Gout

Gout is a common form of arthritis that can affect toe, foot, ankle, knee, hand and elbow joints. Symptoms include pain, swelling and shiny redness over the affected joints.

Treatment of acute gout attacks is designed to relieve pain and inflammation, primarily through medication. Diet and other lifestyle changes can help prevent future attacks.

General information

Gout is a form of arthritis (inflammation of the joints) that can cause sudden, severe attacks of pain in the joints. The most common place for gout to develop is the ball of the big toe but other joints can be affected. It is unusual for gout to affect more than one or two joints at a time.

Gout is common in New Zealand, with an estimated prevalence of 2.7% for the overall population and a prevalence of 3.75% in people aged 20 years or older.

Gout most commonly affects adult men (particularly after age 40) and is uncommon in women until after menopause. It is estimated to affect adult men 3.5-times more than women and is more common in people of Maori and Pacific Island ethnicity.

Without treatment gout may take up to a week for symptoms of an attack to subside. At first, the time period between attacks can be as long as several months or even years. However, over time attacks tend to occur more frequently and be more severe.

Left untreated over time gout can lead to joint and kidney damage and, in conjunction with other risk factors such as high blood pressure and diabetes, can increase the risk of heart disease, stroke, and kidney failure.

Causes

Gout is caused by raised levels of uric acid in the blood. Uric acid is produced naturally in the body. Normally it stays dissolved in the blood and is excreted by the kidneys as a component of urine.

However, accumulation of uric acid in the blood can cause crystals of uric acid to form and deposit in the joints, causing gout.

A number of risk factors are related to the development of gout. These include:

• Obesity
• High alcohol intake
• A genetic predisposition
• High intake of foods rich in purines (eg: some seafoods and meats)
• Certain medicines eg: diuretics (fluid tablets)
• Injury to a joint
• Long-standing kidney disease.

High uric acid levels are more likely to be caused by the body not eliminating uric acid properly (due to obesity, kidney problems or genetics) than by what a person eats and drinks.

Maori and Pacific people are at higher risk of getting gout because they have genes that make it harder to eliminate uric acid from their bodies.

Occasionally there is no obvious cause for an attack of gout.

Signs and symptoms

Gout develops quickly, often within 12 to 24 hours, and tends to come and go. Signs and symptoms of a gout attack include:

• Severe pain and tenderness in the affected joint
• Swelling of the affected joint
• The skin over the joint may feel hot and tight and may look shiny and red
• Limited range of motion in the affected joint.

Some people may also experience nausea, a loss of appetite, and a slight fever.

Diagnosis

Gout can be difficult to diagnose because the symptoms may mimic those of other conditions such as joint infection.

A blood sample may be taken to check for alterations in normal blood levels and a raised uric acid level. Results of this test may not always be helpful, however, as they often indicate normal uric acid levels during an attack of gout. This is likely to be because the excess uric acid has moved out of the blood and has settled as crystals in the joints.

To make a definitive diagnosis of gout the doctor may take a sample of fluid from the affected joint. This is performed using a local anaesthetic and involves inserting a needle inserted into the affected joint and removing a small amount of fluid. The fluid is then sent to a laboratory where it is tested for the presence of uric acid crystals. If they are present, then gout is confirmed. X-rays of the affected area may also be taken to check for joint damage.

Treatment and prevention

Medical treatment is aimed at relieving the pain and inflammation of acute attacks and preventing the occurrence of future attacks. Diet and lifestyle changes also help to prevent future attacks of gout.

Treatment of acute attacks:

The more promptly that effective treatment is commenced, the more quickly the attack can be controlled. The different types of medications used include:

• Medications to reduce pain – particularly non-steroidal anti-inflammatory medications (NSAIDs) like ibuprofen. Taken early in the attack, they can reduce the duration and severity of the attack. Paracetamol, taken in conjunction with other medications, can also help in reducing pain. Aspirin should be avoided as it can reduce the amount of uric acid excreted by the body.
• Colchicine – this medication helps to block production of uric acid. It is most effective when taken early in an attack. However, it can have side effects such as diarrhoea if too much is taken. Dosage instructions should be followed carefully.
• Corticosteroids – such as prednisone may be given in tablet form to help reduce pain and inflammation. Corticosteroid injections directly into the joint may also be effective.

