Gout Treatment

Gout is one of the oldest joint diseases known to mankind.

Gout is a painful inflammatory arthritis caused by deposition of uric acid in the joint. It usually occurs in a single joint especially the joint at the base of the big toe, although it may occur in other joints and may involve more than one joint.

Gout is very common in young males. Gout rarely occurs in children and young women. Young females usually do not suffer from gout as oesterogen is uricosuric and females will suffer from gout only after menopause.

Uric acid is a break down product of purines that are part of many foods. Purines are found in high concentration in meat and meat products, especially internal organs like liver and kidney. Being a break down product, uric acid is naturally present in body. However when it accumulates in the blood in excessive amounts ( known as hyperuricemia ) it has tendency to precipitate in joints.

1. Asymptomatic hyperuricemia

Many people may have raised levels of uric acid in blood without any joint pain.

2. Acute gout :

Sudden onset of severe pain and swelling of the involved joint most often the joint at the base of the big toe. It can also involve other joints like ankles, knees, elbows, wrist and hand joints. The affected joint is swollen, tender, warm and red. Pain is most severe in first 12 hours of onset and then decreases over a week and goes away in a few weeks. Later attacks are likely to last longer and affect more joints with the shorter duration between two attacks.

3. Intercritical gout :

The interval between two gouty attacks is called intercritical gout. The patient is totally asymptomatic during this phase. The duration of intercritical gout varies. Without diet control, lifestyle modification or drugs most patients experience a second episode of arthritis within two years.

4. Chronic tophaceous gout :

When recurrent aute gout and hyperuricemia go untreated, the condition may evolve from a picture of sporadic acute, mono or oligoarthritis to recurrent polyarthritis or persistent low-grade joint inflammation, joint deformity and deposition of uric acid crystals to form visible tophi. Tophi are nodular masses of white chalky paste-like material containing uric acid crystals. Tophi occur in around 5- 10 years after the first attack. The tophaceous deposits develop around the joints of the feet, finger joints, elbows, Achilles tendon, olecranon bursa and pinna of the ear.

•  Male gender
• Age < 40 years
• Obesity
• Family history
• Alcohol use and purine rich foods.
• Renal insufficiency

A rheumatologist will usually suspect gout when a patient presents with an episodic joint pain, swelling, redness, and warmth of the joint at the base of the big toe.

Serum uric acid levels are checked but serum uric acid levels may be normal during an acute attack and may not reflect pre-attack levels. Thus normal serum uric acid levels does not affect the diagnosis of gout and at the same time, high levels of uric acid doesn’t mean that one has gout.

If the joint involved is a large and swollen joint synovial fluid from the joint can be aspirated and examined under a polarized light microscope. Demonstration of needle-shaped birefringent crystals in the synovial fluid is considered as gold standard for diagnosis of gout. But this may not be possible always and the absence of crystals will not rule out diagnosis.

Goals of treatment of gout :

1. To treat the acute attack promptly and effectively to alleviate the pain and restore the function of the affected joint quickly.
2. Prevent recurrences of acute gouty arthritis.
3. Prevent or reverse complications due to crystal deposition in joints, kidneys or other sites.
4. Correct the contributory factors of hyperuricemia like obesity, dyslipidemia or hypertension.

Many people may have higher than normal levels of uric acid in their blood but may be asymptomatic and hyperuricemia is detected incidentally. Few of them may have musculoskeletal pain which might not be related to high uric acid levels. Mere presence of high levels of uric acid is not an indication for specific urate lowering therapy. Instead a meticulous search for the cause of hyperuricemia should be made. Correction of the underlying cause often brings back the uric acid values to normal levels. Some drugs may cause increase in levels of uric acid, like low dose aspirin, diuretics ( drugs that increase urine output), few drugs used in tuberculosis eg: pyrizanamide , ethambutol and few drugs used in cancer and AIDS.

Acute gouty attacks may be successfully treated with NSAIDS ( non steroidal anti-inflammatory drugs ), colchicines and steroids. It is not recommended to give urate lowering therapy in  acute attack as that will dissolve crystals within the joint and not allow the swelling to subside.

Long term treatment of gout is focused on lowering uric acid levels. Febuxostat and allopurinol are widely used for this purpose. The goal of therapy is to reduce serum uric acid levels to below 6mg/dl at minimum. Uric acid  lowering therapy is suggested for patients who have two or more attacks of gout per year or have one or more tophi on clinical examination or imaging study.

Excess uric acid may result from an increase in amount of purine being degraded owing to raised ingestion of purine rich foods or drinks.

1. Organ meat : avoid meat such liver, kidney and brain as they are high in purines and can increase your uric acid levels.
2. Red meat : red meat is better avoided as it is rich in purines.
3. Sea food : sea food such as anchovies, sardines and tuna are high in purines and may increase your uric acid levels if consumed in large quantity and is best avoided.
4. Alcohol : alcohol is one of the most important risk factors in gout. Beer and distilled liquors are associated with an increased risk of gout and recurring attack. Moderate consumption of wine doesn’t appear to increase to increase the risk of gout attacks.
5. Sugary foods and beverages : sugar sweetened foods such as candies, sweetened bread, fruit juices, soda and soft drinks have been shown to increase serum uric acid levels and thus increase risk of gout.
6. Vegetables & fruits : vegetables have a protective effect in gout. Among vegetables, one may avoid purine rich vegetables like peas, beans, spinach, mushrooms. Fruits rich in vitamin c like oranges and grapes may help lower uric acid levels.
7. Dairy products like milk , curd does not increase uric acid levels and can be consumed safely.
8. Drink plenty of water as uric acid is excreted in urine hence drinking plenty of water will help you to flush out excess uric acid from the body.