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Encyclopaedia


Gout

Introduction

Gout

Gout is a type of arthritis in which small crystals form inside and around the joints. It causes sudden attacks of severe pain and swelling.

It's estimated that between one and two in every 100 people in the UK are affected by gout.

The condition mainly affects men over 30 and women after the menopause. Overall, gout is more common in men than women.

Gout can be extremely painful and debilitating, but treatments are available to help relieve the symptoms and prevent further attacks.

Signs and symptoms of gout

Any joint can be affected by gout, but it usually affects joints towards the ends of the limbs, such as the toes, ankles, knees and fingers.

Signs and symptoms of gout include:

  • severe pain in one or more joints
  • the joint feeling hot and very tender
  • swelling in and around the affected joint
  • red, shiny skin over the affected joint

Symptoms develop rapidly over a few hours and typically last three to 10 days. After this time the pain should pass and the joint should return to normal.

Almost everyone with gout will experience further attacks at some point, usually within a year.

Read more about the symptoms of gout.

When to see your GP

See your GP if you suspect you have gout and it hasn't been previously diagnosed, particularly if the pain keeps getting worse and you also have a high temperature (fever).

It's important that a diagnosis is confirmed because other conditions that require urgent treatment, such as an infected joint, can sometimes cause similar symptoms.

If you've already been diagnosed with gout and you have an attack, see your GP if any medication you've been prescribed (see below) doesn't start working within a couple of days.

Read more about diagnosing gout.

What causes gout?

Gout is caused by a build-up of a substance called uric acid in the blood.

If you produce too much uric acid or your kidneys don't filter enough out, it can build up and cause tiny sharp crystals to form in and around joints. These crystals can cause the joint to become inflamed (red and swollen) and painful.

Things that may increase your chances of getting gout include:

  • obesity, high blood pressure and/or diabetes
  • having a close relative with gout
  • kidney problems
  • eating foods that cause a build-up of uric acid, such as red meat, offal and seafood
  • drinking too much beer or spirits

Read more about the causes of gout.

Treatments for gout

If you have gout, treatment is available from your GP to:

  • relieve symptoms during an attack – this can be done using ice packs and by taking medications such as non-steroidal anti-inflammatory drugs (NSAIDs), colchicine or corticosteroids
  • prevent further attacks – through a combination of lifestyle changes, such as losing weight or changing your diet, and taking medication that lowers uric acid levels, such as allopurinol

With treatment, many people are able to reduce their uric acid levels sufficiently to dissolve the crystals that cause gout – and as a result have no further attacks. However, lifelong treatment is usually required.

Read more about treating gout.

Can gout cause further problems?

Sometimes gout can lead to further problems, particularly if it's left untreated.

These can include:

  • kidney stones
  • small firm lumps of uric acid crystals under the skin called tophi
  • permanent joint damage

Read more about the complications of gout.

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Symptoms

The main symptom of gout is a sudden attack of severe pain in one or more joints, typically your big toe.

Other symptoms can include:

  • the joint feeling hot and very tender, to the point of being unable to bear anything touching it
  • swelling in and around the affected joint
  • red, shiny skin over the affected joint
  • peeling, itchy and flaky skin as the swelling goes down

The intense pain can make getting around difficult. Even the light pressure of a bed cover or blanket can be unbearable.

Which joints can be affected?

Gout can affect almost any joint and can occur in more than one joint at the same time.

The joints towards the ends of the limbs tend to be affected more often, including the:

  • toes – particularly the big toe joint
  • midfoot (where your shoelaces sit)
  • ankles
  • knees
  • fingers
  • wrists
  • elbows

If gout is left untreated, it's likely to affect more joints over time.

Pattern of symptoms

Attacks of gout tend to:

  • occur at night, although they can happen at any time
  • develop quickly over a few hours
  • last between three and 10 days – after this time, the affected joint should start to return to normal, but the problem can persist if treatment isn't started early
  • come back – you may experience attacks every few months or years
  • become more frequent over time if not treated

It's difficult to predict how often attacks will occur and when exactly they will happen.

