Gout is a common and painful form of arthritis. It causes severe joint pain and swelling, especially in your toes, knees, elbows, wrists and fingers. If left untreated, gout can cause serious damage to your joints, kidneys and quality of life.
Gout is caused by a build-up of uric acid in your blood. The uric acid forms crystals in your joints.
High uric acid levels are mainly due to genetic factors. While common in Māori and Pasifika men, gout is not normal – see your doctor if you have the symptoms.
If you have more than two attacks of gout per year, your doctor may prescribe a medication to prevent further attacks by lowering your uric acid levels. The key to preventing gout attacks is getting uric acid levels to below 0.36 mmol/L.
If left untreated gout can cause permanent damage to your joints and harm your kidneys.
With effective treatment, a gout attack may be controlled within 12–24 hours. Medication and lifestyle changes can help prevent gout attacks.
Gout in New Zealand
Discover how Mr Tupotahi manages gout.
(Auckland University of Technology, NZ, 2010)
What causes gout?
Gout is caused by a buildup of uric acid in your body
Uric acid mostly (two-thirds) comes from the breakdown of cells in your body. The remainder (one-third) comes from chemicals called purines that are in your food.
Normally, your kidneys filter uric acid from your blood and flush it out of your body in urine (pee).
When uric acid levels in your blood are high, uric acid crystals form in yourjoints. These crystals cause pain, inflammation and lumps (called tophi).
What causes high uric acid?
The most common cause of high uric acid is due to your body not getting rid of it properly.
This is mainly due to genetic factors. Other factors can include certain medications and other health conditions.
Who is at risk of getting gout?
High uric acid levels are caused by the following factors:
Genetics – some Māori and Pasifika people have genes that make it harder to get rid of uric acid from their bodies.
Being overweight – carrying extra weight slows down the removal of uric acid by your kidneys.
Increasing age – in about 90% of cases, gout affects men aged over 40 years and women after menopause.
What you eat and drink – you increase your risk if you drink a lot of sugary drinks or alcohol, or eat too much food that is rich in purines, such as liver, meat or seafood.
Having high blood pressure (hypertension).
Taking certain medicines, such as water or fluid tablets (diuretics) for high blood pressure or heart failure.
Existing kidney problems and some other conditions.
Tip: Ask your doctor whether you need to change any medications you take for other health problems.
What are the symptoms of gout?
The symptoms of gout include severe pain in one or more joints. In most cases, gout affects one joint at a time.
The joint most commonly affected is the large toe. Other sites include your forefoot, instep, heel, ankle and knee. Gout is uncommon in the upper body, but it can affect your fingers, wrists and elbows.
Gout attacks are very painful. A gout attack usually begins suddenly, often at night. Within hours, the joint becomes red, swollen, hot and painful. This is due to uric acid crystals in the joint causing sudden inflammation.
The pain and tenderness can be so severe that even gentle pressure from bedding is a problem. Even though only one small joint is affected, the inflammation can be intense enough to cause fever, muscle aches and other flu-like symptoms.
An attack usually lasts for 5 to 10 days but in rare cases, it can continue for weeks.
How is gout diagnosed?
Your doctor can diagnose gout based on your symptoms, blood tests showing high levels of uric acid and urate crystals in joint fluid (from a sample taken through a small needle put into your joint).
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 your cartilage and bones.
How are gout attacks treated?
See your doctor as soon as you have an attack. With effective treatment the attack may be controlled within 12–24 hours and treatment need not be continued after a few days. There are also things you can do to help relieve the pain:
rest until your symptoms improve
raise the inflamed joint and put an ice pack on it
do not exercise during an acute attack
take pain relief medicines, for example non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen (Naprosyn) or diclofenac (Voltaren) can be very effective in reducing pain and inflammation. If you are unable to take NSAIDs, medication such as colchicine or prednisone can help reduce the pain of gout.
to get the best results, take your NSAIDs as soon as possible at the first sign of an attack, and continue until the pain and swelling goes down.
If gout is not treated, it can cause permanent damage to your joints and harm your kidneys. Attacks will happen again and more joints will be affected. Lumps (tophi) can grow on your elbows, hands and feet. The lumps can become sore and swollen and they may cause skin ulcers. The natural padding between the bones will start to wear away and the joints will become sore and stiff. Kidney stones can form and cause pain and damage to your kidneys.
Preventing gout attacks
To prevent gout attacks and damage to your joints, your doctor may start you on long-term gout medication, called urate lowering medicines. They are most likely to do this if you:
get two or more gout attacks per year
already have evidence of damage from gout on joint x-rays
have tophi, chronic kidney disease or kidney stones.
The aim of these medicines is too keep your uric acid level below 0.36 mmol/L. This will help to prevent gout attacks, joint damage and kidney stones and will make your gouty lumps smaller.
You need to take uric acid medicines every day, even if you are having a gout attack.
When you start taking your urate lowering medicine you might get a gout attack, as your body is getting rid of the extra uric acid. Your doctor will prescribe additional medication such as a low-dose non-steroidal anti-inflammatory (NSAID) or colchicine to reduce the chances of these attacks.
