#condition - Rheumatology

Gout

Gout is a form of inflammatory arthritis that can cause sudden severe pain and swelling in the joints. Typically, it affects only one joint at first, usually the big toe joint, and causes sudden attacks or ‘flares’, often waking the person up at night.
Gout is related to one having too much uric acid in the blood, which can then form crystals in the joints, leading to severe pain, redness and swelling. Uric acid crystals can crystals can also turn into kidney stones that can cause pain and problems with the flow of urine.
There are medications that can reduce the pain and swelling caused by gout and other medications that can be used to help prevent flares. These can be prescribed in addition to other things that may help, including losing weight if you are overweight, and avoiding triggers such as dehydration, dietary factors and alcohol.
Some people with gout may have other health conditions, like heart disease, high blood pressure, chronic kidney disease or obesity, which may also need medical treatment to avoid complications.
Dr Simon Paul specialises in looking after people with gout using a holistic approach, which may include medications, injections, and various non-medicine-based therapies, all tailored to the person’s individual circumstances. Successful treatment allows the person to take control of the disease to reduce the frequency of gout attacks and help reduce potential complications.

What is gout?

Gout is a type of arthritis  that  was noted by the Ancient Egyptians more than 2000 years BC. It causes pain and swelling in the joints. It can develop in some people who have an elevated level of a substance called uric acid or urate in their blood  – this is called hyper- (elevated) uricaemia (urate level in the blood). Urate can build up and form crystals that can inflame joints, but not everyone with hyperuricemia gets gout. The inflammation of gout happens when your own cells try to engulf and digest the urate crystals found in synovial joint fluid, the fluid that bathes and lubricates joint surfaces. This causes a cascade of chemical reactions in and around the joint, which cause the pain, redness, and swelling people feel. Urate crystals can also cause kidney stones, which can damage the renal system.

Gout tends to affect men between the ages of 30 and 45, and women usually after their menopause, but other ages can be affected, especially if there is a family history of gout in a close blood relative.

Risk factors

Risk factors that increase your chances of developing Gout include:

  • being obese
  • having skin conditions like psoriasis
  • being dehydration
  • having high blood pressure
  • having chronic kidney disease
  • heavy drinking of alcohol on a regular basis (particularly beer)
  • eating large amounts of meat or seafood
  • drinking drinks containing high fructose (such as some fizzy drinks)
  • taking  certain medications that  increase blood levels of urate.

What are the symtoms of gout?

Gout attacks or flares give sudden episodes of severe pain accompanied by redness and swelling of and around (usually one) joint, such as a big toe or knee, or in a joint affected by other types of arthritis. However, some people with gout have several acutely inflamed joints at a time. The attacks of pain can wake people up at night, but they can occur at any time. These acute symptoms usually peak within a day and generally completely disappear within 7 days, even if the person does not have any treatment.

Further acute gout attacks can occur within the next couple of years, and if gout is left untreated, the interval between gout attacks / flares may get shorter and the flares may become more severe.

Some people who have repeated gout flares for many years can develop gouty “tophi” –  deposits containing large numbers of urate crystals. Tophi can occur in a number of places, including the ear and around joints and tendons, and may ‘eat into’ (or ‘erode’) bone, leading to joint damage and deformity – this is called ‘erosive chronic tophaceous gout’.

Tophi can cause pressure on the parts of the body they build up on, and when they become inflamed, they can cause a Gout flare.

Urate crystal renal (kidney) stones occur in about 3 in every 20 people with gout. A common symptom of kidney stones is pain on the sides of the back and abdomen.

Kidney stones can also cause blockages and damage to the renal system.

Diagnosing gout

Many illnesses can cause joint pain and inflammation, sometimes making gout hard to diagnose, as symptoms are similar to other conditions; however, usually the history gives your Rheumatologist the clues to making the correct diagnosis. To help, you may be asked to have some blood tests, urine tests, an ultrasound scan or X-rays, and sometimes a needle is used to take a sample of fluid from the inflamed joint, and this fluid is then analysed in the laboratory.

Consider calling call NHS 111 or going to your nearest A&E Department if the pain is getting much worse, and particularly if you have a very high temperature or you feel hot and shivery, as this could mean that you actually have an infection inside the joint, and this might need urgent treatment.

