GOUT
Gout is a common type of arthritis that causes intense pain, swelling, and stiffness in a joint. It usually affects the joints in the big toe.
SYMPTOMS:
The signs and symptoms of gout almost always occur suddenly, and often at night. They include:
- Intense joint pain: Gout usually affects the large joint of your big toe, but it can occur in any joint. Other commonly affected joints include the ankles, knees, elbows, wrists, and fingers. The pain is likely to be most severe within the first four to 12 hours after it begins.
- Lingering discomfort: After the most severe pain subsides, some joint discomfort may last from a few days to a few weeks. Later attacks are likely to last longer and affect more joints.
- Inflammation and redness: The affected joint or joints become swollen, tender, warm and red.
- Limited range of motion: As gout progresses, you may not be able to move your joints normally.
Types
There are various stages through which gout progresses, and these are sometimes referred to as different types of gout.
Asymptomatic hyperuricemia
It is possible for a person to have elevated uric acid levels without any outward symptoms. At this stage, treatment is not required, though urate crystals may deposit in tissue and cause slight damage.
People with asymptomatic hyperuricemia may be advised to take steps to address any possible factors contributing to uric acid build-up.
Acute gout
This stage occurs when the urate crystals that have been deposited suddenly cause acute inflammation and intense pain. This sudden attack is referred to as a “flare” and will normally subside within 3 to 10 days. Flares can sometimes be triggered by stressful events, alcohol, and drugs, as well as cold weather.
Interval or intercritical gout
This stage is the period between attacks of acute gout. Subsequent flares may not occur for months or years, though if not treated, over time, they can last longer and occur more frequently. During this interval, further urate crystals are being deposited in tissue.
Chronic tophaceous gout
Chronic tophaceous gout is the most debilitating type of gout. Permanent damage may have occurred in the joints and the kidneys. The patient can suffer from chronic arthritis and develop tophi, big lumps of urate crystals, in cooler areas of the body such as the joints of the fingers.
It takes a long time without treatment to reach the stage of chronic tophaceous gout – around 10 years. It is very unlikely that a patient receiving proper treatment would progress to this stage.
Pseudogout
One condition that is easily confused with gout is pseudogout. The symptoms of pseudogout are very similar to those of gout, although the flare-ups are usually less severe.
The major difference between gout and pseudogout is that the joints are irritated by calcium pyrophosphate crystals rather than urate crystals. Pseudogout requires different treatment for gout.
Risk factors
There are a number of factors that can increase the likelihood of hyperuricemia, and therefore gout:
Age and gender: Men produce more uric acid than women, though women’s levels of uric acid approach those of men after the menopause.
Genetics: A family history of gout increases the likelihood of the condition developing.
Lifestyle choices: Alcohol consumption interferes with the removal of uric acid from the body. Eating a high-purine diet also increases the amount of uric acid in the body.
Lead exposure: Chronic lead exposure has been linked to some cases of gout.
Medications: Certain medications can increase the levels of uric acid in the body; these include some diuretics and drugs containing salicylate.
Weight: Being overweight increases the risk of gout as there is more turnover of body tissue, which means more production of uric acid as a metabolic waste product. Higher levels of body fat also increase levels of systemic inflammation as fat cells produce pro-inflammatory cytokines.
Recent trauma or surgery: Increases risk.
Other health problems: Renal insufficiency and other kidney problems can reduce the body’s ability to efficiently remove waste products, leading to elevated uric acid levels. Other conditions associated with gout include high blood pressure and diabetes.
Causes
- Gout occurs when urate crystals accumulate in your joint, causing the inflammation and intense pain of a gout attack. Urate crystals can form when you have high levels of uric acid in your blood.
- Your body produces uric acid when it breaks down purines — substances that are found naturally in your body.
- Purines are also found in certain foods, such as steak, organ meats, and seafood. Other foods also promote higher levels of uric acid, such as alcoholic beverages, especially beer, and drinks sweetened with fruit sugar (fructose).
- Normally, uric acid dissolves in your blood and passes through your kidneys into your urine. But sometimes either your body produces too much uric acid or your kidneys excrete too little uric acid. When this happens, uric acid can build up, forming sharp, needlelike urate crystals in a joint or surrounding tissue that cause pain, inflammation, and swelling.
Complications
People with gout can develop more-severe conditions, such as:
- Recurrent gout: Some people may never experience gout signs and symptoms again. Others may experience gout several times each year. Medications may help prevent gout attacks in people with recurrent gout. If left untreated, gout can cause erosion and destruction of a joint.
