Gout

Who gets gout?

There is a popular belief that only middle-aged, overweight men who eat and drink too much suffer from gout. This is a myth – gout can attack young men in their twenties and also women, although it is very unusual in women and occurs mainly after the menopause. One survey of general practice patients found that gout affects 6 in every 1,000 men and 1 in every 1,000 women in the UK.

What’s going on?

An attack of gout is caused by uric acid suddenly forming crystals inside a joint, causing intense inflammation with pain, redness and swelling. Uric acid is produced when purines, which are chemicals present within all living cells, are broken down. Purines are produced by the body itself and are also found in many foods. People prone to gout have an inherited tendency to produce a lot of uric acid. High levels accumulate in the bloodstream and are deposited in the body’s tissues.

Common sites are the joints, the kidneys and the skin over the tops of the ears, hands and elbows. If the kidneys are affected, then they do not work as well as they should at excreting the uric acid in the urine and the levels become even higher. Uric acid deposits under the skin appear as whitish lumps, called ‘tophi’. They may ulcerate and discharge material that looks like toothpaste. It is not always clear what causes the uric acid suddenly to form crystals in the joints and set off inflammation, but a common trigger is minor injury to the joint.

Symptoms

A typical attack of gout is easily recognisable.

What happens during an attack of gout:

• At first, there is only minor discomfort but, within a matter of hours, the joint is swollen, hot, red and extremely painful.

• The pain is so severe that wearing shoes is out of the question, and you may not even be able to bear the touch of a bedsheet.

• Even with no treatment, the attack subsides completely within a few days, and always within a week.

• Attacks may recur, although sometimes not until months or years later.

• In 70 per cent of people, the knuckle joint of the big toe is the first joint, and often the only joint, to be affected, although symptoms can develop in any joint.

Diagnosis

Often your doctor will be able to recognise that you have gout from your symptoms and the appearance of the affected joint. You will need to have blood tests to measure the amount of uric acid in your bloodstream and to check whether your kidneys have been affected. A sample of fluid may sometimes be taken from an acutely inflamed joint with a fine needle and syringe.

Examination of the fluid under a special polarising microscope will show crystals of uric acid. This test will distinguish between gout and a condition called ‘pseudogout’. In pseudogout, the symptoms of an acute attack may mimic gout but the crystals responsible are calcium pyrophosphate. Pseudogout occurs in elderly people with osteoarthritis and is not usually inherited.

Treatment

Non-steroidal anti-inflammatory drugs are very effective and can shorten an attack if they are taken right at the beginning. Before these drugs became available, the traditional treatment for an attack of gout was a drug called colchicine, derived from the autumn crocus.

Colchicine is still used and it is also very effective, although it can cause troublesome diarrhoea in some people. In fact, both anti-inflammatory drugs and colchicine are so effective if taken early that people who have frequent attacks of gout are well advised to keep a supply in the medicine cabinet, so that they can take it at the first sign of trouble.

Diagnosing gout as a cause of joint pain

An attack of gout is caused by uric acid suddenly forming crystals within a joint, causing intense inflammation with pain, redness and swelling.

Looking ahead

If you still get frequent attacks, say more than three times a year, despite these measures, your doctor may suggest that you take drugs to lower the level of uric acid in your body. The main one is allopurinol which, taken daily as tablets, blocks the chemical pathway leading to uric acid production.

The uric acid deposits in the body tissues are then slowly removed into the urine and so leave the body. This effect takes place slowly, and you will still be prone to attacks of gout while the level of uric acid in your body remains high. Other drugs, less commonly used, work by making the kidneys more effective at excreting uric acid.

When you first start taking any of these long-term treatments, there is a temporarily increased risk of having an attack of gout, so you will usually be advised to take an anti-inflammatory drug at the same time for the first three months. Once you are on the long-term preventive treatment, you will probably have to continue with it indefinitely.

Help yourself avoid gout

• Drink plenty of clear dilute fluids (water or cordial), at least three litres a day, especially in hot weather and when you’re on holiday, because an attack is more likely if you become dehydrated.

• Reduce your weight so that it is within the normal range for your height.

• Keep your alcohol consumption within recommended levels – 21 units a week for a man and 14 for a woman. A unit is half a pint of beer, a small glass of wine or a single measure of spirits.

• Cut down on food and drink containing high levels of purines; these include high-protein foods such as red meat and pulses, offal (liver and kidneys), sardines and anchovies. It is better to eat meals based around complex carbohydrates, such as pasta. If you are concerned about what you should be eating, ask to see a dietitian.

• Avoid taking aspirin, which stops the kidneys from excreting uric acid; take paracetamol instead for minor aches and pains.

KEY POINTS

• Gout attacks are very painful but they get better within a few days, even without treatment

• If attacks are frequent, then you may need to take tablets every day to reduce the level of uric acid in your body