Gout

Gout attacks often begin at night or in the early morning with sudden, very painful joint swelling. The inflamed joint is sensitive to pressure, and becomes overheated and red. The swelling and other symptoms are usually at their worst after six to twelve hours. The joint often becomes so sensitive that even the weight of a duvet or comforter is unbearable. When the swelling goes down after a few days, the skin around the joint may begin to peel.

An initial gout attack often only affects one joint, usually the base of the big toe. The midfoot and ankle joints, knees, elbows, wrists and knuckles may also become inflamed. Attacks of gout are very rare in the shoulders or hips. If the gout is chronic, the joints will remain slightly inflamed all the time. They may become disfigured over the long term, making it harder to move them.

Gout may arise from too much uric acid in the bloodstream. It is estimated that only about one in three people with high uric acid levels develop gout, though.

Uric acid is a waste product of substances called purines, which are components of nucleic acid, an important building block in our body.

Our kidneys normally get rid of a certain amount of uric acid by releasing it into our urine. But in some people, the kidneys don’t get rid of enough uric acid. That causes uric acid levels in the body to increase. If they are too high, the uric acid may start to form crystals that build up in body tissue. The crystals usually build up in the joints, where they can trigger attacks of gout.

Certain medical conditions may also contribute to the build-up of too much uric acid, including some blood disorders or specific cancers such as leukemia. In rare cases, gout occurs because the body is producing too much uric acid. This could happen due to a hereditary disease that affects the functioning of particular proteins (enzymes) involved in uric acid metabolism.

Besides increased uric acid levels, other factors may also be involved, such as the balance of fluid in the joints. Too little joint fluid can increase the risk of uric acid crystals forming there. The acidity (pH) level of the joint fluid and the temperature of the joint also have an influence.

Anything that increases uric acid levels can also increase the risk of gout. People who have already had a gout attack are at greater risk of having more attacks. The following things have been scientifically proven to be risk factors for gout:

• Medicines that increase uric acid levels: These include diuretics and acetylsalicylic acid (the drug in medicines like Aspirin), as well as special drugs that are taken after an organ transplant. Levodopa, a Parkinson's treatment, and cancer medications can also increase the risk of gout.
• Meat, fish and seafood: These foods contain a lot of purines. If they are eaten in large quantities, they slightly increase the risk of gout. Some plant-based foods are also rich in purines, but studies haven't found any proof that they influence the development of gout.
• Alcohol: Alcoholic drinks promote the production of uric acid and have a diuretic effect. Alcohol also causes the kidneys to release less uric acid. Beer in particular contains a relatively high amount of purines too. Studies have shown that beer and high-proof alcohol can increase the risk of gout. Wine (in moderation) appears to have no influence.
• Sugary drinks: Drinks that have too much sugar may play a role as well. This is true of both sugary drinks like cola, and possibly of fruit juices as well. Soft drinks that contain sweeteners instead of sugar and fruit have not been associated with gout.
• Being overweight: Being overweight – and having a higher body mass index – increases the risk of gout.

Even if certain foods and other factors may slightly increase the risk of gout or gout attacks, it is more critical that the kidneys are working well and are consistently able to reduce high levels of uric acid.

Gout is the most common inflammatory joint disease (arthritis) in industrialized countries like Germany. It is estimated that 1 to 2 % of the population are affected. Men are a lot more likely to get it than women. It is five times more common in men, and they develop it at a younger age than women do. While gout mostly occurs in men aged 40 and up, it usually only affects women after menopause. That's due to the influence of hormones on the kidneys.

Following an attack of gout, the affected joint usually recovers on its own within one to two weeks. Most people who have had a gout attack will have another one anywhere between six months to two years later. Repeated attacks may last longer and affect several joints.

After an average of about twelve years, gout can become chronic and damage the joints. Acute gout doesn't always become chronic, though. The risk of that happening depends on various factors, including how high the uric acid levels are.

Another possible consequence of gout is the development of chalky nodules called tophi, which form from uric acid deposits in soft tissue. They usually build up over several years, and are especially common in the elbows, the Achilles tendons, the toe and finger joints, and the ear. Most tophi are not painful. If untreated, about 30 out of 100 people with acute gout develop tophi within five years. The tophi may disappear again over time if uric acid levels are lowered by treatment.

