gout
WHAT
The language of medicine can be complicated and at times confusing. This section lays out in plain and simple English the basics of these conditions. As far as possible, technical terms and medical language is minimised or explained. What is the basic starting point for each of the conditions. What is the literal translation of the diagnostic label? What does this mean and what are the key symptoms of the disease?
Gout is a type of form of crystal arthritis – a condition where inflammation is triggered in response to the deposition of crystals within or around a joint. It is characterized by sudden attacks of joint inflammation and most commonly affects people over the age of 40, men more often than women. In gout, the crystals that form are called “monosodium urate” and an excessive level of uric acid within the bloodstream leads to the chemical crystallizing within joint spaces. These are especially irritant to the immune system resulting in joint pain, warmth, swelling and eventually deformity.
These events may seemingly occur randomly and intermittently over time, however some triggers for such flares have been identified. With the right treatment, gout flares can be treated and in the majority of cases the condition can be prevented from flaring with good uric acid level control.
WHO
The next section is who, the scientific word for this is the epidemiology of the condition. Epidemiology refers to the study of patterns and trends associated with diseases or injuries within a population. In other words, how common is the condition, what age range is affected? Are men and women affected equally? Does the frequency of the illness depend on what part of the world I live in? In other words, who is more likely to suffer from this condition.
Gout can affect anyone, but it becomes more common with age and is quite rare in people under 40. It is more frequently diagnosed in men, with the first attacks typically occurring in middle age. The condition has genetic links, leading to variations in its prevalence worldwide. In the UK, about 1 in 40 people are affected by gout, but its incidence is rising due to lifestyle changes, such as increased alcohol consumption and unhealthy diets. The prevalence also varies across different populations, with studies showing higher rates in ethnic groups like Pacific Islanders and Indigenous peoples.
Gout is often linked to other medical conditions, especially those that hinder the removal of uric acid, such as kidney disease, and conditions that impact metabolism, like diabetes. Factors like dehydration, kidney failure, injury to affected limbs, high purine intake (from meat and alcohol), and rapid weight gain can increase the risk of future flare-ups.
To reduce the risk of debilitating attacks and potential complications like joint damage, it is essential to stay hydrated, engage in regular physical activity, maintain a stable weight, avoid triggers, and seek early intervention when symptoms arise. While gout is a lifelong condition, medical treatment and medications can help manage acute symptoms and improve long-term quality of life. Regular consultations with healthcare providers can help develop personalized care plans tailored to each individual’s needs.
WHY
Why has this condition affected me, and what is happening in my body that is causing it? We can break this down into two parts: aetiology (which is the study of what might be causing the condition) and pathophysiology (which is about what is happening in the body as the disease progresses). Scientists are still studying these areas, and we don’t have all the answers yet. This section will provide a simple summary of what we do know, without all the complex medical terms.
Uric acid is a waste product that is normally excreted from the body through the kidneys, but in people with gout, the kidneys don’t get rid of enough uric acid, leading to its accumulation in the bloodstream. When this concentration reaches a critical level, it starts to form crystals that have a sharp, needle-like appearance. These are irritant to the body’s immune system and the subsequent attack on leads to joint inflammation, pain, and swelling. As these crystal deposits start to grow, they expand in size and form little nodules that look yellow-ish under the skin. These are referred to as tophi and typically occur in the fingers, elbows, toes but can also be found on the ear. Eventually they can burst through the skin releasing chalky material and raising the risk of an infection.
The exact cause of gout is not fully understood, but there are a number of factors that can contribute to its development. One of the most crucial of these is the inability to remove uric acid due to faults within a gene that helps extract this in the kidneys. Other factors include diet, and lifestyle factors such as being overweight, having high blood pressure, and consuming alcohol (especially beer). Gout is often seen first in joints that are “distal” (far away from the core), which is possibly due to temperature differences making these areas more prone to becoming cold and promoting crystal formation. The base of the big toe is a classic location for gout. A number of medical conditions and medications can increase the risk of developing gout. The metabolic changes in diabetes for example or people with other types of kidney diseases as well as being overweight or having a high cholesterol level. Medications, particularly diuretics (water pills), can also increase the risk of gout by reducing the amount of uric acid that is removed from the body and concentrating the uric acid within the bloodstream.
