written by
Harvard Medical School
Gout
www.patientedu.org
Gout is a painful form of arthritis most commonly found in older men caused by high uric acid levels. Gout typically affects joints of the body, most often the big toe. This brochure explains what gout is, signs and symptoms, and how it can be treated.
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What Is Gout?
G
out is a type of arthritis caused by too much uric acid in the blood and tissues. Uric acid is a waste product that normally gets excreted in the urine. Gout occurs when either the kidneys don’t get rid of the uric acid properly, the body makes too much of the acid, or both. Too much uric acid forms into crystals, which get deposited in joints, causing pain and inflammation. The crystals can also end up in the kidney, where they cause kidney stones.
Gout typically affects older men. About 90% of people with gout are men older than 40. African-American men are twice as likely as Caucasian men to be affected. When women get gout, they tend to get it at least 10 years after menopause.
Uric Acid Build-up Associated Inflammation Bone Erosions
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There are 3 main causes of the high levels of uric acid that lead to gout: are broken down 1) by the body into uric Purines acid. Some foods that A diet rich in purines.
contain purines include: • Anchovies • Red meat • Nuts
• Organ foods such as liver, kidney, and sweetbreads Diet is usually not the main cause of gout because most people do not eat enough of these foods on a regular basis. This can occur in 2) people with certain inherited genetic metabolic High uric acid production.
disorders, in those with leukemia, in some who take chemotherapy for cancer, and in others for unknown reasons.
3) This can be caused by kidney disease, starvation, The kidneys do not get rid of enough uric acid.
and alcohol use, especially binge drinking. It also can occur in people taking diuretics, which are used to treat high blood pressure or heart failure. Gaining weight quickly or being obese also puts you at risk for gout. In many, gout is caused by a combination of factors. People with a family history of gout are more likely to develop the condition, as are those with high blood pressure, high cholesterol, or diabetes.
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Signs & Symptoms When gout first shows up, it usually affects only one joint, most often the big toe. It may also appear in a knee, ankle, wrist, foot, or finger. • The affected joint becomes red, swollen, painful, and very sensitive to the touch. Even light contact between a bed sheet and the joint can cause severe pain. • The inflammation can be intense enough to cause fever, muscle aches, and other flulike symptoms. • First episodes of gout often come on suddenly, and usually occur at night. • If you don’t treat gout, the pain and inflammation can last several days. The first day or 2 of an attack are usually the most severe. •M ore than half of people have repeat flare-ups, sometimes months or years after having no symptoms. • The episodes can get progressively more serious. Over time, more joints may be affected, and the episodes may last longer. Without treatment, gout can also cause long-term arthritis, with chronic swelling and permanent joint damage. Uric acid crystals can build up, producing large lumps under the skin called tophi. Crystals may also be deposited in the kidneys, causing kidney stones.
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How Gout is Diagnosed To determine whether you may have gout, your doctor will: • Ask you about your symptoms • Take a family history • Examine your painful joints • Look for tophi If your symptoms don’t point to a definitive diagnosis, your doctor will likely conduct the following tests: • Perform blood tests to measure your uric acid levels and to test your kidney function. • Use a needle to take a small amount of fluid from the inflamed joint. If you have gout, the fluid will contain white blood cells and uric acid crystals, which can be seen through a special microscope. • Test a sample of your urine. Sometimes, it can be hard to tell if a person’s joint pain is caused by gout, another type of arthritis, or other conditions. There is even a condition that mimics gout and is commonly known as “pseudogout.” Pseudogout is caused by calcium pyrophosphate crystals (not uric acid crystals) building up in joints and other tissues.
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Management Unfortunately, there is no cure for gout. The pain and inflammation can be treated, however, and there are a number of things you can do to prevent future attacks and to prevent the long-term effects of untreated gout, such as serious joint damage and tophi. The goal of longterm management of gout is to lower uric acid to healthy levels. The target level is less than 6 mg/dL.
