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Condition
Gout
Class
Musculoskeletal system
Description
Gout is a type of arthritis that causes sudden and extremely painful inflammatory attacks in the joints. Gout usually occurs in the joints of the big toe, ankles and knees but any other joint can be affected too.

Gout affects about 1 in 200 adults, most commonly men between the age of 30 and 60, although it can occur any time after puberty. Gout is relatively rare in women; they are 5 times less likely to develop gout than men. If a woman does get gout, it tends to be after the menopause. Gout is rare in children.
Causes
Gout is caused by excess uric acid in the bloodstream. All of the cells in the body and many foods contain substances known as purines. As old cells are broken down or as foods are digested these purines are converted to uric acid. Most people with gout have high levels of uric acid because it is not efficiently removed by the kidneys and washed out in the urine.

Gout can be caused by high levels of uric acid in the diet. Foods that contain large amounts of uric acid include liver, offal, oily fish, shellfish and yeast extracts such as Marmite. Certain beers, stout and port also contain high levels of uric acid. Drinking lots of alcohol may in itself increase the risk of gout through causing dehydration that concentrates levels of uric acid in the blood.

Other factors that may contribute to gout include, crash dieting, stress, prolonged illness and injury. Some drugs, notably thiazide diuretics and aspirin may also increase uric acid levels.

In around 10 percent of cases there is a family history of the disorder that causes an overproduction of uric acid.

Whatever the cause, an overload of uric acid in the body means that crystals of uric acid start to form in and around the joints causing inflammation and pain.
Symptoms
A sudden, unexpected (acute) attack of gout often develops during the night or early hours of the morning. It reaches a peak within a few hours, often making even the touch of bed clothes on the affected joint unbearable. The skin may be red and shiny and the inflammation may be so severe that the skin may peel. A mild fever, a loss of appetite and a feeling of tiredness can also accompany acute attacks of gout.

An acute attack generally lasts for a few days, then dies down and the joint gradually returns to normal. Some people never experience another attack. If the uric acid level remains high, most will have a second attack between six months and two years after the first. Left untreated, attacks will become more frequent and more prolonged and may result in damage to the cartilage and bone of the joint.

Urate crystals may also develop under the skin, for example appearing as small white pearls, known as tophi, on the outer edge of the ear. Occasionally, stones may form in the kidneys which, in extreme cases, may cause severe pain and interfere with the ability to urinate.
Treatment
The pain and inflammation of an acute attack of gout is first treated with non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac, etoricoxib, indometacin, ketoprofen, naproxen, or sulindac. Aspirin should not be used as it increases levels of uric acid in the body and so can make symptoms worse.

Colchicine is an alterative for people who are unable to take NSAIDs, for example those who also have heart failure, as it does not cause fluid retention. Colchicine interferes with the production and action of the chemicals that are involved in the inflammatory response and so it helps minimise the extent of joint inflammation and thereby reduces acute pain.

If joint pain is severe, it may be relieved by corticosteroids that may be taken orally or which may be injected directly into the joint.

For the long-term control of gout and to prevent the recurrence of symptoms, drugs that inhibit the formation of uric acid from purines may be used. Allopurinol and febuxostat are two drugs that inhibit the action of an enzyme, called xanthine oxidase. This enzyme converts hypoxanthine, a naturally occurring purine, to xanthine and then to uric acid. The consequent build up of hypoxanthine by the inhibition of xanthine oxidase also prevents the synthesis of more purines. Allopurinol and febuxostat are not effective in treating acute attacks of gout and may actually prolong the attack if used at that time. Consequently, they are normally started about 2 weeks after gout symptoms have eased.

Drugs that increase the excretion of uric acid by the kidneys may also be used for the long term control of gout. Drugs of this type include probenecid and sulfinpyrazone. They are used when blood levels of uric acid are high, a condition known as hyperuricaemia.
When to see your pharmacist
If you are experiencing pain and stiffness in your joints there are a number of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen that can be bought from the pharmacy to relieve pain and inflammation. They come in preparations that can either be taken by mouth or rubbed into the skin at the affected area.

It is important always to ask your pharmacist which medicines are safe to take, especially if you are already taking other prescribed or over the counter medicines, or have a history of allergies or stomach complaints.

If your symptoms are severe or occur frequently, your pharmacist will advise you to see your doctor.

If you have poor grip strength and find it difficult to open medicine bottles, tell your pharmacist. When dispensing your medicines your pharmacist will fit special caps on the bottles that will make them easier to open.
When to consult your doctor
Visit your doctor as soon as possible if you have any of the symptoms or signs described above. Your doctor will be able to check whether you have gout and, if so, prescribe the drug that is most appropriate for you to relieve the pain and swelling.

To confirm a diagnosis of gout, your doctor may decide to test a sample of your blood to check the level of uric acid. You may also be referred to a rheumatologist who may decide to take a sample of the fluid from the joint that has been affected. The presence of needle-like crystals in the fluid confirms the diagnosis of gout.

If you suffer from repeat attacks, speak to your doctor about long-term treatments.

Living with Gout
If you do experience an acute attack of gout, rest the joint and try to keep as much weight of it as possible. Placing a cold flannel or a bag of frozen peas wrapped in a towel over the affected joint will help reduce inflammation and pain.

Once the attack has passed, the next step is to help prevent the attacks returning. If overweight, try to lose weight, but lose it slowly. Do not ‘crash diet’ as this can lead to an increase in uric acid levels. Take up gentle exercise to keep the joint flexible, but try to avoid impact activities.

Eat smaller portions of food by eating at regular meal intervals. Cut down on the amount of red meat, offal, seafood and shellfish in your diet as these foods are rich in purines.

Reduce your consumption of alcohol. Alcohol causes dehydration, concentrating the levels of uric acid in the blood. Some alcoholic drinks, particularly fortified wines and port, are also rich in purines. Drink several glasses of water throughout the day to maintain your level of hydration, particularly in hot weather or after exercising.
Useful Tips
  • lose weight if you are overweight
  • keep generally fit with regular exercise
  • limit your alcohol intake
  • drink several glasses of water daily
  • avoid foods such as red meat, liver, kidneys and shellfish which can also increase uric acid levels
Further information
Arthritis Care  - Arthritis Care is the UK’s largest charity working with and for all people who have arthritis. The website provides useful information about gout and makes available a series of guides that contain practical advice to help you take control of your symptoms and to live and work with the condition.

Arthritis Care
18 Stephenson Way
London NW1 2HD

Helpline: 0808 800 4050
www.arthritiscare.org.uk

UK Gout Society - The UK Gout Society is a registered charity whose objectives are to increase awareness of the condition and to provide information about its causes and treatment to sufferers from gout.

UK Gout Society Secretariat
PO Box 527
London
WC1V 7YP

Email: info@ukgoutsociety.org
www.ukgoutsociety.org



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