Treating gout attacks

The aim of treatment is to reduce symptoms as quickly and safely as possible. You may be advised to

  • Take medicine (e.g. a non-steroidal anti-inflammatory drug (NSAID) such as Ibuprofen, or a different medication called Colchicine, if you are allowed to have these (always check with your GP or a Pharmacist), and you should notice a response within 3 days.
  • Rest and raise the inflamed joint.
  • Apply an ice pack or a bag of frozen peas wrapped in a towel (to avoid skin burns) for up to 20 minutes at a time.
  • Drink lots of water (unless you have been told not to by your doctor)
  • try to avoid putting pressure on the affected area

NSAID medications: these include Ibuprofen, and they are for short-term use. Further information on NSAID medications can be found at:

https://www.versusarthritis.org/media/14626/painkillers-nsaids-information-booklet-2019.pdf

Colchicine, which was originally derived from the Autumn Crocus plant, may be prescribed for a gout flare instead of a non-steroidal anti-inflammatory like Ibuprofen. It is a prescription-only medication and can be very effective for stopping flares, but it can cause gastrointestinal side effects in higher doses.

Glucocorticoids, otherwise known as steroid medications, are effective and frequently used for treating Gout flares. They are prescription-only and may be given orally or delivered straight into the joint by injection. Further information about joint injections can be found at:

https://www.versusarthritis.org/media/12771/steroid-injections-information-booklet-2019.pdf

Preventing gout

Rheumatologists suggest long-term prevention therapy to some people, to limit the chances of damaging joints and to reduce the risk of getting further acute tacks and complications such as tophi, kidney stones and kidney damage.

If you are having frequent, prolonged, painful or disabling Gout flares, or if you already have joint damage or tophi, your Rheumatologist may well  advise starting long-term urate-lowering therapy. Blood tests can show a reduction in serum urate with the correct treatment, and Rheumatologists try to set a target to lower blood urate closer to a concentration of 300 micromol/L. Often the medication is required indefinitely, as coming off medication can precipitate hyperuricemia and gout returning.

Prescribed medications lower urate by increasing your kidney excretion of urate, or by reducing the body’s production of urate, or by directly breaking down urate. Allopurinol and Febuxostat work by preventing urate forming, and  Allopurinol is the most  commonly used preventative medication. Both are effective, but they can cause side effects in some people.

Further information about Allopurinol and Febuxostat can be found at:

https://www.versusarthritis.org/media/14624/allopurinol-information-booklet-2019.pdf

https://www.versusarthritis.org/media/12939/febuxostat-information-booklet-2019.pdf

Colchicine is often prescribed alongside Allopurinol for the first 6 months of Allopurinol treatment, as some people notice more attacks when starting Allopurinol, Colchicine can help prevent these occurring.

Dietary modification

Changes in diet are often recommended, and may help lower your urate by up to 15%. Losing weight can also help in the management of gout, as obesity is a known risk factor. A healthy diet and weight loss can bring benefits to your health in general. However, extreme diets are not advised.

The UK Gout Society (http://www.ukgoutsociety.org) has more detailed advice on diets for people who have gout, which can be found at:

http://www.ukGoutsociety.org/PDFs/Goutsociety-allaboutgoutanddiet-0917.pdf

The NHS website on Gout (https://www.nhs.uk/conditions/gout/) advises:

  • “get to a healthy weight, but avoid crash diets – you could try the NHS weight loss plan,
  • aim for a healthy, balanced diet, with plenty of vegetables and some low-fat dairy foods,
  • have at least 2 alcohol-free days a week,
  • drink plenty of fluids to avoid getting dehydrated,
  • exercise regularly – but avoid intense exercise or putting lots of pressure on joints,
  • stop smoking and
  • ask a GP about vitamin C supplements”

Treating associated conditions

Gout can be associated with being overweight, high levels of cholesterol, diabetes, high blood pressure and cardiovascular disease. It is important that people with gout are checked for all these associated problems and that these issues are treated in their own right as well as the gout being appropriately managed.

Further information on Gout  can also be found at:

https://www.versusarthritis.org/media/1253/gout-information-booklet.pdf

About Dr Simon Paul

Dr Simon Paul specialises in looking after people with gout using an holistic approach, which may include medications, injections and various non-medicine-based therapies, all tailored to the person’s individual circumstances. Successful treatment allows the person to take control of the disease, reduces the frequency of gout attacks and helps reduce potential complications.

For further information about Dr Simon Paul CLICK HERE