Gout

Gout is the most common type of inflammatory arthritis. It causes sudden and intense attacks of joint pain, often in the big toe and at night. It can also strike joints in other toes or the ankle or knee. People with osteoarthritis in their fingers may experience their first gout attack in their finger joints.

Men are three times more likely than women to develop gout. It tends to affect men after age 40 and women after menopause, when they lose the protective effects of estrogen. Gout symptoms can be confused with another type of arthritis called calcium pyrophosphate deposition (CPPD), formerly called pseudogout. However, the crystals that irritate the joint in CPPD are calcium phosphate crystals, not the uric acid crystals that cause gout.

What Causes Gout?

Gout develops in some people who have high levels of uric acid from the breakdown of purines — natural chemicals found in every cell of your body and in many foods, especially red meat, organ meats, certain seafoods, sugary sodas and beer.

When uric acid builds up, either because the kidneys don’t excrete it the way they should or from consuming too many from a high-purine diet, it can form needle-like crystals that lodge in joints, causing sudden, severe pain and swelling.

Gout attacks usually peak after 12 to 24 hours, then slowly go away on their own, whether they’re treated or not. You may have only one gout attack in your lifetime or one every few years. Recurrent gout attacks that aren’t treated may involve more joints, last longer, and become increasingly severe over time. Some people eventually develop tophi, large masses of uric acid crystals that form in soft tissues or bones around joints and may appear as hard lumps.

Risk Factors

You’re more likely to develop gout if you:

• Eat lots of purine-rich foods, including red meat and some kinds of fish, especially scallops, sardines and tuna, though the health benefits of eating fish likely outweigh any gout risk.
• Consume food and drinks sweetened with high-fructose corn syrup or drink excessive amounts of alcohol, especially beer.
• Are overweight, leading your body to produce more uric acid and to have a harder time eliminating it.
• Have a family history of gout.
• Have certain chronic conditions, including diabetes, obesity and heart or kidney disease.
• Take high blood pressure drugs, such as diuretics and beta blockers.
• Have an imbalance in your microbiome, the trillions of bacteria, viruses and fungi that live in your gut and regulate the immune system. The microbiome is implicated in most inflammatory diseases, including arthritis.

Diagnosing Gout

Your medical history, a physical exam and  tests can help diagnose gout. Your doctor will also want to rule out other reasons for your joint pain and inflammation such as an infection, injury or other type of arthritis. Tests you might have include:

• Joint fluid analysis. This is best way  to diagnose gout. Your doctor withdraws fluid from the painful joint(s) and examines it under a microscope for uric acid crystals.
• Blood test to check uric acid levels. However, many people who have high blood uric acid never develop gout, and some people with gout have normal uric acid levels.
• Imaging tests, such as X-rays, ultrasound, magnetic resonance imaging and dual-energy computerized tomography, which helps visualize uric acid crystals in joints.

Treatments

The treatment plan you and your doctor choose for your gout depends on the frequency and severity of your symptoms and your personal preference.

• Lifestyle changes. For some people, weight loss, if needed, and a Mediterranean diet or DASH diet  may help prevent gout attacks. For decades, doctors told gout patients to limit red meat (beef, pork, lamb and organ meats) and alcohol, but it’s now known that an overall healthy eating plan is far more effective and has added benefits for the heart — a common concern in people with gout. One study of nearly 45,000 men found that those who ate a typical American diet — red meat, French fries, sweets and alcohol — had a 42% greater chance of developing gout than those eating a DASH diet. Eating the low-sodium DASH diet, with an emphasis on fruits, veggies, nuts, whole grains and other whole, unprocessed foods, reduced uric acid levels and gout risk significantly.
• Anti-inflammatories. When you’re in the midst of an attack, you want to stop it as fast as possible. Doctors are likely to recommend a brief course of:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin, Advil) and naproxen (Aleve), which are available over the counter or in stronger prescription versions. NSAIDs are generally prescribed for people under 65 who don’t take blood thinners or have a history of bleeding, because NSAIDs can cause ulcers and intestinal bleeding.
  • Colchicine, a prescription anti-inflammatory relieves gout pain but may have unpleasant side effects like nausea, diarrhea or vomiting. Lower doses are as effective as higher doses and produce fewer side effects.
  • Corticosteroids — also effective at bringing down inflammation quickly but with potentially serious side effects.
• Uric acid-lowering drugs. If you have several gout attacks a year, tophi or signs of joint damage on X-rays, your doctor may suggest taking drugs to lower uric acid and prevent further complications. According to the American College of Rheumatology’s (ACR) 2020 gout guidelines, allopurinol is the first choice for all patients. Febuxostat (Uloric) may be considered for some patients who cannot take allopurinol, but it carries a higher risk of heart-related death. The ACR also recommends trying a treat-to-target approach for gout, in which you and your doctor decide on a goal — usually less than 6 mg/dL blood level of uric acid — and adjust your medication and other treatments until you reach it.

Stigma and Mental Health

Gout has for centuries been associated with excess and is the butt of innumerable jokes. That stigma, along with fear of another painful flare, can increase stress and contribute to more inflammation in your body. Like other forms of arthritis, inflammation in gout is associated with a slightly increased chance of depression, especially in people who have frequent flares.

If you feel down or discouraged, don’t be embarrassed to talk about gout to your friends and family. And keep in mind that regular exercise, restorative sleep and healthy food can go a long way toward improving your mood. The better your mood and outlook, the more able you’ll be to manage gout.