Being overweight can increase your risk of gout – carrying extra weight slows down the removal of uric acid by your kidneys. If you are overweight, gradual weight loss can help to lower your uric acid levels and reduce your risk of gout attacks.
Cutting out sweetened foods and drinks from your diet and avoiding eating too much food high in purines can help to prevent gout attacks.
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]
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: Editorial team. Reviewed By: Professor Lisa Stamp, Rheumatologist, University of Otago Christchurch
Last reviewed: 03 May 2018
It is important to treat gout attacks and prevent them from happening. If left untreated, gout can cause permanent damage to your joints and harm your kidneys.
Treating gout attacks
During a gout attack, you need to rest the inflamed joint. Try raising it and put an ice pack on it to ease the pain. Do not exercise during an acute attack. Rest until your symptoms improve. Start taking pain-relief medication straight away. With effective treatment, the attack may be controlled within 12–24 hours and treatment need not be continued after a few days.
If you have experienced more than 2 gout attacks in the past year, your doctor may recommend long-term use of urate lowering medicines to reduce your uric acid levels and prevent gout attacks. The goal of these medicines is to keep the uric acid levels in the blood below 0.36mmol/L. This causes the gout crystals to dissolve, and gradually reduces the risk of gout attacks and joint damage.
The most common urate lowering medicine is allopurinol.
These medicines are usually started at a low dose and increased gradually, to reduce side effects.
You must take your urate lowering medicine every day, even when you feel well. Continue taking them while you have a gout attack. They will not relieve pain but they will help to control your uric acid levels.
Urate lowering medicines are an ongoing, long-term treatment that you have to continue taking for many years.
Urate loweringmedicines take time to work
Medicines that lower uric acid levels will not start to work immediately. They may take a few weeks to months to work. When you start taking uric acid medicines, gout attacks can occur in the first few weeks or months, while you are increasing your dose. Your doctor will prescribe other medication such as a low-dose non-steroidal anti-inflammatory (NSAID) or colchicine to reduce the chances of these attacks.
You will need to have regular blood tests to monitor your uric acid levels. These are usually done every 1 or 2 months while you are starting treatment to make sure you are on the correct dose of medication. When your uric acid level is below 0.36mmol/L and your medication dose is stable, blood tests will be needed once or twice a year to check your uric acid levels stay low.
Treating gout with medication is really important, as it helps prevent permanent damage to your joints and harm your kidneys. Along with medication, there are some lifestyle changes you can make to help prevent gout attacks.
Being overweight can increase your risk of gout and certain foods or drinks may trigger gout attacks. Losing weight, removing sweetened foods and drinks from your diet, and avoiding foods high in purines may help to prevent gout attacks.
How can losing weight help my gout?
Being overweight can increase your risk of gout because carrying extra weight slows down the removal of uric acid by your kidneys. Gout is caused by high uric acid levels in your blood – as your level of uric acid rises, your risk of gout increases. If you are overweight, gradual weight loss can help to lower your uric acid levels and reduce your risk of gout attacks.
Weight loss is best achieved by eating a balanced diet and regular physical activity.
Avoid fasting or crash diets, where you go without adequate food for long periods and lose weight rapidly. This type of dieting can increase uric acid levels and trigger a gout attack.
Examples of foods to include in your diet are low-fat dairy, soy-based foods, vegetable sources of protein and foods high in vitamin C.
Exercise moderately, but during an acute attack rest, elevate and cool affected joints.
Is my diet responsible for my gout?
Gout is mainly (80%) caused by your body not getting rid of uric acid properly. This could be because of your genes, your weight or kidney problems. Diet has a much smaller role in causing your gout (20%). But if you notice certain foods or drinks trigger your gout attacks, you may benefit from cutting down the amounts of these in your diet.
(Image source: Stop Gout Booklet, Ministry of Health & Workbase NZ, 2015)
Follow these dos and don'ts to help reduce gout attacks:
✔ If you are overweight, get to a healthy weight.
✔ Exercise regularly, except during a gout attack.
✔ Keep eating a healthy diet.
✔ Eat lots of vegetables and some fruit.
✔ Eat at least 2 servings of low-fat dairy products (such as low-fat yoghurt or cheese such as Edam) every day.
✔ Keep yourself hydrated by drinking plenty of water.
✘ Try crash diets that cause rapid weight loss.
✘ Don’t drink too much beer, RTDs or other alcohol.
✘ Don’t drink sugary drinks such as energy drinks, ordinary soft drinks, orange juice or powdered drinks.
✘ Eat full-fat dairy products.
What foods are high in purines and why should I avoid them?
In your body, uric acid is made from the breakdown of chemicals called purines, which come from the foods we eat. Some foods have more purines than others. It's important to eat a balanced diet and include a variety of healthy foods in your diet, but to avoid eating too many foods that are high in purines. Eating these foods can trigger an attack of gout.
Examples of foods that have high purine content are:
seafood, such as mussels and other shellfish, crab, fish roe, whitebait and trout
game such as venison and rabbit
offal such as liver, kidneys, heart and sweetbreads
meat and yeast extracts such as Marmite, Bovril and commercial gravy.
