Gout

Gout is caused by hyperuricemia, a condition where there's too much uric acid in the blood. Your body produces uric acid when it breaks down purines — substances that are found naturally in your body and in certain foods. Normally, uric acid dissolves in your blood and passes through your kidneys into your urine.

Sometimes your body produces too much uric acid or your kidneys excrete too little. 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.

An attack of gout can occur suddenly, often waking you up in the middle of the night with the sensation that your big toe is on fire. The affected joint is hot, swollen, and so tender that even the weight of a bedsheet may seem intolerable. Gout attacks typically last 3-10 days, but without treatment, attacks may become more frequent and last longer.

Gout symptoms almost always occur suddenly and often at night. The signs and symptoms of gout include:

During an Acute Attack

• Intense joint pain: Severe joint pain that is usually most severe within the first 4-12 hours
• Big toe involvement: Classic foot or toe pain, especially in the big toe (podagra)
• Swelling and inflammation: Foot or toe swelling with redness and warmth
• Limited range of motion: Difficulty moving the affected joint
• Extreme tenderness: Even light touch can be unbearable

Commonly Affected Joints

• Big toe (most common)
• Ankle pain and ankle swelling
• Knee pain and knee swelling
• Wrist pain and wrist swelling
• Hand or finger pain and hand or finger swelling
• Elbow joints

Other Symptoms

• Lingering discomfort after acute pain subsides
• Red or purplish skin around affected joint
• Peeling or itchy skin as swelling decreases
• Low-grade fever during attacks
• Leg swelling if lower extremity joints affected

Chronic Gout Symptoms

• Tophi (visible lumps of urate crystals under skin)
• Joint deformity
• Chronic joint pain and stiffness
• Kidney stones
• Decreased kidney function

Gout develops when urate crystals form in joints. Several factors can increase uric acid levels:

Primary Causes

• Overproduction of uric acid: Body makes too much uric acid
• Underexcretion of uric acid: Kidneys don't eliminate enough uric acid
• Combination: Both overproduction and underexcretion

Risk Factors

Dietary Factors

• High purine foods (red meat, organ meat, some seafood)
• Alcohol consumption, especially beer
• Sugary drinks with high-fructose corn syrup
• Dehydration

Medical Conditions

• Obesity
• High blood pressure
• Diabetes and metabolic syndrome
• Heart and kidney disease
• Psoriasis
• Lead exposure

Medications

• Thiazide diuretics
• Low-dose aspirin
• Anti-rejection drugs (cyclosporine)
• Niacin

Other Factors

• Family history of gout
• Age and sex (men 30-50, postmenopausal women)
• Recent surgery or trauma
• Crash diets or fasting

Diagnosing gout involves several tests and examinations:

Diagnostic Tests

• Joint fluid test: Most definitive test - microscopic examination for urate crystals
• Blood test: Measures uric acid levels (though can be normal during attack)
• X-rays: Rule out other causes, show chronic damage
• Ultrasound: Detect urate crystals in joints
• Dual-energy CT scan: Detect urate crystals even between attacks

Clinical Criteria

Diagnosis often based on:

• Pattern of joint involvement
• Characteristic symptoms
• Response to treatment
• Presence of tophi
• Elevated serum uric acid levels

Gout treatment has two main goals: treating acute attacks and preventing future attacks and complications.

Acute Attack Treatment

Medications

• NSAIDs: Indomethacin, naproxen, or ibuprofen for pain and inflammation
• Colchicine: Reduces gout pain, most effective when taken early
• Corticosteroids: Prednisone for those who can't take NSAIDs or colchicine
• Local injection: Corticosteroids directly into affected joint

Supportive Care

• Rest and elevate affected joint
• Apply ice for 20-30 minutes several times daily
• Stay well hydrated
• Avoid alcohol and purine-rich foods

Long-term Management

Uric Acid-Lowering Therapy

• Allopurinol: First-line xanthine oxidase inhibitor
• Febuxostat: Alternative xanthine oxidase inhibitor
• Probenecid: Increases uric acid excretion
• Pegloticase: For severe, refractory gout

Target Goals

• Serum uric acid below 6 mg/dL
• Below 5 mg/dL for tophaceous gout
• Regular monitoring of levels
• Gradual dose adjustments

Untreated or poorly managed gout can lead to:

• Joint damage: Permanent destruction and deformity
• Tophi: Large deposits of urate crystals under skin
• Kidney stones: Uric acid stones in urinary tract
• Kidney disease: Chronic kidney dysfunction
• Cardiovascular disease: Increased risk of heart problems
• Type 2 diabetes: Higher risk of developing diabetes
• Sleep apnea: Associated with gout
• Depression: Due to chronic pain and limitations

While not all gout can be prevented, you can reduce your risk:

• Maintain a healthy weight through gradual weight loss
• Stay well hydrated with 8-16 glasses of water daily
• Limit alcohol consumption, especially beer
• Follow a low-purine diet
• Exercise regularly but avoid extreme exertion
• Manage related conditions (hypertension, diabetes)
• Take medications as prescribed
• Regular monitoring of uric acid levels
• Avoid medications that raise uric acid when possible

With proper treatment and lifestyle changes, most people with gout can lead normal, active lives:

• Work closely with your healthcare team
• Take medications as prescribed, even when feeling well
• Keep a gout diary to identify triggers
• Plan for attacks with medications on hand
• Join support groups for chronic conditions
• Stay informed about new treatments
• Maintain regular check-ups and lab work
• Communicate dietary needs when dining out