Gout

Gout is a common painful form of arthritis (joint swelling or inflammation).

It causes sudden bouts of severe joint pain in places such as such as the big toe, ankles, heels, knees, wrists, fingers or elbows, and the ball of the foot is commonly involved. Swelling can flare up within hours. If gout attacks are left untreated, the pain can last from days to weeks.

In New Zealand, gout is most common in Māori and Pacific men due to a range of genetic and lifestyle factors. If left untreated, gout can cause serious damage to joints, kidneys and your quality of life.

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Video TV One interviews Dr Nicola Dalbeth about gout in NZ. South Auckland: Gout's capital of the world

With the right treatment, gout attacks can be prevented and you can get back to doing the things you enjoy. Gout is caused by crystals in the joints that form when blood levels of uric acid are high. The key to effective gout management is getting uric acid levels down.

Key points

  1. Gout is a painful form of arthritis that can be well managed/effectively treated.
  2. With delayed or no treatment, gout can cause serious damage to joints and kidneys.
  3. Gout is caused by a build-up of uric acid in your blood, which forms sharp crystals in the joints.
  4. If you have more than two attacks of gout per year, ask your doctor for a medication that will prevent further attacks.
  5. Find out what your uric acid level is and aim for below 0.36 mmol/L.
  6. Gout is caused more by your genes than your diet.
  7. While common in Maori and Pacific men, gout is NOT normal – see your doctor!
  8. Keep to a healthy weight or lose weight if out of the healthy range. See our BMI calculator.
  9. Gout won't go away unless you take your medications regularly.

Causes

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.

Sometimes people can have high levels of uric acid in the blood (hyperuricaemia) but have no joint pain, and others who have gout attacks (painful episodes) can have near-normal uric acid levels.

Accumulation of uric acid may also cause kidney problems, and 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. Other risk factors include:

  • Genetics can influence the body's handling of uric acid. The risk of having high uric acid levels and gout tends to run in some families.
  • 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 (predisposed to) 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 

When uric acid (urate) 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 five 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 

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.

Treatment 

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

  • 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.
  • 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.
  • 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.

Pain medications

NSAIDs are not suitable for some people; to decide if they are right for you, your doctor will take into account factors such as whether you have other medical conditions or take other medicines.

Rest and applying cold packs on the painful joint may also reduce the pain.

Other pain treatments

Other drugs such as colchicine, or corticosteroids (given as tablets or by injection into the joint), can also be used for a short period to control gout.

Medicines used for gout attacks have no effect on reducing uric acid levels. If you have experienced more than one gout attack, your doctor may recommend medicines to reduce uric acid levels and prevent further attacks.

Rest and applying cold or heat packs on the painful joint may also reduce the pain.

Medications to lower uric acid levels

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.

These drugs 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. 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.

It is also very important when beginning such drugs to realise that 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 at least and 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.

Self care

If you have had your first gout attack, or had gout for some years, you can make a difference if you know what to do and decide to take action now.

  • If you have two or more attacks of gout per year, medication to lower the uric acid level in the blood is recommended.
  • The goal of treatment is to reduce the blood uric acid level below 0.36 mmol/L. If this low level is maintained, the gout crystals gradually dissolve, and gout attacks will be prevented.
  • The most common medication for this is allopurinol (also known as Zyloprim, Progout or Allorin) which stops uric acid forming.
  • This medicine must be taken long term, often for years, to lower your uric acid into the normal range, and keep it there.
  • Once this occurs, further attacks of gout will be prevented, as long as the drug is continued.
  • Do not stop the medication even when your painful gouty attacks stop, because the uric acid level could well rise again and damage your joints and possibly your kidneys.
  • If you do take the tablets regularly, you can eat more of the foods you enjoy, and drink alcohol again in moderation.

To keep well and gout free follow the 5 steps:

Step 1: Know your uric acid level and aim for it to be less than 0.36 mmol/l
  • Aim for the target - uric acid <0.36 mmol/l.
  • If you are prescribed medications to reduce the uric acid, take these every day, even when you are feeling well.
Step 2: Have an action plan to manage acute gout attacks
  • Make sure you have a supply of medications available to treat a gout attack if it occurs.
  • If you feel a gout attack starting, take this medication as soon as possible to prevent it becoming very severe.
3. Avoid triggers

Identify and correct those factors that can trigger your gout attacks, such as;

  • prolonged stress
  • injury
  • unusual physical exercise
  • surgical operations
  • severe illness
  • crash dieting
  • diets containing high levels of purine such as meat, seafood, livers
  • sugary drinks
  • dehydration
  • alcohol – especially beer
  • drugs – including diuretics which can interfere with the normal excretion of uric acid.
Step 4: Reach and maintain a healthy weight

Tips for weight loss

  • Eating less fatty food and high sugar foods.
  • Avoid eating large meals or going for many hours without eating.
  • Small meals eaten at regular times are best.
  • Eat a sensible breakfast, every day (People who miss or skip breakfast tend to weigh more).
  • Remember to drink plenty of fluids, at least 8 glasses per day if possible.
  • Avoid fizzy drinks (these are often sweetened with fructose which increases uric acid levels).
  • Milk, low fat dairy products, coffee and vitamin C appear to reduce the risk of developing gout.
  • Regular exercise, such as a brisk walk for 30 minutes five times a week, will reduce your weight, and have other good effects on your heart, blood pressure, and blood sugar levels.
Step 5: What else you can do
  • take control by knowing your uric acid level
  • work with your healthcare team and be an important part of it
  • know about your treatment options eg physical therapies, prescription and non-prescription medications
  • find new ways to stay active
  • learn techniques to help manage your pain
  • acknowledge your feelings and seek support
  • make food choices that count.

Attending a self management course is a great way to find out what you can do to help yourself, meet new friends, support each other and make some healthier choices for yourself and your family. Ask your doctor for groups in your area.

Learn more

Arthritis New Zealand 
The NHS website 
The Maori gout action 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]
Credits: Health Navigator with Assoc Prof Peter Gow. 2014 review by Assoc Prof Nicola Dalbeth on behalf of Maori Gout Action Group. Last reviewed: 18 Feb 2015