Gout is a disease caused by the build-up of uric acid in the joints leading to intermittent episodes of joint pain and swelling.
Uric acid is a waste product of purines, which is normally dissolved in the blood and excreted by the kidneys. Purines are organic compounds obtained from our diet that is used in DNA and other biochemical processes. There are certain foods like red meat, seafood, and alcohol that have a higher purine content, which increases the risk of gout. Elevated uric acid occurs when the intake of purines is high or when the output through the kidneys is low. This can occur in the setting of kidney disease, medication, or as the body ages.
When the uric acid level is above 6.8 mg/dL it is unable to be dissolved in the blood and will start to precipitate as crystals called urate. When urate builds up in the joint, it can lead to inflammation and joint pain. Not every person with elevated uric acid will have gout. When the uric acid level is above 10 mg/dL there is a 30% chance of a gout attack in the next 5 years. The crystals in the joint cause an inflammatory response leading to joint pain and swelling. The small peripheral joints are most likely to be affected because they are cooler than the rest of the body. This allows the uric acid crystals to precipitate easier. Over time if it is not treated it can lead to joint destruction.
Gout is characterized by intermittent episodes of joint pain in the setting of elevated uric acid. Attacks can begin as early as 30 to 40 years old. And, it's important to note that men can be affected earlier in life.
Women do not usually have symptoms of gout until they are in their 60s. The first toe is the most common joint to be affected first.
A gout attack is associated with:
Gout attacks will self-resolve early in the course of the disease after about 2 weeks. If there is long-standing elevated uric acid, then gout attacks will become more frequent and can attack more joints.
Eventually, there will be the development of tophaceous gout. Tophi are collections of uric acid crystals. They can appear as chalky masses under the skin around the joints. Uric acid can also deposit in another area of the body leading to soft tissue swelling around the joint (bursitis), nodules, and kidney stones.
Gout is diagnosed by extracting fluid from the joint with a needle and examining it under microscopy. Identifying urate crystals under the microscope is the gold standard for diagnosis. It is important to rule out other causes of acute joint pain, like an infection. This is also done by evaluating the fluid under the microscope. X-ray imaging is not helpful in the initial diagnosis of gout, but it can be useful if there is a long history of gout to evaluate the extent of joint damage.
The mainstay of treatment of an acute gout attack is anti-inflammatory medications. These include NSAIDs, Steroids (prednisone), Colchicine (Colcrys/Mitigare). These medications should be started at the onset of an acute attack and continue until the uric acid level is <6 mg/dL.
Chronic therapy is started to lower the uric acid level to prevent attacks in the future. Many different medications can be used to help lower the uric acid level.
One common medication is Allopurinol. It is started after a gout attack and should be taken with an anti-inflammatory medication until the uric acid level has normalized. If allopurinol is taken alone, it can lead to a gout attack. It is important to closely follow up with your physician to monitor the uric acid level to adjust therapy. A low purine diet can also help reduce the uric acid level in the body.
To learn more about diagnosing, treating, and managing gout contact our team to schedule an appointment.
Kelsey Rigby, DO,
Kent Hospital,
Internal Medicine Resident