What is Gout?
Gout (gouty arthritis) is the most painful and crippling form of arthritis. A first gout attack or flare typically occurs in a specific joint of a lower extremity like the big toe (podagra), ankle, foot or knee. Chronic gout patients can experience symptoms in several parts of the body like their fingers, wrists and elbows.
General characteristics of a joint during a gout attack are redness, swelling, tenderness, heat and excruciating pain. It can occur suddenly in the middle of the night or it can build up to a debilitating state within 24 hours. During a flare up, the joint can be so sensitive that the slightest movement causes agony.
Without proper treatment, severe gout symptoms can have you bedridden for days and hobbled for weeks. Even when symptoms become tolerable, the lingering effects of stiffness and swelling can force gout sufferers to walk with a limp for as long as two weeks.
What Causes Gout?
Gout is caused by an increased production of uric acid mainly by the liver, and/or an inability to remove uric acid by the kidneys through urine. The basic process of developing gout:
- Foods containing purines cause the liver to overproduce uric acid
- Excess uric acid remains in the blood what kidneys cannot filter out
- Uric acid accumulates and crystallizes at a joint
- Needle shaped urate crystals cause irritation at the joint
What are Purines?
A purine is an organic compound found in a variety of foods that typically contain protein. Common types of food and drink that contain high amounts of purines are organ meats, red meat, legumes, anchovies, fish roe, shellfish, sweetbread, and beer. The increased presence of purines is directly related to the overproduction of uric acid by the liver.
[For more information on specific foods that trigger gout read: The Worst Foods To Eat For Gout Sufferers]
What is Uric Acid?
Uric acid is a normal byproduct when the liver metabolizes purines. An abnormally high uric acid level in the blood is called hyperuricemia.
The three hyperuricemia scenarios that causes gout symptoms are:
- Increased uric acid production with normal kidneys functions
- Normal uric acid production with poor kidney functions
- Increased uric acid production with poor kidney functions
When uric acid crystallizes, it forms into needle or spike shaped structures. The extreme sensitivity and intense pain is due to the these crystal spikes agitating your nerve endings directly.
[ Microscopic uric acid crystal. Credit: Wikipedia Commons]
The build up of urate crystals not only affects the bones but also affects the surrounding tendons, tissue and skin.
“Although hyperuriceamia is a characteristic feature of gout; it should be noted that during gouty attacks, serum uric acid (SUA) might drop to normal levels. Hyperuricemia is a weak marker for gout diagnosis and the disease might still be diagnosed even with normal serum levels. ”The National Center for Biotechnology Information, 2017 Sept.; Gout: An old disease in new perspective – A review.
How is Gout Diagnosed?
Other underlying medical conditions that can increase developing gout symptoms are stress, high cholesterol, obesity, genetics (family history), diabetes, traumatic injury, major surgery, certain medications (diuretics), illicit drugs, fasting and dehydration.
After a physical examination of the gout stricken area, a doctor may require further tests to rule out other conditions. A blood test determines the amount of uric acid. Most sources consider uric acid levels higher than 8.0 (mg/dL) above normal (for men). As a result, if your uric acid level remains high and gout attacks recur, prescription medication will likely be necessary.
The other way to diagnose gout is the joint fluid test. This involves extracting synovial fluid via syringe from the swollen joint. The test checks for urate crystals as well as infections or other forms of arthritis.
X-rays will not detect urate crystal build up, but can show any joint/bone damage from previous gout flares. However, an ultrasound scan can detect urate crystals in the joint. These two methods are usually for extreme cases.
There is no substantial evidence to predict the location of the next gout attack before symptoms occur. Most common reports suggest the target areas are usually at the joint with poor blood circulation.
How is Chronic Gout Treated?
Some people may experience gout once and never have symptoms again. Others can start experiencing flare ups frequently. If dietary changes have not resolved the issue, obtaining prescribed medication for preventative maintenance would be necessary.
Non-steroidal Anti-inflammatory Drugs
The first level of medicines to try to reduce painful inflammation are Non-steroidal anti-inflammatory drugs (NSAIDs). Common over the counter NSAIDs are Motrin/Advil (ibuprofen), Aleve (naproxen), Indocin (indomethacin) and Celebrex (celecoxib). For full blown gout flares, these over the counter may not be so effective. However, a doctor may prescribe these drugs at higher dosages.
For cases where over the counter NSAIDs are ineffective or cause bad reactions, colchicine (Colcrys) can be prescribed. Note, it can take up to 24 hours to take effect. That’s why it is recommended to take colchicine at the first signs of gout. Side effects include diarrhea, dehydration, fatigue, nausea and abdominal cramps.