The pain and inflammation of gout can be treated, and there are a number of things you can do to prevent future attacks. Treating Pain & Inflammation If you see your doctor for painful, swollen joints, he or she may start you on a medication to ease your symptoms. Nonsteroidal anti-inflammatory drugs (NSAIDs), for example, work well for these purposes. They are especially effective if they are started as soon as possible after the start of an attack, and if they are used at the maximum recommended dose. NSAIDs include: • Indomethacin • I buprofen • N aproxen Aspirin should not be taken by people with gout because it can raise the level of uric acid in your blood. Other options include corticosteroids, adrenocorticotropic hormone, and colchicine.
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Lowering Uric Acid Levels Your doctor may prescribe you a medication to lower your uric acid levels. These medications can help people who have: • Frequent attacks • Elevated uric acid levels • Attacks that don’t respond promptly to treatment • Attacks that affect more than 1 joint at the time • Tophi Medications approved to lower uric acid levels include allopurinol, febuxostat, probenecid, and sulfinpyrazone. • Allopurinol and febuxostat work by making your body produce less uric acid. • Probenecid and sulfinpyrazone work by helping the body eliminate uric acid. These drugs work well in 70% to 80% of people with gout. Although these drugs can be used in those with mild to moderate kidney disease, they should not be taken by people who have severe kidney disease or who have had a kidney stone. These uric acid-lowering medications usually need to be taken daily to be effective. When you first start taking a medication to lower your uric acid levels, you may experience a gout flare-up. This happens because as uric acid level is lowered, crystals begin to dissolve in your joints. Your doctor may give you a medication to help prevent this attack. A low dose of colchicine or a low dose of an NSAID may be used for this purpose.
Whenever you start a new medication, remind your doctor of any other drugs you take and any other conditions you have.
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Diet & Lifestyle Here are some tips for the long-term management of gout: • Keep well-hydrated • Lose excess weight (being overweight increases the risk of gout)
•E xercise •A void foods that seem to trigger gout attacks • Ask your doctor if there are medications you are taking (especially diuretics) that can cause uric acid buildup, and see if you can switch to something else. • Limit alcohol intake. For many people, attacks of gout come on after drinking alcohol. Alcohol has a high purine content, and the body breaks down purines into uric acid. • Your doctor may also prescribe medicine to help treat the attack and also medicine to lower uric acid.
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Living with Gout The medications used to treat and prevent gout are effective. If your doctor prescribes these medications to you, it is important to take them regularly and to treat flare-ups for gout quickly. Be sure to talk to your doctor if your treatment plan doesn’t seem to be working or if you experience any side effects from your medications.
Gout: Not Just for the Rich One common myth about gout is that it only affects the ‘well-to-do.’ This idea is false, though it has been around for a long time. Descriptions of gout date back as far as the 5th century BC. Throughout the ages, gout was called the “King of Diseases” and “Disease of Kings.” Why? Gout attacks seemed to follow banquets during which participants drank excessive amounts of alcohol. Eating large amounts of caviar and organ meats (such
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as pancreas or liver) may also have played a role in triggering gout attacks, because these foods are rich in the proteins that are broken down into uric acid. For those less able to afford large quantities of this food and drink, gout may have been less common.
The mistaken notion that gout only occurs in the wealthy developed in the same way that medical myths often develop: When 2 things occur together (gout and wealth), 1 is assumed to cause the other.
For More Information Arthritis Foundation www.arthritis.org
Gout and Uric Acid Education Society www.gouteducation.org
National Institute of Arthritis and Musculoskeletal and Skin Diseases www.niams.nih.gov
American College of Rheumatology www.rheumatology.org
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Learn more about gout, visit the Patient Education Center at www.patientedu.org.
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About This Brochure: This brochure was written by practicing physicians from Harvard Medical School. It is part of a series developed and distributed by the Patient Education Center. All the information in this brochure and on the associated Web site (www.patientedu.org) is intended for educational use only; it is not intended to provide, or be a substitute for, professional medical advice, diagnosis, or treatment. Only a physician or other qualified health care professional can provide medical advice, diagnosis, or treatment. Always consult your physician on all matters of your personal health. Harvard Medical School, the Patient Education Center, and its affiliates do not endorse any products. Consulting Physician: Anthony L. Komaroff, MD Editorial Director: Keith D’Oria Creative Director: Jon Nichol Š Copyright Harvard Medical School.
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