HOW
The how section answers more practical questions. This discusses what the next steps are in getting towards a diagnosis. If you have been suffering from the symptoms of a rheumatic condition, you will ultimately need to be reviewed by an appropriate specialist and will likely require some form of further investigation to help confirm or refute a particular diagnosis. This section lays out the typical medical work up you can expect for any given condition.
Gout is usually diagnosed when a person presents with a typical history of the condition in combination with examination findings or blood tests that would fit the diagnosis. It is one of the most acute (rapid onset) types of arthritis with patients often describing going to bed feeling fine and waking up with sudden and severe pain in the affected joint. The base of the big toe is a very common starting point with the joint appearing red, feeling hot and sometimes having a shiny appearance. You are likely to be asked about your family history, medications, and diet.
The physical exam will focus on the affected joint but may also look more broadly for tophi (crystal deposits) or seek out signs of related conditions such as high cholesterol or high blood pressure. These can sometimes be found in areas outside the joints such as the elbows or around the ears.
A blood test is helpful in assisting the diagnosis of gout, in particular checking for elevated levels of uric acid, but also for markers of inflammation and evidence of related conditions. During an acute flare however, the uric acid may be falsely lowered so a repeat test may be required when symptoms settle. Imaging studies, such as an X-ray or ultrasound, are useful to look for signs of joint damage or a “double contour” sign where crystal deposits can be visualised on the cartilage. A special type of CT imaging called “dual energy” scans can be remarkably specific as well. The “gold standard” of diagnosis if to obtain a sample of joint fluid and analyse this under a specific type of microscope (called a polarised light microscope) – then the needle shaped crystals become visible and definite confirmation of gout is possible.
WHAT NOW
Having now gained some better understanding of the condition; you now hopefully have a number of crucial questions on the background of the disease answered. The “What now” section outlines the road ahead. This includes an overview of the most common interventions that are likely to be considered for this including common medications and non-drug therapies. The list is not exhaustive and not all options listed are appropriate for every patient. What now also seeks to provide you a list of valuable additional resources where you can learn even more and get local and online support for your condition.
The management and treatment of gout involve a combination of medication, lifestyle changes, and therapy. The positive news however is that in most cases, treatment can be effective enough to essentially “cure” the condition, unfortunately this usually requires long term treatment to maintain remission and avoid gout flares.
During an acute attack, the priority is to settle the pain and inflammation that results in the suffering from gout flares. The first line of treatment for an acute gout attack typically involves nonsteroidal anti-inflammatory drugs (NSAIDs). Some are unable to tolerate this, or the medications may be contra-indicated with their other medical problems or medications. Colchicine is an alternative but needs to be carefully dosed to avoid side effects. If neither option is appropriate, corticosteroids given as a tablet or injection are a potent way to control the flare stage. During a flare it is also important to address any triggers that might have prompted it (such as an acute infection) and maintain good hydration.
While the treatment of flares is usually effective in early-stage gout, it is likely the condition will progress without preventative measures. Historically the medical profession has been cautious about introducing long-term treatment for gout and has opted to wait until more than one flare has occurred. However, there is mounting evidence that high levels of uric acid are a risk factor for cardiovascular disease (much like having a high blood pressure) and treatment should not be delayed. Urate-lowering drugs help to lower blood levels of uric acid. The most common type are blockers of an enzyme called Xanthine oxidase, examples include allopurinol and febuxostat. When introduced, the rapid lowering can actually trigger a gout flare. Titrating up the dose slowly where possible and giving stand-by courses of medication for a flare (such as NSAIDs) can help manage the introduction phase. The uric acid is lowered to a specific target level which, once reached, should prevent further attacks in the long term. Other drugs that are less commonly used help increase the amount being removed in the kidneys, examples include benzbromarone and probenecid.
Education is also an
important aspect of managing gout. Patients need to understand their condition
and its treatment, including the importance of adherence to medication and
lifestyle changes. This includes seeking out any related medical conditions and
treating these as appropriate. You may be provided educational resources and access
to support groups.
FURTHER LINKS