Corticosteroids is an anti-inflammatory alternative to NSAIDs and colchicine. Common corticosteroids for chronic gout include: Deltasone (prednisone), Omnipred or Millipred (prednisolone), and Medrol or Solu-Medrol (methylprednisolone). Evidently, these medications have faster effects than the colchicine, but may cause more adverse reactions. Side effects can include easy bruising, mood swings, water retention, increased sugar levels, high blood pressure and bone thinning (long term). Corticosteroids may be in pill form, or injected into the joint for extreme conditions.
Medications for Reducing Uric Acid Production
Medication to reduce the production of uric acid is essential for chronic gout. The two common medications are allopurinol (Aloprim, Lopurin, Zxloprim) and febuxostat (Uloric). By lowering uric acid production, less excess will enter the blood and reach the joints to cause gout. Evidently, urate-lowering medications prove to be more practical because they treat the root cause of gout rather than the symptoms. Although allopurinol is more patient friendly, both drugs have similar side effects like skin rash, nausea, low blood counts, and headaches.
Medications for Improving Uric Acid Excretion
Probenecid (Probalan) and lesinurad (Zurampic) are the two common medications that assist the kidneys remove uric acid from the body. Probenecid and colchicine contains probenecid, which is a uricosuric agent, and colchicine, which has antigout activity, the mechanism of which is unknown. These type of drugs are usually prescribed to patients with kidney disorders. Side effects include a rash, stomach pain and kidney stones.
Supplements and Natural Alternatives
As gout affects more people, the quest for viable complementary and alternative medicine increases as well. This includes options like dietary or herbal supplements, vitamins, teas, acupuncture, and massage therapy.
There are hundreds of different supplements you can purchase at health shops, grocery stores and online that can help in manage gout symptoms. However, the benefits of supplements and vitamins remain a highly debated subject since many are not FDA approved.
Higher regulatory and manufacturing standards are necessary to confirm claims, purity, composition, identity, strength and quality of the product . A supplement’s efficacy will depend on the individual, dosage and the time it takes to see significant results, if any.
Popular recommendations of food and herbal supplements:
- Vitamin C (fruits/juice/pill) – helps uric acid removal, anti-oxidant
- Red or Black Cherries – (pill/juice/tea) – anti-inflammatory, anti-oxidant
- Ginger – (natural/pill/teas) – anti-inflammatory, anti-oxidant
- Devil’s Claw – anti-inflammatory
- MSM (Methylsulfonylmethane) – anti-inflammatory, helps form connective tissue
- Turmeric – (pill/powder) – anti-inflammatory
- Apple Cider Vinegar – antioxidant, helps uric acid removal
- Detoxification Teas – for digestion, liver and kidneys cleanse
In 2014, from the Journal of Clinical Rheumatology, a year long study concluded that the number of gout flares did not differ between test subjects who used complimentary and alternative medicines versus subjects who did not.
Low Purine Diet
Prescribed medications are often the most effective way to treat chronic gout symptoms and prevent recurrent attacks. In addition, following a low-purine diet and avoiding the foods that trigger gout, will always play a major role in reducing your risk. These general principles are important in the management of gout:
- Stay well hydrated – Drinking plenty of water is vital to kidney function. Healthy kidneys can reduce and uric acid build up and flush out other toxins.
- Eat less foods with high purine content. Organ meats, wild game meats, shellfish, certain seafood, sweetbread, and high yeast products.
- Avoid drinking alcohol. Beer and liquor contain purines from the malt(yeast) content. Alcohol in general causes dehydration and hinders kidney and liver functions.
- Avoid crash diets and fasting. Uric acid levels increase from long periods of dehydration and starvation.
- Avoid beverages with high fructose content. Fructose directly causes uric acid production.
- Avoid MSG (monosodium glutamate) and products containing it. A flavor enhancer that metabolizes into purines. Always check a product’s ingredients list.
- Eat more fruits and vegetables. Cherries have proven effects. Some other foods containing natural antioxidants are berries, apples, pineapples, garlic, kale, cucumbers and celery.
- Maintain a healthy weight and exercise regularly. Build muscle and improve blood circulation. Excess fat impedes organ functions.
Complications and Risks
Chronic gout attacks if left untreated can lead to crippling joint damage and deformity, as well as kidney stones. The excess deposits of urate crystals can form into lumps called tophi (TOE-fie). Tophi can develop at the surface of joints, cartilage, or in the skin. It usually does not cause any pain, but it will reduce the sensitivity and range of motion of the affected joint.
Other serious health risks associated with gout are high blood pressure, heart disease, diabetes, kidney disease, and depression.
A common misconception is that chronic gout only strikes gluttons of food and alcohol. This is not always the case since many ‘non-drinkers’ who are not obese can still be susceptible to gout from other known factors and preconditions. Furthermore, the prevention and severity of a gout attack certainly depends on how well your body manages uric acid production and elimination. The real challenge is knowing when to or not to overindulge on those delicious but purine-rich foods.