  5. Gout won't go away unless you take your medications regularly and follow the 5 steps for preventing gout.

undefinedundefined 
Video: TV One interviews Dr Nicola Dalbeth about gout in NZ. 

What causes gout?

Gout results from uric acid building up in your body

  • Uric acid comes from the breakdown of substances called purines. 
  • Purines are in your body's tissues and in foods such as liver, meat and seafood.
  • Normally, uric acid dissolves in the blood, is filtered by the kidneys and flushed out of the body in urine.
  • Sometimes uric acid can build up and form needle-like crystals in your joints or cause kidney stones.
  • Some people can have high levels of uric acid in the blood (hyperuricaemia) but have no joint pain. Others who have gout attacks (painful episodes) can have near-normal uric acid levels.

What causes high uric acid in your body?

  • 80% of high uric acid is caused by your body not getting rid of uric acid properly. This could be because of:
    • your genes
    • your weight
    • kidney problems.
  • 20% of high uric acid is caused by what you eat and drink.

Accumulation of uric acid may also cause kidney problems. This is another important reason for controlling uric acid levels with medications.

Who is at risk of getting gout?

People most at risk of having a gout attack have a high uric acid level in their blood. Risk factors for this include:

  • Genetics – the risk of having high uric acid levels and gout tends to run in some families.
  • Ethnicity – rates of gout in New Zealand are very high for Maori and Pacific men due to a range of genetic and lifestyle factors.
  • Increasing age – in about 90% of cases, gout affects men aged over 40 years and women after menopause.
  • Being overweight.
  • Having high blood pressure (hypertension).
  • Taking certain medicines, eg, water or fluid tablets (diuretics) for high blood pressure or heart failure.
  • Existing kidney problems and some other diseases.
  • High alcohol intake.
  • High intake of sugary drinks.
  • Diet too rich in purines, eg, liver, meat, seafood.

If you are prone to having high uric acid levels, there are changes you can make to reduce the risk of developing gout.

Tip: Ask your doctor whether you need to change any medications you take for other health problems.

Symptoms of gout

When uric acid crystals form in a joint they can cause pain.

  • This often occurs overnight and within 12 to 24 hours there is severe pain, which usually lasts 5 to 10 days, but can continue for weeks.
  • The pain is accompanied by joint inflammation (it appears red and swollen, and feels hot and extremely sensitive even to light touch).

Gout commonly strikes the big toe where it joins the ball of the foot, but other joints can be affected, including the instep, ankle, knee, kneecap, wrist, tip of the elbow and fingers. It can also cause inflammation of the tendons and the fat pads of the feet.

Diagnosis of gout

Your doctor can diagnose gout based on your symptoms, blood tests showing high levels of uric acid and urate crystals in joint fluid. 

In the early stages of gout, x-rays are not usually helpful in diagnosis, but in advanced gout x-rays can show any damage to cartilage and bones.

Managing gout

You may not always be able to avoid gout attacks, but medications and self-care can help reduce your symptoms.

  • You can get rid of 80% of uric acid by taking uric acid medicines everyday.
  • You can get rid of 20% of uric acid by:  
    • eating less seafood and meat
    • not drinking beer, fizzy drinks and orange juice
    • drinking water
    • being active – walk, swim, go to the gym
    • losing weight if you need to.

Read more about medications for gout and 5 steps for preventing gout

Treating acute gout attacks

  • For an acute gout attack, one of the non steroidal anti-inflammatory drugs (NSAIDs) such as naproxen (Naprosyn) or diclofenac (Volaten) can be very effective.
  • To gain the best results the drug should be taken as soon as possible at the first sign of an attack, and continued until the pain and swelling go down.
  • If you are unable to take NSAIDs, medication such as colchicine or prednisone can help reduce the pain of gout.
  • Rest and elevate the inflamed joint if you can.
  • Cold packs can also reduce the pain.
  • Also drink 4 or 5 extra glasses of water a day. 

Seek medical advice early. With effective treatment the attack may be controlled within 12-24 hours and treatment need not be continued after a few days.

Treating recurrent gout

Medications to lower uric acid levels below 0.36mmol/L

If the attacks continue or become more frequent, your doctor will usually recommend long term use of medicines to reduce your uric acid levels. The goal of these medicines is to reduce the uric acid levels below 0.36mmol/L.

If the uric acid level is kept at this level long-term, the gout crystals will dissolve, and the risk of gout attacks and joint damage from gout will gradually reduce.

  • The most common drug to reduce the uric acid level is allopurinol
  • Probenecid is another commonly used medicine to reduce uric acid build up.
  • Two other medicines for lowering uric acid are febuxostat and benzbromarone.

Uric acid lowering medications take time to work

Drugs used to reduce uric acid levels will not relieve your pain immediately, but it is important to keep taking them as advised (even when feeling well) because the benefits of controlling your uric acid levels will occur over years.

  • For the first few months of treatment, gout attacks may become more frequent.
  • This can be controlled by taking one or two tablets a day of an additional drug (such as colchicine) for several months.
  • If any acute attacks do appear they must be treated in the usual way and the long term-medicines continued. It will be worth it.

Drugs for reducing uric acid levels must be taken as advised by your doctor because they can have side effects – your doctor will explain this in more detail.

Self care for gout

Whether you have just had your first gout attack or have had gout for some years, you can work towards preventing future attacks if you know what to do and decide to take action now.

5 steps for keeping well and preventing gout:

1. Know your uric acid level and aim for it to be less than 0.36 mmol/l.
2. Have a medication action plan to manage acute gout attacks.
3. Avoid triggers.
4. Reach and maintain a healthy weight.
5. Know what else you can do.

Read more about these 5 steps for preventing gout

Learn more

Arthritis New Zealand 
Gout section NHS Choices website, UK
The Maori Gout Action Group website 

References

  1. Winnard D, Wright C, Jackson G, Gow P, Kerr A, McLachlan A, Orr-Walker B, Dalbeth N. Gout, diabetes and cardiovascular disease in the Aotearoa New Zealand adult population: co-prevalence and implications for clinical practice. NZ Med J. 2012 Jan 25;126(1368):53-64. [Abstract]  [Full article]
  2. Batt C, Phipps-Green AJ, Black MA, et al. Sugar-sweetened beverage consumption: a risk factor for prevalent gout with SLC2A9 genotype-specific effects on serum urate and risk of gout Ann Rheum Dis 2014;73:2101–2106 [abstract]  [full pdf]
Credits: by Assoc Prof Peter Gow. Reviewed By: Assoc Prof Nicola Dalbeth on behalf of the Maori Gout Action Group & Northern Region Clinical Pathways Last reviewed: 18 Feb 2015