- Advanced gout: Untreated gout may cause deposits of urate crystals to form under the skin in nodules called tophi (TOE-fie). Tophi can develop in several areas such as your fingers, hands, feet, elbows or Achilles tendons along the backs of your ankles. Tophi usually aren't painful, but they can become swollen and tender during gout attacks.
- Kidney stones: Urate crystals may collect in the urinary tract of people with gout, causing kidney stones. Medications can help reduce the risk of kidney stones.
Diagnosis
Tests to help diagnose gout may include:
- Joint fluid test: Your doctor may use a needle to draw fluid from your affected joint. Urate crystals may be visible when the fluid is examined under a microscope.
- Blood test: Your doctor may recommend a blood test to measure the levels of uric acid and creatinine in your blood. Blood test results can be misleading, though. Some people have high uric acid levels but never experience gout. And some people have signs and symptoms of gout but don't have unusual levels of uric acid in their blood.
- X-ray imaging: Joint X-rays can be helpful to rule out other causes of joint inflammation.
- Ultrasound: Musculoskeletal ultrasound can detect urate crystals in a joint or in a tophus. This technique is more widely used in Europe than in the United States.
- Dual-energy CT scan: This type of imaging can detect the presence of urate crystals in a joint, even when it is not acutely inflamed. This test is not used routinely in clinical practice due to the expense and is not widely available.
Treatment
Treatment for gout usually involves medications. What medications you and your doctor choose will be based on your current health and your own preferences.
Gout medications can be used to treat acute attacks and prevent future attacks. Medications can also reduce your risk of complications from gout, such as the development of tophi from urate crystal deposits.
Medications to treat gout attacks
Drugs used to treat acute attacks and prevent future attacks include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs include over-the-counter options such as-
- ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve),
- as well as more-powerful prescription NSAIDs such as indomethacin (Indocin) or celecoxib (Celebrex).
- Colchicine: Your doctor may recommend colchicine (Colcrys, Mitigare), a type of pain reliever that effectively reduces gout pain. The drug's effectiveness may be offset, however, by side effects such as nausea, vomiting, and diarrhea, especially if taken in large doses.After an acute gout attack resolves, your doctor may prescribe a low daily dose of colchicine to prevent future attacks.
- Corticosteroids: Corticosteroid medications, such as the drug prednisone, may control gout inflammation and pain. Corticosteroids may be in pill form, or they can be injected into your joint.Corticosteroids are generally used only in people with gout who can't take either NSAIDs or colchicine. Side effects of corticosteroids may include mood changes, increased blood sugar levels, and elevated blood pressure.
Medications to prevent gout complications
If you experience several gout attacks each year, or if your gout attacks are less frequent but particularly painful, your doctor may recommend medication to reduce your risk of gout-related complications. If you already have evidence of damage from gout on joint X-rays, or you have tophi, chronic kidney disease or kidney stones, medications to lower your body's level of uric acid may be recommended. Options include:
- Medications that block uric acid production: Drugs calledSide effects of allopurinol include a rash and low blood counts. Febuxostat side effects include rash, nausea, reduced liver function and an increased risk of heart-related death.
- Medication that improves uric acid removal: These drugs, called uricosurics, include probenecid (Probalan) and lesinurad (Zurampic). Uricosuric drugs improve your kidneys' ability to remove uric acid from your body. This may lower your uric acid levels and reduce your risk of gout, but the level of uric acid in your urine is increased. Side effects include a rash, stomach pain, and kidney stones. Lesinurad can be taken only along with an XOI.
Prevention:
During symptom-free periods, these dietary guidelines may help protect against future gout attacks:
- Drink plenty of fluids: Stay well-hydrated, including plenty of water. Limit how many sweetened beverages you drink, especially those sweetened with high-fructose corn syrup.
- Limit or avoid alcohol: Talk with your doctor about whether any amount or type of alcohol is safe for you. Recent evidence suggests that beer may be particularly likely to increase the risk of gout symptoms, especially in men.
- Get your protein from low-fat dairy products: Low-fat dairy products may actually have a protective effect against gout, so these are your best-bet protein sources.
- Limit your intake of meat, fish, and poultry: A small amount may be tolerable, but pay close attention to what types — and how much — seem to cause problems for you.
- Maintain desirable body weight: Choose portions that allow you to maintain a healthy weight. Losing weight may decrease uric acid levels in your body. But avoid fasting or rapid weight loss, since doing so may temporarily raise uric acid levels.
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