Drinking extra fluid (preferably water) while taking these medications is recommended. The affected joint should also be rested and elevated.

Preventing future attacks:

Preventing attacks of gout is as important as treating the symptoms of an acute attack. Ways in which gout can be prevented include use of medications and lifestyle changes.

Medications – the mainstay drug for people with gout is allopurinol, which acts to reduce uric acid production. People who cannot take allopurinol because of side effects or other reasons may be prescribed alternative medications which either reduce uric acid production or increase the excretion of uric acid by the kidneys.

In the initial stages of treatment with medications to prevent gout, attacks may occur more frequently and may be more severe. For this reason, the dosage of the medications may be low to start with and is then gradually increased. These medications should only be discontinued on the advice of a doctor as stopping and starting them can also bring on a gout attack.

Dietary modifications – changes in diet are aimed at restricting or avoiding foods high in purines. Purines are substances found in some foods and produce uric acid when broken down by the body. Foods high in purines include:

• Shellfish (pipis, paua, oysters, mussels) and fish roe
• Offal foods (brains, liver, kidney, tripe)
• Red meat (beef, pork/bacon, lamb)
• Yeast extracts (Marmite, Vegemite)
• Foods containing yeast (bread, beer)
• Oily fish (sardines, herrings, and anchovies).

Limiting alcohol intake – is also important. Alcohol causes the body to lose fluid (by increasing urine output and drawing water from the blood), thus increasing the uric acid levels in the blood. Beer is rich in purines so should be avoided.

Drinking plenty of non-alcoholic fluids – especially water (eight to 10 glasses a day) is recommended. This will help to flush the uric acid crystals out of the body. Soft drinks, fruit juice and drinks sweetened with fruit sugar (fructose) are best avoided as they can increase uric acid levels.

Maintaining a healthy body weight – will help to reduce stress on affected joints and decrease the likelihood of developing gout.

Complications

If uric acid levels remain raised for long periods of time, or there are frequent recurrent attacks of gout, deposits of uric acid salts may form around the affected joint and appear on the skin as chalky coloured nodules. These are called tophi and may also appear in other areas of the body such as the ears.

Recurrent severe attacks of gout and the development of tophi can cause permanent damage to the joints. Surgery may be required to restore joint function. This may involve joint replacement surgery.

Damage to the delicate filters within the kidneys and the development of kidney stones can also occur if uric acid levels in the blood remain raised for long periods of time. This in turn can impair kidney function. To prevent the complications of gout it is important to carefully follow the treatment instructions given by a doctor to deal with gout attacks quickly, and prevent them from recurring.

Further information

For further information and support contact your doctor, practice nurse, or:

Arthritis New Zealand

Free phone: 0800 663 463

Email: [email protected]

Website: www.arthritis.org.nz

References

Dalbeth N, et al. Gout in Aotearoa New Zealand: are we going to ignore this for another 3 years? N Z Med J. 2016 Jan 29;129(1429):10-3.
Mayo Clinic (2019). Gout (Web Page). Rochester, NY: Mayo Foundation for Medical Education and Research. https://www.mayoclinic.org/diseases-conditions/gout/symptoms-causes/syc-20372897 [Accessed: 17/04/19]Ministry of Health (2019). Gout (Web page). Wellington: New Zealand Ministry of Health. https://www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses/gout. [Accessed: 17/04/19]
O’Toole, M.T. (Ed.) (2017). Gout. Mosby’s Dictionary of Medicine, Nursing & Health Professions (9th ed.). St Louis, MI: Elsevier.
Winnard D, et al. National prevalence of gout derived from administrative health data in Aotearoa New Zealand. Rheumatology (Oxford). 2012;51(5):901-9.

Last Updated: May 2019

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