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Gout- diagnosis and treatment

Although classic gout- ie. gout appearing as a painful, swollen, and red big toe- is easily recognized by most people, gout does not always present in this fashion. Similarly, treatment of gout may seem straight forward at first, but there are so many details to consider depending on the individual, their co-morbidities, and the way their gout behaves. Therefore, gout diagnosis and treatment often require an expert’s touch!

 

Diagnosing gout

Gout is suspected when someone has acute onset of a red, hot, swollen and tender joint. If the affected joint is a great toe, the suspicion is even stronger. Blood tests may show an elevated uric acid level which would be expected with gout. Xrays may be normal or may show evidence of joint destruction from tophi.

 

Although at times the clinical picture is all the information we have to make the diagnosis, relying on the uric acid levels alone may be misleading. Uric acid levels may be spuriously low during an attack, giving us a false negative. Also, most people with an elevated uric acid may not have gout, so there is a high chance of false positives. Other types of arthritis, including infection of a joint, can also look like gout clinically.

Needle-shaped uric acid crystals photographed under polarized light from a synovial fluid of a person with gout. From: Bobjgalindo
Needle-shaped uric acid crystals photographed under polarized light from a synovial fluid of a person with gout.
From: Bobjgalindo

 

 

The gold standard of gout diagnosis is presence of monosodium urate crystals in the fluid from a joint. These crystals are needle-shaped structures that look either blue or red- depending on their orientation- under a polarized microscope. To find these crystals, a sample of the fluid is removed from the joint with a needle and looked at under the microscope.

 

How is gout treated?

Acute gout

The goal in treatment of an acute gout attack is to relieve symptoms quickly. Some of the ways this is achieved are:

  • Non-steroidal anti-inflammatory drugs (NSAIDs)– example: ibuprofen (advil), indomethacin (Indocin), Naproxen (Naprosyn), etc.
  • Colchicine (Colcrys)
  • Steroids – example: prednisone
  • Pain medications like vicodin
  • Cold packs

 

NSAIDs should be used with caution in people with kidney disease, heart disease, history of gastric ulcers, and cannot be used in people who take blood thinners. Colchicine should be used carefully in people with kidney disease. Steroids can elevate blood sugar so people with diabetes will need to be monitored on this medication.

 

Large doses of colchicine can cause diarrhea. In the past, people with acute gout were instructed to take a tablet of colchicine every hour until they developed diarrhea. The new recommendations are to take about two tablets per day, which seems to be just as effective as the higher dose with much less side effects.

 

Chronic gout

If gout attacks become chronic, long-term medications are used to lower uric acid and prevent future attacks. These include:

  • Probenacid– increases uric acid filtration through the kidneys
  • Allopurinol– prevents formation of uric acid in the blood
  • Febuxostat (Uloric)– similar to Allopurinol, but can be used more safely in people with poor kidney function
  • Colchicine (Colcrys)– Low dose colchicine can also be used long term as a prophylaxis drug for gout. Many rheumatologist will combine colchicine with the other long term drugs for the first few months to prevent gout flares as the uric acid level is lowered.
  • Pegloticase (Krystexxa)- breaks down uric acid into a product that is more easily eliminated. Since this IV drug can potentially cause severe allergic reactions, it is reserved for very severe cases of gout not otherwise controlled.

 

Gout prevention

Diet and lifestyle changes can have a large impact on management of gout. See:

 The Gout diet – simplified

 

Reference:

UpToDate http://www.uptodate.com/contents/gout-beyond-the-basics?source=search_result&search=gout+patient&selectedTitle=1%7E150

PubMed Health http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001459/

Wikipedia http://en.wikipedia.org/wiki/Gout

Web MD http://arthritis.webmd.com/tc/gout-topic-overview

 

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Gout- for both the prince and the pauper

Gout- symptoms, etiology, diagnosis and treatment

 

What is gout?Gout

Gout is a type of arthritis that causes sudden onset of pain, redness, heat, and swelling in a joint. It is more common in men, and is rare in women before menopause. Although gout is caused by elevated levels of uric acid in the blood (called hyperurecemia), most people with hyperurecemia will never develop gout. The reason for this is not clear.

 

What causes gout?

Uric acid is a by-product of pruines, which is a component of the foods we eat. Uric acid is filtered and excreted through the kidneys. There is usually a fine balance between the production of the uric acid and its filtration in the kidneys, so the level stays constant. If this balance is altered, we can end up with too much uric acid. For example, eating foots with high purine content or kidney failure can lead to buildup of uric acid. Most gout cases are caused by underexcretion of uric acid through the kidneys.

