Gout / Podagra

Gout (a.k.a. podagra when it affects the big toe joint) is a fairly common form of arthritis that is a result of an abnormal metabolism of uric acid. People with gout either produce too much uric acid, or it may be the case that their bodies simply have difficulty getting rid of it. When uric acid builds up in the tissues and the blood, it causes inflammation in the joints, and this leads to gout. The prevalence of gout as a medical condition seems to be on the rise; currently it is estimated that gout affects over 6 million Americans.

gout infographic

The increased prevalence of gout may be linked to several different disorders. Some of the conditions that have a correlation to gout include: heart disease, kidney stones, high blood pressure (hypertension), high levels of lipid, and obesity. Chronic gout can be controlled with the help of medication. If the condition is diagnosed early on and treated appropriately, the damage caused to one’s joints will be minimal. Standard treatments tend to include lifestyle changes, and these can be very effective in terms of preventing and managing gout and many of its associated conditions. The joint most commonly affected by gout is the metatarsal-phalangeal joint which is situated at the base of the big toe. This condition is often called podagra. This joint is affected in about 50% of cases. However, gout can affect almost any part of the body. Sometimes it is termed the “rich man’s disease” or the “disease of kings”, due to how gout has been stereotypically linked to habits like overindulgence in food and drink. The truth is, however, that the risk factors for gout vary greatly, and almost anyone can be affected by it.

gout

Gout Symptoms

The onset of gout is often characterized by intense episodes of pain in individual joints, generally accompanied by swelling, redness, tenderness, and heat. An acute gout attack may wake you up in the early hours of the morning with an unbearable burning sensation in your big toe. The pain experienced during an attack of gout is often described as excruciating, throbbing, or crushing pain. Even the weight of a bed sheet may trigger more pain in the big toe joint. Acute gout may affect just one joint, or it could affect a few. Besides the metatarsal-phalangeal joint, gout commonly affects the knee and ankle joints.

In addition to the standard symptoms, someone suffering from an attack of gout may also have a fever. The attack may subside in several days, but may also return occasionally. Subsequent attacks of gout often last for longer than the initial one. If an individual develops chronic gout, this condition is termed gouty arthritis. Gouty arthritis may lead to a loss of motion and damage to the joints. Those with chronic gout may experience pain, swelling, and tenderness most or all of the time.

Gout Causes & Risk Factors

Hyperuricemia, which signifies abnormally high levels of uric acid in one’s blood, is the direct underlying cause of gout. When we metabolize food, and when bodily tissues are broken down during regular cell turnover, our bodies produce uric acid. 10% of gout patients have bodies that generate an excess of uric acid. These patients are referred to as “over-producers.” Other gout patients are “under-excreters”; these do not effectively pass the uric acid from their bodies in their urine. Under-excreters account for the remaining 90% of gout patients.

Why does gout develop? No one knows exactly why. A particularly common factor that increases your risk of getting gout is the excess consumption of alcohol. Beer in particular is high in purines, which causes higher levels of uric acid. Gout is also associated with injuries, surgical procedures, high stress periods, and hospitalization. The condition is at times also a consequence of diuretic medications.

Further, there are established links between gout and kidney disorders, cancers, enzyme deficiencies, tumours, and lead poisoning. Patients with transplanted organs have a higher risk of gout, as do those with pre-existing conditions such as psoriasis and anaemia.

Gout/Podagra Treatment

Self-help

There are many self-help techniques that are available to sufferers of gout, which will help minimize the pain and swelling experienced. These include:

  • Resting and raising the affected leg or joint. If possible, keep the painful joint at an elevation higher than your chest for much of the time.
  • Refraining from vigorous activity
  • Wearing a splint to immobilize the joint
  • Keeping the joint cool – you can ice the area for twenty minutes each time, this will help with swelling, pain, and possible bruising. (Use ice wrapped in a towel; do not apply ice directly! Further, be sure to allow the joint to return to a normal temperature before reapplying the ice.)
  • Drinking lots of water

When undergoing an attack of gout, you also should take care to keep as much weight as possible off the joint in question. This may involve using a cane or some other kind of support.