When to seek medical advice

See your GP if you suspect you have gout and it hasn't been previously diagnosed.

Contact your GP immediately or call NHS Direct Wales on 0845 46 47 if you have both:

  • severe, worsening joint pain and swelling
  • a high temperature (fever) of 38C (100.4F) or above

This could mean you have an infection inside the joint (septic arthritis).

If you've already been diagnosed with gout and you have an attack, see your GP if any medication you've been prescribed doesn't start working within a couple of days.

Read more about diagnosing gout and treating gout.

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Causes

Gout is caused by small crystals forming in the joints, resulting in severe pain, tenderness and swelling.

These crystals can grow when a waste product called uric acid starts to build up to high levels in the body.

Uric acid

Uric acid is created when the body breaks down chemicals known as purines.

If your kidneys don't filter out enough uric acid, or your body is producing unusually high levels of it, it can build up in the body and turn into microscopic crystals.

These crystals usually form in and around the joints, possibly because the temperature in these areas is slightly lower than the rest of the body. If they get into the space between joints, the crystals can cause painful inflammation (redness and swelling).

What can increase your risk?

A high level of uric acid in the blood is the main factor that increases your risk of developing gout. However, it's still uncertain why some people with a high level of uric acid in the blood develop gout, while others with an equally high level don't.

Other factors that may increase your risk of developing gout are outlined below.

Medical conditions

Some underlying medical conditions can increase your risk of developing gout, including:

Medication

Certain medications can increase your uric acid levels and your risk of developing gout. These include:

  • diuretics (water tablets) – used to treat high blood pressure or an abnormal build-up of fluid in your body
  • certain medicines used to treat high blood pressure – including beta-blockers and ACE inhibitors
  • low-dose aspirin – used to reduce the risk of blood clots
  • niacin – used to treat high cholesterol
  • ciclosporin – used to treat conditions such as psoriasis
  • some chemotherapy medicines

Diet

Uric acid is created when the body breaks down purines. Eating foods that contain a high level of purines can increase your risk of gout.

Foods naturally high in purines include:

  • red meat – such as beef, lamb and pork
  • seafood – especially shellfish and oily fish
  • offal – such as liver, kidneys and heart

Alcohol

Alcoholic drinks can raise the level of uric acid in the blood.

Beer, fortified wines like port, and spirits do this more than wine. Moderate consumption of wine – one or two glasses a day – shouldn't significantly increase your risk of gout.

Sugary drinks

Certain sugary drinks may also increase your risk of gout.

Some research has found that drinking sugar-sweetened soft drinks and drinks with high levels of fructose (a naturally occurring sugar found in many fruits) had an increased risk of gout.

Family history

Studies have shown that gout often runs in families. Around one in five people with gout have a close family member with the condition.

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Diagnosis

Your GP may suspect gout based on your symptoms. Sometimes further tests will be needed to confirm the diagnosis and rule out other possible causes.

Seeing your GP

See your GP if you experience symptoms of gout for the first time.

Your GP will ask about your symptoms and medical history, and examine the affected area, to help make a diagnosis.

They may also ask you about your diet, particularly your intake of beer, spirits and foods high in purines, such as red meat and seafood.

Further tests

Many conditions can cause gout-like symptoms.

Your GP may be unable to make a firm diagnosis straight away and you may be referred for further tests. These will either confirm the diagnosis of gout or rule out other conditions.

Joint fluid test

A sample of fluid may be taken from the affected joint. The fluid can be checked for the small crystals that cause gout, and it can be tested for infection to rule out septic arthritis.

Blood test

A blood test known as a serum uric acid test may be used to measure the amount of uric acid in your blood. A high level or uric acid is often associated with gout.

It’s sometimes best to wait until two to four weeks after an attack of gout before this test is carried out, as the level of uric acid in your blood is often not raised at the time of an attack. This is because the level of uric acid in your blood can drop when uric acid crystals form in the joints.

X-ray

An X-ray is rarely used to diagnose gout because the condition isn't usually detectable using this method.