 

Risk factors:

Gout used to be known as the disease of the kings. Now we know that is probably because historically the majority of people could not afford an abundance of meat and alcohol in their diet, except when they were wealthy. Now that purine-rich foods are accessible to more people, it can affect everyone- princes and paupers alike. These are some of the risk factors for developing gout:

  • Diet- large amounts of beef, seafood, high-fructose corn syrup (like sodas)
  • Alcohol- particularly beer. More than 1 drink/day for women and 2 drinks/day for men
  • Gender- gout is more common in men than in women. After menopause, women catch up!
  • Kidney disease
  • Obesity
  • Certain medications that can affect uric acid levels (like diuretics or water pills)
  • Low dose aspirin use
  • Injury
  • Recent surgery
  • Blood cancers

 

Gout symptoms

Acute gout

Sudden onset of severe pain in a joint, often associated with redness, swelling, and heat. The most common affected joint is the 1st toe, but any joint can be involved. The pain is worse at night, and may be so severe that one is not able to bear their bed sheets on their toe. Symptoms usually peak within 24 hours and resolve in 10-14 days.

 

Chronic gout

Whereas at the beginning, gout involves one joint at a time and there may be 1-2 years between attacks, as hyperurecemia and gout become chronic the gout-free periods shorten and more than one joint at a time may be affected. In severe cases, one attack can lead to another and there may be no gout-free period.

 

Tophaceous gout

After several years, large amounts of uric acid crystals deposit to form rock-like masses- or tophi- in the joints and their surrounding tissues. Tophi can cause erosion (eating away) of the joint and significant deformity.

 

Complications

People with gout are at increased risk of developing uric acid-containing kidney stones. Deposits of uric acid in the kidneys can also cause damage to the kidneys (urate nephropathy).

 

Reference:

UpToDate   http://www.uptodate.com/contents/gout-beyond-the-basics?source=search_result&search=gout+patient&selectedTitle=1%7E150

PubMed Health    https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022793/

Wikipedia  http://en.wikipedia.org/wiki/Gout

Web MD   http://arthritis.webmd.com/tc/gout-topic-overview

Categories:
Gout in toe, gout diet

The Gout diet — simplified

Gout in toe, painful toe, gout diet

Most people who have ever had a gout attack are interested in learning about the gout diet. After all, gout attacks are so painful we want to avoid them if at all possible. But many recommended gout diets are so confusing, listing so many foods that can cause gout, that you’re soon left with nothing to eat. So I decided to make this a little simpler.

 

Why a diet at all?

Gout is caused by excess levels uric acid in the blood. The extra uric acid can precipitate in the joint in form of crystals, causing a lot of inflammation and pain. Uric acid is produced in the body from the breakdown of purines, which are components of DNA, and present in our bodies as well as the foods we eat. Naturally, we all have some level of uric acid in our blood. In fact, it is thought that uric acid may have antioxidant properties that is useful for our health, at low levels.

 

Balance between purine production and excretion in gout
Balance between purine production and excretion in gout

There is normally a fine balance between production of uric acid and its excretion through the kidneys. When this balance is offset- either from excess production from foods rich in purines, or from  kidney disease leading to decreased excretion- there may be a buildup of uric acid, causing gout. In addition, genetics also pay a role, causing gout to be more common in some families than in others. We may not have much control over our genetics or our kidney function, but we can control what we eat. Hence, the gout diet.

 

The diet at a glance

Now that we know that purine-rich foods are the culprit, let’s divide common foods we consume into purine-rich and purine-poor categories:

    Purine-rich

  • Red meat (beef, pork, lamb)
  • Organ meat (kidney, liver, brain)
  • Beer
  • Poultry
  • Scallops
  • Mussles
  • Tuna
  • Herring
  • Anchovies
  • Mackerel
  • Yeast
  • Sardines
  • High-fructose corn syrup (soda, fruit-juices)
  • High fat dairy

 

Purine-poor

  • Vegetables
  • Refined grains (bread, cereal)
  • Coffee and tea
  • Low fat dairy
  • Nuts
  • Peanut butter

 

 

 

 

 

 

Foods that can help prevent gout:

  • Cherry juice
  • Dark berries
  • Omega-3

 

 

 

 

 

 

 

 

I thought you said this was going to be simple!

I usually advise my patients to be aware of the top 3 offenders: Red meats, Shellfish, and Beer.

I think it is impossible (and quite frankly, cruel) to ask patients to remember all the foods that can potentially cause gout. Eliminating the variety can also really affect one’s lifestyle and pleasure in food. I think the best course of action is to limit the top offenders. Beyond that, we do have medications that can also help.

 

Lose weight!

Obesity has been linked to gout and high levels of blood uric acid. So losing those extra pounds may help control or eliminate your gout.

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