If the gout becomes chronic and damages the joints, it restricts mobility and can also weaken the muscles.

In rare cases, uric acid crystals will form in places that are not typical for gout, for example around the spinal cord or the carpal tunnel in the wrist. If tophi form there, they can put pressure on nerves and trigger complications such as carpal tunnel syndrome or symptoms of paralysis due to pressure on the spinal cord.

People with gout are also at greater risk of kidney stones. Kidney stones can be painful and increase the risk of urinary tract infections. On average, nearly 1 out of 100 men with gout will develop kidney stones within one year.

Doctors are often able to recognize gout based on its typical symptoms and risk factors. Painful, reddened swelling at the base or the final joint of the big toe is a fairly sure sign of gout.

"Arthrocentesis" is needed for a definitive diagnosis. This procedure involves using a fine hollow needle to take a sample of the joint fluid, which is then analyzed in a laboratory. If uric acid crystals are found in the fluid, the diagnosis is confirmed. Arthrocentesis is done if the symptoms aren't clear or if other possible causes need to be ruled out. In particular, these include a bacterial infection of the joint, for instance caused by an injury. This needs to be treated quickly.

Simply measuring uric acid levels in the blood is not enough for a clear diagnosis because they often drop to a normal range during a gout attack.

The treatment of gout has two aims:

• In the short term, it should provide pain relief during gout attacks.
• In the long term, it should prevent further attacks and lower the risk of chronic inflammations and joint damage.

Gout attacks are treated with anti-inflammatory medications. These include

• anti-inflammatory painkillers, such as ibuprofen, indometacine or naproxen,
• steroid medicines (usually tablets with prednisolone), as well as
• the gout medicine colchicine. Because colchicine is slow to start working and has certain possible side effects, it is no longer used very often.

If a single drug can’t provide enough pain relief, the treatments can be combined. Cooling the affected joint probably also helps, and most people find it very soothing.

The goal of long-term gout treatment is to prevent gout attacks and complications by lowering the level of uric acid. This can be done in two ways:

• Changing your diet: Especially eating less meat, fish and seafood, and drinking less alcohol.
• Taking medication to lower your uric acid levels, typically allopurinol.

Not everyone who has gout needs to take medicine to lower their uric acid levels. In particular, people who have already had a gout attack usually don’t need to take it. This is because some people don't have any problems after that for years, and others only have them rarely.

Medications for lowering the levels of uric acid are mostly considered if changing your diet doesn't have the desired effect or if the gout attacks become more frequent or are especially bad. It also makes sense to take it if complications such as tophi or kidney stones have already developed, or if the functioning of the kidney is affected.

The pain during a gout attack can be very severe, making many daily activities completely impossible. It can become challenging to walk, cycle, put on shoes or grasp objects. But over time some people develop a feel for when a gout attack is coming on. The joint may begin to twitch, tingle, feel numb or go stiff right beforehand. They can then prepare for an attack. For instance, they can make sure that certain activities are completed before the pain gets worse so that they can rest the joints during the attack.

But a gout attack isn’t just a physical problem. It can make it impossible to get a good night's sleep, and also take a psychological toll. Going to work or doing household chores is usually out of the question. It can be helpful if family and friends are aware of how painful a gout attack is. Then they will understand why it’s so important to rest and take it easy. There’s no reason to feel guilty because you can’t work and can’t do as much with your partner or family and friends.

Gout used to be considered a disease of the wealthy that mostly affected portly older men who drink a lot of alcohol. Because of this, some people with gout still have the feeling that they seen as living lives of excess. But this is a stereotype – the disease may have different causes altogether. What’s more, a lot of people have high uric acid levels but no symptoms. So you shouldn’t feel that you are to blame for having the disease, and you also shouldn’t worry too much about your diet.

Gout attacks can change the way you feel about your own body. Younger people in particular may find it very hard to have a disease that is usually associated with older people. Women with gout sometimes feel unattractive, for instance because they are limited as to what shoes they can wear. Any kind of pressure on the affected area can be very painful during an attack of gout, including physical activities and even gentle touch.

When people are ill or need medical advice, they usually go to see their family doctor first. In our "Health care in Germany" topic you can read about how to find the right doctor – and our list of questions can help you to prepare for your appointment.