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Gout

Gout is a common, painful form of arthritis (joint inflammation). It causes severe joint pain and swelling that can flare up within hours such as the big toe, ankles, heels, knees, wrists, fingers or elbows. It is caused by crystal in the joint that form when blood levels of uric acid are high.

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

With the right treatment, further gout attacks can be prevented and you can get back to doing the things you enjoy. The key to effective gout management is getting the uric acid level down.

Video: South Auckland: Gout's capital of the world


Image links to TV One video interviewing Dr Nicola Dalbeth, about gout in NZ.

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Clinical Pathway

Key Messages for gout sufferers and their families:

  1. Gout is a painful form of arthritis that can be well managed or effectively 'cured' with the right treatment
  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 2 attacks of gout per year, ask your doctor for preventive medication
  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, do NOT accept gout attacks as 'normal' - see your doctor!
  8. Keep to a healthy weight or lose weight if above healthy range

Overview - What is gout?

Gout is a common type of arthritis (joint inflammation). It causes sudden bouts of severe joint pain and swelling, usually in just one or two joints (the ball of the foot is commonly involved), and which, left untreated, last from days to weeks. These bouts of acute gouty arthritis are also called gout attacks.

  • Gout affects men (middle-aged generally) much more often than women.
  • In New Zealand, high rates of gout are seen in Maori and Pacific Island people (especially men).
  • Gout is closely linked with the body's level of uric acid - a normal breakdown product of digesting certain foods. High uric acid levels and gout attacks can be treated by your doctor.

Uric acid

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 (very painful) or kidney stones.

Sometimes people can have high levels of uric acid in the blood (hyperuricaemia), but have no joint pain, and other people who have gout attacks 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.

Symptoms of gout

When uric acid crystals form in a joint they cause a painful arthritis called a gout attack.

  • 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.

Am I at risk of developing gout?

The strongest predictor for gout is a high uric acid level. 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 the menopause.
  • Being overweight
  • Having high blood pressure.
  • Certain medications e.g., 'water tablets' or 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.  For example: liver, meat, seafood

If you are 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.

Diagnosis and Tests

Your doctor can diagnose gout based on your symptoms, blood tests showing high levels of uric acid and, by finding urate crystals in any joint fluid if this has been obtained.

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

Treatment of gout

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

Non-steroidal anti-inflammatory drug (NSAID): can be very effective pain relievers. To gain the best results, the dose should be adequate and the drug taken at the first sign of an attack. Hence, medical advice must be sought early.

  • With effective treatment the pain and inflammation can be controlled within 12 to 24 hours and treatment discontinued after a few days.
  • NSAIDs are not suitable for some people, however, and your doctor will take into account individual 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 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.

Drugs 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 your uric acid and prevent further attacks.

Read more....

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 medication to reduce the uric acid level. Two further 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 as side effects may occur - your doctor will explain all of this to you.

What can I do? - Self-care

If you think you are having a gout attack:

  • seek help from your doctor as early as possible, take any medications prescribed by your doctor and continue taking them for as long as advised
  • rest and try to keep the weight of any bedclothes off the painful joint
  • try using ice or a heat pack on the joint (stop if the pain worsens)

See your doctor to discuss preventing further gout attacks:

  • Get your uric acid level checked
  • Ask about medications to reduce uric acid levels
  • If you are prescribed medications to reduce uric acid, take these every day, even if you are feeling well.
  • Exercise and keeping active is very important and worth the effort
  • Avoid sugary drinks and foods that trigger your gout.

Learn more about managing gout well by:

  1. Attend a self management programme - great opportunity to learn tips for "living a healthier life"
  2. Find out what others say  - Your stories - living well with gout
  3. Ask your doctor/nurse for a heart and diabetes check as people with gout have a higher risk of these conditions. (1)

Resources for everyone

pdf Booklet - Stop Gout - 2014 (NEW) Ministry of Health  (Note: 5 MB) 

pdf Out with Gout - NZ Gout Booklet - 2008  PHARMAC NZ   (Multiple languages)

Your stories - living well with gout - Health Navigator 

more ....

Resources for Health Professionals

A recent study by Jackson et al (2) Oct 14, shows many New Zealanders with recurrent gout are not taking uric lowering medication regularly.

  • Of those on allopurinol, 69% were receiving allopurinol regularly,
  • Only 34% of people dispensed allopurinol had serum urate testing in a 6-month period.
  • Despite having twice the chance of being hospitalised with acute gout, Maori and Pacific people with gout were less likely to be on regular allopurinol treatment. (2)

 

html  Acute gout clinical pathway   2) Gout Prevention - Northern Region, NZ Healthpoint

html Maaori Gout Action Group Website - Range of useful resources including:

pdf Update on management of gout March 2013 - Best Practice Journal

pdfGenes, fructose, allopurinol and gout - Nov 2010 -  Best Practice Journal

pdfTreatment of Gout - Hit the target - 2007  - Best Practice Journal

Further information and support

html Gout - Arthritis New Zealand

html Rheumatology Services & Specialists Healthpoint

References

  1. Winnard D1, 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. Jackson G1, Dalbeth N, Te Karu L, Winnard D, Gow P, Gerard C, Minko N. Variation in gout care in Aotearoa New Zealand: a national analysis of quality markers.N Z Med J. 2014 Oct 17;127(1404):37-47. [Abstract]

Credits:  Thanks to Assoc Prof Peter Gow for helping write the original article. Reviewed by Assoc Prof Nicola Dalbeth on behalf of Maori Gout Action Group, July 2014.  Latest update with recent studies added Nov 14. 

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Last updated on November 8, 2014