Gout

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Figure 1: “The Gout” by James Gilray 1799
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Summary

Gout is a painful arthritic condition that can affect any joint, but commonly involves the joint at the base of the great toe (See Figure 1). Gout occurs when uric acid (normally present in the blood) crystallizes in the lining of the involved joint. These urate crystals incite an intense inflammatory reaction that often creates marked pain and swelling. Risk factors for gout include elevated blood uric acid levels, combined with an increased acidity in the bloodstream. Initial treatment is aimed at decreasing symptoms and may include the use of anti-inflammatory medications, rest, and ice. Long-term management is oriented towards preventing recurrent attacks and limiting the long-term effects that gout may have on the involved joint.

Clinical Presentation

Patients often report a relatively sudden onset of severe symptoms including pain, swelling, and redness. Gout may involve almost any joint in the body, but in about 75% of first attacks it affects the joint at the base of the big toe (Podagra), and less commonly it affects the ankle. Acute episodes of gout are usually associated with elevated blood levels of uric acid and increased acidity of the bloodstream, and therefore the following have been known to increase the risk of gout attacks in susceptible individuals:

  • Elevated blood uric acid levels. Approximately 10-20% of people with high blood uric acid levels will eventually have a gout attack
  • A prior history of gout is perhaps the biggest risk factor for future attacks
  • Intake of foods high in protein (increased intake of purines). These foods include:  red meat, fatty fish (tuna, salmon, mackerel, herring, and sardines), and seafood (shrimps, prawns, scallops, and lobster)
  • Alcohol intake may precipitate a gout attack
  • Kidney problems may increase the risk of an attack of gout because about 70% of the uric acid in the blood is eventually excreted through the kidneys. So if the kidneys are not working optimally, the uric acid level in the blood will tend to rise
  • Obesity
  • Diabetes (elevated blood sugar)

The diagnosis of gout is initially based on the patient’s symptoms. An initial treatment can be started based on the patient’s symptoms. Elevated blood uric acid levels will further support the diagnosis. The diagnosis of gout is confirmed by removing fluid from the affected joint (“tapping” or “aspirating” the joint) and looking at it under the microscope. Elongated rods of uric acid crystals will be seen when viewed under the microscope with polarized light.

Imaging Studies

X-rays are likely to be normal, except after multiple attacks or if there are other problems in the joint, such as hallux rigidus in the great toe. In patients who have suffered from gout over a long period of time, crystal collections (called “tophi”) may reach a size where they can be seen on x-rays. X-rays can be helpful to rule out other conditions that may cause similar symptoms, such as fractures, severe osteoarthritis, charcot athropathy, infection, or pseudogout. MRI is usually not indicated in making the diagnosis of gout.

Treatment

The initial treatment of a gout attack is aimed at reducing the pain, which can be quite severe. After the initial symptoms have been resolved, long-term management of gout focuses on minimizing the risk of future attacks of gout.

Initial Treatment

  • Anti-inflammatory medications (NSAIDs): NSAIDs are the primary treatment of an acute attack of gout. NSAIDs help blunt the intense inflammatory response the urate crystals created in the joint lining. Anti-inflammatory medications can start decreasing symptoms within a few hours. Patients may experience stomach discomfort and, in many instances, anti-inflammatory medications should be combined with a medication that helps “protect” the stomach. In patients that have had serious stomach problems, such as ulcers or bleeding, NSAIDs should not be given and another treatment option should be considered.
  • Oral corticosteroid medications: Oral steroids, such as prednisone, can also help decrease the inflammation in the involved joint. These can be quite effective, but have potential serious side effects.
  • Colchicine: This medication can be effective if taken within 12 hours of the attack. However, it is associated with potential stomach problems (diarrhea and nausea).
  • Steroid injection in the joint: Injecting steroids directly in the joint may have some benefit. In addition, removing fluid at the time of the injection may allow the diagnosis of gout to be confirmed. However, the injections themselves can be painful and there is always a small chance that infection will be introduced into the joint.
  • Ice: Ice applied to the joint for 10-15 minutes at a time may help improve the acute pain associated with a gout attack. It is unclear if applying heat to the involved area is a good idea. Applying heat will increase the blood flow to the area and may aggravate symptoms. However, it has been suggested that increasing the temperature to the area may decrease the formation of crystals in the joint.
  • Elevating the involved joint: Elevating the involved extremity 10”-18” above the level of your heart (ex. propping your foot up on a pillow if the big toe or ankle is affected) may help symptoms by helping to decrease the swelling.
  • Drinking lots of water: It is thought that drinking lots of fluid will help dilute the uric acid crystals and thereby decrease the chance of more crystals forming in the joint. In addition, increase fluid intake may encourage the excretion of uric acid in the urine.
  • Hemorrhoid Creams: It has been suggested that hemorrhoid cream applied directly to the involved joint may help decrease the skin swelling that is often present with an acute gout attack.

Long Term Management of Gout

A variety of treatment approaches have been recommended to minimize the risk of recurrent gout attacks including:

  • Allopurinol: This medication decreases uric acid level in the blood stream (by inhibiting Xanthine Oxidase). It is commonly used and generally safe. However, it should NEVER be taken with Azathiorine (Imuran) as a potentially fatal reaction can occur.
  • Low Fat, Low Protein Diet: Purines are commonly found in beef and seafood. Breakdown of purine leads to uric acid. Therefore, decreasing the intake of purines will tend to decrease uric acid levels in the blood and ultimately minimize the risk of future gout attacks.
  • Avoid high sugar soft-drinks: Many soft-drinks will increase blood uric acid levels, and therefore limiting the intake of soft-drinks may be an important part of the long-term management of gout.
  • Surgical Resection of Gouty Tophi:  Occasionally, the collection of uric acid will form lumps (gouty tophi) in the lining of the involved joints.  In rare instances, these lumps can become large enough that they will need to be removed surgically.
  • Wound infection
  • Nerve injury Nearby sensory nerves may be stretched or irritated by scar tissue, leading to localized numbness or burning
  • Recurrence of the cyst, especially when deep or multi-lobulated

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