Medical Treatment

The medical treatment of gout aims to perform several functions. It should:

  • Offer relief from acute attacks of gout
  • Be preventative, reducing the risk of recurring attacks
  • Prevent joint damage
  • Manage and prevent any further complications

If or when you have an onset of gout, you should seek out medication and professional help as soon as you possibly can. Initially, treatment should aim to settle the obvious symptoms of the acute attack. Ice treatments, administered several times a day, are very effective in reducing the amount of pain experienced by the patient. If attacks are recurring, however, different drugs can be prescribed to reduce the levels of uric acid in the serum.

When acute gout occurs, treatment options include various NSAIDs (non-steroidal anti-inflammatory drugs), and colchicine; in extreme circumstances steroids may also be used. There are a number of preventative drug options; these include febuxostat, allopurinol, and probenecid. Ultimately, if the level of uric acid is lowered successfully, the condition may be cured. If a comorbidity occurs, the careful treatment of both the primary and secondary condition, and of both conditions in combination, must be handled very carefully.

Treating Gout Pain & Inflammation

Naproxen, ibuprofen, and indomethacin are some of the common NSAIDs that are prescribed when gout symptoms begin. You should consult carefully with your health care provider about the correct dosage of NSAIDs that should be taken. For the first few days, it is usual practice to be prescribed a stronger dose. NSAIDs are medications that have a similar effect to aspirin; they are able to decrease the amount of pain and inflammation in your joints and in other tissues. NSAIDs have become the treatment of choice for gout patients, being very effective and safe. (Fact sheets on NSAIDs will list the types of patients who should not take NSAIDs.)

At times, you may be prescribed strong pain medication, like oxycodone, codeine, or hydrocodone. Colchicine is another prescription drug that is effective in minimizing swelling, inflammation and pain – it works well especially if used as soon as any symptoms appear. However, common side effects of colchicine include nausea, vomiting, and diarrhea, so this makes it a less common treatment option.

In cases of extreme pain, the affected joint may be injected with steroids. Corticosteriods like prednisone are particularly effective. They may be injected or taken in pill form, and they will help control the pain and inflammation. Your health care provider may also choose to withdraw a fluid sample from your joint, using a needle. This procedure often happens during the same visit where you receive a corticosteroid injection. Generally only people who cannot take colchicine or NSAIDs are given corticosteroids.

Within half a day of beginning treatment, pain usually reaches a manageable level, and within two days the pain should be gone.

Lowering Uric Acid Levels

Often medication that lowers the level of uric acid in the blood is used. This is usually necessary for those who have chronic gout, kidney stones, tophaceous gout, or abnormally high uric acid levels. These medications do not help with pain and inflammation, so they are normally administered following acute attacks, after the symptoms have subsided. Medicines that lower the levels of uric acid work by blocking the formation of uric acid, or by increasing the amount of uric acid that is excreted by the kidney.

The most common drug that is used for this purpose is allopurinol, also known as Lopurin or Zyloprim. Allopurinol serves to block the production of uric acid. Recently, febuxostat (or Uloric) has also been used, and it operates in the same way as allopurinol.

Probenecid (or Benemid) is a drug that helps the kidneys get rid of uric acid more efficiently. This drug is only recommended to patients who have healthy kidneys, which do not produce too much uric acid. Pegloticase (or Krystexxa), on the other hand, is a drug that helps the breakdown of uric acid, and it is administered by injection. Pegloticase is usually given to patients who are not able to tolerate or respond to other treatment options.

There are new drugs under development, which will aim to lower uric acid levels and treat gouty arthritis more effectively. Should you be prescribed medication for gout, it is possible that you might have to take these medications for the rest of your life, in order to prevent recurring attacks. Remember that all treatment options should be discussed thoroughly with your health care provider.