However, an X-ray is sometimes used to help rule out similar conditions that affect the joints, such as chondrocalcinosis (a build-up of calcium crystals in the joints) or to assess whether there has been any joint damage due to repeated or persistent attacks of gout.

Ultrasound scan

An ultrasound scan of an affected joint is a simple and safe investigation that's increasingly used to detect crystals in the joints. It can also detect crystals deep in the skin that aren't obvious during a physical examination.

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Treatment

Treatment for gout includes pain relief to help you cope with a gout attack, as well as medication and lifestyle changes to prevent further attacks.

Pain relief for a gout attack - What to do during an attack

You should:

  • take any medication you've been prescribed as early as possible after you notice an attack (see below) – this should start to have an effect within two or three days
  • rest and raise the limb
  • avoid knocking or damaging the affected joint
  • keep the joint cool – remove surrounding clothing and apply an ice pack, such as a bag of frozen peas wrapped in a towel
  • ensure you're well hydrated

Apply the ice pack to your joint for around 20 minutes. Don't apply ice directly to your skin and don't apply it for more than 20 minutes at a time because this could damage the skin.

If necessary, you can keep reapplying an ice pack to your skin during an attack, but you should wait until your skin has returned to a normal temperature first.

NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs) are usually recommended as the first treatment for gout. They work by reducing pain and inflammation during an attack.

NSAIDs used to treat gout include naproxen, diclofenac and etoricoxib.

If you've been prescribed NSAIDs, it's a good idea to have them with you at all times so you can use them at the first sign of a gout attack. Continue to take your medication throughout the attack and for 48 hours afterwards.

Your GP may also prescribe a medication called a proton pump inhibitor (PPI), to take alongside your NSAID. This reduces the risk of the NSAID causing indigestionstomach ulcers and bleeding from the stomach.

Colchicine

If you're unable to take NSAIDs or if NSAIDs are ineffective, a medicine called colchicine can be used instead.

Colchicine reduces some of the swelling and pain associated with a gout attack.

It's best to have it with you at all times so you can use it at the first sign of a gout attack. Your GP will tell you how long to take it for and how often.

When taken in high doses, side effects of colchicine include feeling sick, abdominal (tummy) pain and diarrhoea.

Corticosteroids

Corticosteroids are sometimes used to treat severe cases of gout if other treatments don't work or you're unable to take an NSAID or colchicine.

A short course of steroid tablets often provides relief, but they can't be used long-term in high doses as they cause side effects, including:

  • weight gain
  • thinning of the bones (osteoporosis)
  • easy bruising
  • muscle weakness

Corticosteroids can also be given by injection to provide rapid pain relief. This can be either into a muscle, a vein or directly into the affected joint.

Medication and lifestyle changes to prevent further attacks

You can reduce your chances of having further gout attacks by taking medication and making lifestyle changes to reduce the level of uric acid in your body.

Medication

Medication to reduce uric acid levels – known as urate-lowering therapy (ULT) – is usually recommended if you have recurrent attacks of gout or you have complications of gout.

Most people with gout will eventually need to have ULT, so you may want to discuss the advantages and disadvantages of this treatment with your doctor as soon as you've been diagnosed with gout.

They should explain that while ULT can significantly reduce your risk of having further attacks, the medication needs to be taken on a daily basis for the rest of your life and there's a small risk of side effects.

If you decide to start ULT, a medicine called allopurinol is usually tried first. If this isn't suitable or doesn't work, other medications may be used instead. These medications are described below.

Allopurinol

Allopurinol helps reduce the production of uric acid. It can help prevent gout attacks, although it won't help relieve symptoms during an attack.

Allopurinol is a tablet taken once a day. When you first start taking it, your dose will be adjusted to make sure the level of uric acid in your blood is low enough. Regular blood tests will be needed to monitor this until the most effective dose is found.

Allopurinol can sometimes cause a gout attack soon after you start taking it and it can take up to a year or two before no further attacks occur. It's important to persevere with treatment even if you do have attacks during this time.

To help relieve attacks, your doctor will prescribe one of the pain relieving medications described above to take alongside your allopurinol at first.