A number of vegetables such as such as asparagus, mushrooms, cauliflower and spinach are also rich in purines, but these appear less likely to trigger gout than shellfish and game meats.
Most people taking medicines to reduce uric acid levels find they can still eat purine-rich foods without attacks of gout by being careful with how much they eat.
Eat low-fat dairy products
Having 2 servings of low-fat dairy products every day can help protect you against gout. A serving is 1 glass of trim milk or 1 pottle of yoghurt or 2 slices of low-fat cheese (such as Edam) or one-third of a cup of cottage cheese. Avoid full-fat dairy products.
Avoid sweetened foods and drinks
Foods and drinks sweetened with artificial fructose increase the risk of getting gout. These are contained in fizzy drinks and fruit drinks and are usually seen on food labels as corn syrup or glucose-fructose syrup. Other examples of foods sweetened with fructose are bread, cereal and jam.
Fructose is found occurs naturally fruit and vegetables. Do not completely avoid these without advice from your doctor or dietitian.
Drinking alcohol increases the level of uric acid in your blood and can increase your risk of a gout attack. Beers have a high purine content which can cause higher uric acid levels. Try to limit the amount of alcohol you drink and avoid binge drinking.
Drink plenty of water
Being dehydrated can increase your risk of a gout attack. Try drinking the recommended 2 litres of water per day, unless you have heart or kidney problems – talk to your doctor about the right amount of fluids for you to drink.
If you feel a gout attack starting, take this medication as soon as possible to prevent it becoming very severe.
If you are on uric lowering tablets, do NOT stop these when you get a gout attack. Keep taking them as well as your pain medication.
Step 3: Avoid triggers
Identify and correct those factors that can trigger your gout attacks, such as:
unusual physical exercise
diets containing high levels of purine such as meat, seafood, livers
alcohol – especially beer
drugs – including diuretics which can interfere with the normal excretion of uric acid.
If you do take uric lowering tablets regularly, you can eat more of the foods you enjoy, and drink alcohol again in moderation.
Step 4: Reach and maintain a healthy weight
Tips for weight loss:
Eat less fatty and high sugar foods.
Small meals eaten at regular times are best – avoid eating large meals or going for many hours without eating.
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).
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: Know 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, ie, physical therapies, preventive medicines, 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 – milk, low-fat dairy products, coffee and vitamin C appear to reduce the risk of developing gout.
People with gout often have higher risk for diabetes, high blood pressure, heart disease and kidney problems. Ask your doctor/nurse for a heart & diabetes check.
Create your own care plan and ask any health provider you see to fill it in.
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.
For treating acute gout attacks the following medications may be used:
The first option is NSAIDs as these reduce the pain, swelling and inflammation quickly. Examples are naproxen and diclofenac.
If your patient cannot take NSAIDs and there is no infection, consider using corticosteroids. These can be given as an injection of steroid into the joint (a good option when suitable as it has less side effects); or, orally as a prednisone tablet.
A third option for acute gout is colchicine. This is used if your patient cannot take NSAIDs or prednisone. Colchicine is also used to reduce gout flares while starting allopurinol, or other uric acid lowering medicines.
Allopurinol is a uric acid lowering medication used for the prevention of gout attacks. Allopurinol has traditionally not been started at the time of the attack because of the risk of triggering acute gout. However, there is some evidence emerging to suggest a slow titration of allupurinol with NSAID or colchicine cover may be an option to improve allopurinol uptake.
Under-treatment is a global issue
A study by Jackson et al (1) Oct 14, shows many New Zealanders with recurrent gout are not taking uric lowering medication, such as allopurinol, 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.
Under-treatment is a global issue with large studies from the UK, Taiwan and USA finding similar low rates of treatment or adequate titrating to maintain uric acid < 0.36mmol/l.
"Professor Nicola Dalbeth shares an update on the management of gout. Nicola is a rheumatologist at the University of Auckland and Auckland District Health Board. She is a founding member of the Māori Gout Action Group, chair of the Atlas of Health Care Variance Gout Expert Advisory Group and was clinical lead advisor for the gout clinical pathways and bpac gout treatment guidelines."
Diane Phone a pharmacist from Middlemore Hospital and Angela Moananu a primary care nurse, talk about their clinic's “own my own gout” programme, where patients connect directly with their pharmacist to manage their gout.
Webinar: Managing & preventing gout
(Goodfellow Unit, 2017)
Goodfellow Unit Medtalk: Management of gout in Aotearoa New Zealand
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]
van Durme CM, Wechalekar MD, et al. Non-steroidal anti-inflammatory drugs for acute gout. Cochrane Database Syst Rev. 2014 Sep 16;9:CD010120. doi: 10.1002/14651858.CD010120.pub2. [abstract & full article]
Kydd ASR, Seth R, Buchbinder R, Edwards CJ, Bombardier C. Uricosuric medications for chronic gout. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD010457. DOI: 10.1002/14651858.CD010457.pub2. [abstract & full article]