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Spotlight on gout

Gout is a form of arthritis which is caused by a build-up of uric acid in the body. Normally uric acid is processed by the kidneys and excreted through urine. In most people with gout, the kidneys do not excrete uric acid adequately while in a minority of people with gout, too much uric acid is produced. Chronically high levels of uric acid in the blood form crystals, which are then deposited in joints, and sometimes tendons and skin as well. These deposits can cause pain-often severe-and swelling in the affected area or areas.

Gout affects approximately 1 in 30 people-up to nine times more commonly in men than in women. It can strike at any age, but tends almost always to affect men after the age of 40 and women after menopause.

A number of different groups of people are at higher risk of developing gout. A family history of gout increases the chances of developing gout, as do certain medical conditions like hypertension, diabetes, and arteriosclerosis (narrowing of the arteries).

Lifestyle factors like alcohol consumption-more than one drink a day for women and two for men (beer is particularly bad) and excessive consumption of certain types of food are thought to increase the risk of gout. Foods thought to increase the risks of gout include: red meat in excess, organ meats-for example liver, kidneys, brains-and shellfish.

Diagnosis of gout

Onset of gout is generally quick and severe. Often, the first signs of gout include:
  • Intense pain, usually in one joint. Most often, gout pain appears in the big toe. Other joints sometimes initially affected by gout include the feet, ankles, knees, hands, and wrists.
  • Swelling, heat and redness in the affected joint(s).
  • Fever, in severe cases.

Gout pain often first occurs at night. A patient may go to bed feeling healthy, and be awakened in the night by the intense pain associated with an acute attack of gout. Pain may be so severe that even the weight of a blanket on the affected area feels unbearable.

Most often, gout initially affects only one joint at a time, unlike in other forms of arthritis like rheumatoid arthritis, where multiple joints are often affected simultaneously.

Doctors may be able to tentatively diagnose gout based on a patient's description of disease onset and sensation of pain and swelling, combined with a physical examination of the affected joint.

The most reliable method for confirming a diagnosis of gout is a test called arthrocentesis, or joint aspiration. Under local anesthesia, a small amount of joint fluid is removed using a needle. The fluid is then analyzed for uric acid crystals. Blood tests may also be performed to test for high levels of uric acid in the blood, but these are generally less reliable than arthrocentesis.

Treatment of Gout

Once a doctor has diagnosed gout, there are several simple, effective methods to help manage the symptoms. While there is no known cure for gout, people with the disease are usually able to manage their symptoms, or avoid flare-ups of disease activity all together, with lifestyle changes and medications.

There are a number of strategies prevent acute attacks of gout. These include diet, lifestyle changes, and medications.

Some simple changes in diet can help to reduce uric acid levels in the body. People with gout should avoid foods rich in purine-a chemical that is converted into uric acid in the body. These foods may include red meats and seafood generally, and especially organ meats, like liver, kidney, and brain, as well as shellfish.

Alcohol intake, especially beer and liquor, is associated with increased disease activity. If you have gout, you should discuss your alcohol consumption habits frankly and honestly with your doctor. Moderate amounts of wine will likely not have a negative impact.

On a related issue, it is very important for people who have gout to avoid becoming dehydrated-for example, due to alcohol consumption, hot weather, or traveling. People with gout should ensure that they are drinking enough water.

Healthy body weight maintenance is another vitally important component of a well-rounded treatment plan for gout. In people who are overweight, weight reduction may help to limit the risk of recurrent gout attacks. For this reason, people with gout who are overweight should follow a weight-reduction plan, including a healthy, lower-calorie diet and aerobic exercise. For some suggestions about weight loss, see the article "Weight loss and arthritis" in the December 2006 issue of JointHealth™ monthly.

There are several main types of medications used in the treatment and management of gout. These include pain relievers, medications to reduce inflammation, and medications used between flare-ups of disease activity to prevent future attacks. It is important to note that people with gout may be advised not take medications containing acetylsalicylic acid (ASA, Aspirin®), as these may decrease or prevent the kidneys' excretion of uric acid. Of course, if ASA is required for other medical reasons, it may still be used. Other medications that typically worsen gout include certain water pills or diuretics (thiazide diuretics).

During an attack of gout, some people find it helpful to rest and elevate the affected joint. As well, ice may be used to reduce pain and inflammation.

Usually non-steroidal anti-inflammatory medications (NSAIDs) are be used to treat gout. These are potent medications which can reduce joint inflammation and pain, but do not work to prevent joint damage. It is important to note that NSAIDs can rarely cause serious cardiovascular, kidney or gastro-intestinal side effects, like stomach ulcers; for this reason, it is vital to speak with your doctor before adding an NSAID to any treatment plan for gout.

Examples of NSAIDs available without a prescription include ibuprofen (Motrin® or Advil®). Some more powerful NSAIDs require a prescription. These include naproxen (Naprosyn®). It is thought that one of the most powerful NSAIDs for gout is indomethacin (Indocid).

Cox-2 inhibitors are a newer class of NSAID, which work to reduce inflammation but do not carry the same risk of gastrointestinal side effects. Celecoxib (Celebrex) is an example of a cox-2 inhibitor. It is important to note that, while cox-2 inhibitors cause fewer gastrointestinal side effects, research has shown that they have the same or higher risk of cardiovascular (heart) side effects compared to traditional NSAIDs. Celecoxib has been used 'off-label' for gout.

Corticosteroids, like prednisone, may be used to treat gout, but should only be used in the short-term, because of the risk of side-effects. A corticosteroid injection or 'cortisone' injection is frequently a safer way to treat gout in a single joint.

Colchicine is a medication that has been used for thousands of years. It can reduce inflammation during a gouty attack however the most common side-effect is diarrhea.

After an initial attack has subsided, there are several types of medications that that work to reduce uric acid levels in the body, prevent gout attacks, and prevent long-term joint damage from gout. These medications work either by increasing the excretion of uric acid in the urine, or by preventing uric acid production. These include probenecid (Benemid®), sulfinpyrazone (Anturane®), and allopurinol (Zyloprim®). Allopurinol is the most common medication used to prevent gout attacks. It is important to note that this group of medications is almost always used only after an acute attack of gout has passed-for reasons not yet fully understood, these medications can actually worsen inflammation when taken during an acute attack of gout.