Most people taking allopurinol won't experience any significant side effects. However, side effects can include:

  • a rash – this is usually mild and goes away on its own, but it can be a sign of an allergy; if you develop a rash, stop taking the medication immediately and contact your GP for advice
  • indigestion
  • headaches
  • diarrhoea

Febuxostat

Like allopurinol, febuxostat is a medication taken once a day that reduces the body's production of uric acid. It's often used if allopurinol isn't suitable or causes troublesome side effects.

As with allopurinol, febuxostat can make your symptoms worse when you first start taking it. Your doctor will initially prescribe one of the pain relieving medications described in case you experience attacks.

Side effects of febuxostat can include:

  • diarrhoea
  • feeling sick
  • headaches
  • a rash

Other medications

Less commonly used ULT medications include benzbromarone and sulfinpyrazone.

These types of medication tend to only be used if people are unable to take allopurinol or febuxostat. They need to be prescribed under the supervision of a specialist.

Lifestyle changes

Certain lifestyle changes can also help reduce your risk of experiencing further attacks of gout, including:

  • avoiding foods containing high levels of purine (the chemical involved in the production of uric acid), such as red meat, offal, oily fish, seafood and foods containing yeast extract – see the gout and diet leaflet (PDF, 1Mb) produced by the UK Gout Society
  • avoiding sugary drinks and snacks – these are associated with an increased risk of gout
  • maintaining a healthy weight – follow a balanced diet; don't crash diet or try high-protein, low-carbohydrate diets
  • taking regular exercise – try activities that don't put too much strain on your joints, such as swimming
  • drinking plenty of water – keeping yourself well hydrated will reduce the risk of crystals forming in your joints
  • cutting down on alcohol – avoid beer and spirits in particular and don't binge drink

There's some evidence to suggest that taking regular vitamin C supplements can reduce gout attacks, although the effect may only be small. Talk to your GP first if you're thinking about taking vitamin C supplements, as they aren't suitable or safe for everyone.

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Complications

Complications of gout can include small lumps forming under the skin (tophi), joint damage and kidney stones. These are more likely to occur if gout is left untreated.

Tophi

Gout is caused by a chemical called uric acid forming small crystals in and around the joints. These crystals also often build up under the skin and form small white or yellow lumps known as tophi.

Tophi are usually painless, but they can form in awkward places, such as at the ends of your fingers and around your toes. Sometimes they can make everyday tasks such as preparing food or getting dressed difficult.

They can also can become inflamed and produce a toothpaste-like discharge.

Tophi can develop anywhere in the body, but usually form on the:

  • toes
  • heels
  • knees
  • fingers
  • ears
  • forearms
  • elbows

It normally takes several years after the first attack of gout for tophi to develop, but some people develop them even before experiencing an attack. They're usually a sign of severe gout and a good reason to start treatment to reduce the level or uric acid in your body.

Successful treatment will prevent the tophi from getting any bigger, and long term treatment often gradually shrinks them.

If you have very large or painful tophi, they may have to be surgically removed.

Joint damage

Without treatment, gout attacks may become more frequent and prolonged, and your likelihood of developing permanent joint damage will increase.

In the most serious cases, surgery may be required to repair or replace a damaged joint.

Kidney stones

Occasionally, high levels of uric acid can lead to the formation of kidney stones.

Some kidney stones interfere with the flow of urine, resulting in pain when you pass urine, and can make you feel that you need to pass urine more often.

You may be prescribed medication to make your urine less acidic, which should help dissolve any kidney stones that have developed. Read more about treating kidney stones.

Psychological and emotional effects

Gout can also affect your mood, work and home life. The severe pain that gout causes can make it difficult to do everyday tasks and to get around, which in turn can lead to feelings of depression or anxiety.

If gout is affecting your mood or making everyday life difficult, talk to your GP. They will be able to offer treatment and support.

There are also a number of organisations that offer information and advice for people who have gout, including The UK Gout Society, Arthritis Research UK and Arthritis Care.

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The information on this page has been adapted by NHS Wales from original content supplied by NHS Choices.
Last Updated: 21/12/2015 10:05:12

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