Gout

Gout is caused by a build-up of a substance called uric acid (urate) in the blood, although not everyone with high levels of uric acid in their blood will develop gout. This overload of uric acid in the body causes urate crystals to form in and around the joint cartilage.

Sometimes urate crystals can form under the skin creating white pimples called “Tophi”. In severe cases, these can become quite large and lead to deformity. Occasionally, urate stones may form in the kidneys.

All cells in the human body, and many of the foods we eat, contain chemicals known as purines. As old cells are broken down, or as foods are digested, these purines are converted to uric acid, which is carried in the blood as a salt called urate. It’s therefore normal to have some urate in your blood.

About three-quarters of the urate in our bodies comes from the breakdown of purines already contained within the body tissues whilst only about one-quarter comes from purines in the food and drink we consume.

Most people with gout have high levels of urate in their blood because they do not pass enough urate in their urine. It can also be caused by high levels of uric acid in the diet, crash dieting, stress, prolonged illness, injury, or by some drugs (e.g., aspirin or water tablets). A much less common cause of gout is when people produce too much uric acid in the first place, due to an inherited (genetic) abnormality or a disorder associated with increased production of cells in the body.

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

Pseudogout is the second most common crystal-induced arthritis. It is caused by the deposition of calcium crystals into the joints. Like gout, it is characterised by an acute episode of joint pain and swelling, but in the case of pseudogout the most typical affected joint is the knee, followed by the wrist. It rarely affects individuals younger than 60 years old, unless they are affected by other diseases than can predispose to calcium crystal disease, such as hyperparathyroidism or haemochromatosis.

In general, crystal-induced arthritis can be managed in the community, and your GP should be able to guide you on what treatment you need to treat or prevent your joint attacks.

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.

Attacks of gout typically:

• Come on 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.

Gout can affect almost any joint and can occur in more than one joint at the same time, although the joints towards the ends of the limbs tend to be affected more often. This includes:

• 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.

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

Complications

It’s rare to get lots of attacks (chronic gout), but if you do, it can damage your joint.

Chronic gout can also cause tiny white lumps, called tophi, to appear under your skin, usually on your ears, fingers or elbows. They can be painful.

You can get kidney stones if your uric acid levels are very high, so you’ll need treatment to reduce the levels.

The only certain way to diagnose gout, is if crystals of uric acid from a sample of joint fluid taken during an attack can be seen under a microscope. Whilst it is easy for a trained person to take a sample of joint fluid from a large swollen joint such as a knee, it can be tricky or impossible when a small joint is affected. Doctors will therefore often make a presumptive diagnosis of gout if there has been a typical attack of pain, swelling and redness in a joint, especially a big toe, without taking a sample of joint fluid.

The diagnosis is easiest if a doctor can see and examine a red and swollen joint, but it can help if you take a photograph of any swollen joint if there is likely to be a delay in being seen by a doctor.

During an attack of gout, uric acid levels in the blood can often be low or normal, so checking the uric acid levels in the blood during an attack is not always helpful. However, if you have had a typical attack plus have high uric acid levels, the diagnosis of gout is very likely.

Uric acid levels should be checked between attacks of gout to get an accurate reading.

Whilst imaging techniques such as X-ray and ultrasound scan may be used to identify alternate diagnoses or complications, they are not particularly helpful in identifying gout itself.

The management of gout can be regarded as a three-step process:

1. Treatment of the acute attack

2. Lowering uric acid levels to prevent further attacks

3. Diet & lifestyle modification (see “Selfcare”)

Treatment of the acute attack

The pain and inflammation of an acute attack of gout is usually managed using painkillers such as non-steroidal anti-inflammatory drugs (NSAIDs), Colchicine or corticosteroids.

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 always have them with you so that 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 dyspepsia (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 always have it with you 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.

Lowering uric acid levels to prevent further attacks

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

Most people with gout will eventually need to have ULT and whilst it can significantly reduce your risk of having further attacks, the medication needs to be taken daily for the rest of your life and there’s a small risk of side effects.

Allopurinol is the ULT 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.

Diet & lifestyle modification

Certain lifestyle changes can also help reduce your risk of developing or experiencing recurrent attacks of gout. These include:

• 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
• Avoiding fatty foods
• Stopping smoking
• 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 is some evidence to suggest that taking vitamin C supplements can reduce gout attacks, although the effect may only be small. If you’re considering taking vitamin C supplements, talk to your GP first as they aren’t suitable or safe for everyone.

Selfcare during an acute attack

An acute attack of gout can be excruciatingly painful, but simple first aid measures can help:

• Take any medicine you’ve been prescribed as soon as possible – it should start to work within 2 days
• Rest and raise the limb
• Keep the joint cool – apply an ice pack, or a bag of frozen peas wrapped in a towel, for up to 20 minutes at a time
• Drink lots of water (unless a GP tells you not to)
• Try to keep bedclothes off the affected joint at night
• Don’t put pressure on the joint

Contact 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:

• Severe, worsening joint pain and swelling
• Hot, swollen, red skin over the affected joint
• A high temperature (fever) of 38C (100.4F) or above
• You also feel sick or cannot eat

These symptoms could mean that you have an infection inside the joint (septic arthritis) which requires urgent medical attention.

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.

Useful information about gout:

• All about gout & diet factsheet – UK Gout Society
• All about gout and treatments factsheet – UK Gout Society
• Versus Arthritis
• Arthritis Action
• UK Gout Society
• NHS UK
• Patient.info
• Calcium crystal disease (pseudogout) – Arthritis Foundation

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