Gout

Gout is a type of arthritis caused by the accumulation of uric-acid crystals in one or more joints, most often the big toe. Gout can occur alone or in combination with any of the following: abnormal amounts of uric acid in the blood (hyperuricemia), acute inflammatory arthritis, deposits of sodium biurate (tophi) in tissues near a joint or in the kidney (renal tophi), and urinary stones (urolithiasis). Either an overproduction or an under-excretion of uric acid may cause gout. However, an elevated uric acid level is not synonymous with gout. In gout, deposits of uric acid in the joints and in cartilage cause inflammation and severe pain. Uric acid crystals in the kidney can form kidney stones (urinary calculi) and can lead to permanent kidney damage or failure.

Most attacks occur without apparent cause. Occasionally, an attack may follow an operation, infection, trauma, alcohol ingestion, starvation, over indulgence in foods with high purine content (meat, fish, fowl, and certain vegetables), ingestion of drugs that cause changes in urate concentration, or minor irritations. Gout may be associated with obesity, high blood pressure (hypertension), narrowing of blood vessels due to atherosclerosis, and elevated lipids (hyperlipidemia).

The first attacks of gout most often occur between the ages of 40 to 60 years. Males are affected by gout more than females. Gout tends to primarily involve the lower extremities. Joints most often involved include the great toe, instep, ankle, heel, wrist, elbows and fingers. Over time, deposits of uratic acid crystals in these joints may cause deformity of the joints.

History: The first attack of gout usually occurs without warning. It typically occurs at night, waking the individual with severe joint pain. In males, gout most often involves only one joint initially. The great toe is involved in 80% of the cases. In females, the initial attack is more apt to involve multiple joints. The acute attack may be mild, lasting only a few hours to a few days, or it may be severe lasting several weeks.

The symptoms then disappear completely until the next attack. The time between the first attack and a second attack varies widely. Most individuals will experience a second attack within two years. Some individuals may never experience another attack, but most will have a recurrence of symptoms. As the disease progresses, the attacks become more frequent, last longer and have more severe symptoms.

Physical exam: Findings on physical exam may include a warm, tender joint. Pain is elicited with slight pressure. If the individual has had several attacks of gout, he or she may also have excess fibrous buildup in the ears, hands, feet and elbows. The physical exam may be normal if the individual does not seek treatment during an acute attack, however.

Tests: Diagnosis involves aspiration of the joint with examination for urate crystals, or tissue biopsy for evaluation of sodium biurate deposits (tophi) are performed. Sedimentation rate, complete blood count (CBC) with differential, 24-hour urine collection are done to assess uric acid levels. X-rays of the involved joint may be done to rule out other conditions.

Rheumatologists will often be involved in the treatment of gout because they specialize in managing this and other forms of arthritis.

A number of medications may be recommended to reduce joint pain and inflammation. To avoid any interactions, patients must advise their physicians if they are taking other drugs.

Medications to treat gout include: