Gout
An Information Booklet
Introduction
Gout is often said to be the most painful of all the rheumatic diseases. Luckily, it is probably the one for which we have the most satisfactory treatments. This booklet aims to explain what causes gout, the symptoms and the main treatments, and what can be done to help prevent attacks of gout. Medical terms are explained in the glossary at the back of the booklet – we have put these terms in italics where they first appear in the text. We have also included some sources of further information (see 'Further reading' and 'Useful addresses').
What is gout and what causes it?
Gout has been known for more than 2000 years. It can affect men of any age, but is much less common in women and then, apart from a few rare situations, only occurs after the menopause. The old saying that gout is caused simply by eating and drinking too much has now been proved wrong. It is true that if you over-indulge in alcohol (especially beer and wine) or food, attacks of gout are more likely, but that is not the whole story.
People get gout because there is something unusual about the chemical processes which take place within the body. A substance called urate can build up as crystals in joints (see 'Where does urate come from?' below). This tendency can be inherited from a parent or grandparent. Gout often runs in families.
When urate crystals are deposited in a joint they cause inflammation – the joint becomes red, hot, swollen and intensely painful. The joints are not the only parts of the body to be affected. Urate crystals may also collect under the skin, including sometimes on the ears, forming small, firm, white pimples called 'tophi'. These are not usually painful and generally cause no problems at all.
Figure 1. Gout most commonly affects the big toe. The joint becomes red, hot, swollen and extremely painful.
Figure 2. Urate may collect under the skin forming small white pimples ('tophi'), but these are not usually painful.
Where does urate come from?
Urate forms as a final product of various chemical processes within the body. All of the cells in the human body, and many of the foods we eat, contain substances known as purines. As old cells are broken down or as foods are digested these purines are converted to uric acid, which is carried in the blood as a salt called urate. It is normal (and healthy) to have some urate in the bloodstream, and the level is usually higher in men than in women. The presence of urate does not itself lead to gout, and even people with higher-than-usual levels of urate may never go on to develop gout. When the amount of urate in the blood rises the body normally rids itself of the excess through the kidneys into the urine. If this does not happen the urate continues to increase until it reaches a level at which urate crystals can start to form. These fine needle-shaped crystals may collect in the joints or under the skin.
Figure 3. Cross-section of a joint, showing urate crystals deposited in the cartilage.
There are several reasons why the body may not be able to rid itself of urate effectively:
- You may have an inherited ('genetic') tendency where your kidneys retain more urate than average within the body. This does not mean that you have kidney disease.
- If you do have kidney disease (e.g. as a result of raised blood pressure over a long time) it may mean that your kidneys are not able to process urate as well as they should.
- In certain blood disorders the body produces too many blood cells – as these cells are broken down they may release urate into the bloodstream more quickly than the kidneys can cope with. This is sometimes called 'secondary' gout.
- Tablets such as diuretics ('water tablets' used to treat heart disease or high blood pressure) which drain water from the body may increase urate to a level which the kidneys cannot handle effectively.
- There is a tendency for people with diabetes or heart disease to have a raised level of urate. The underlying reasons for this are complicated and are not fully understood.
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What happens in an 'acute' attack?
Gout is one of the most painful forms of arthritis. Attacks usually start during the night, often with pain in the big toe. The toe becomes very red, swollen, and extremely tender. Even someone bumping into your bed or the weight of the bedclothes can cause pain. The affected joint will feel warm and the skin often looks shiny. The symptoms develop very quickly (doctors usually describe the sudden onset of symptoms as 'acute'). The swelling sometimes resembles a boil near the joint and it can be difficult for the doctor to tell whether the trouble is gout or inflammation in a bunion. Although gout most commonly occurs as an attack in a single big toe, other joints – the knee, the elbow or the wrist, for example – may be affected. Sometimes several joints are inflamed at once. This is called polyarticular gout.
If you have had gout before and you injure or bruise a joint which later becomes increasingly painful, or takes longer than expected to get better, always see your doctor. The injury may have triggered a new attack of gout which will need prompt treatment.
Apart from injury, other things such as exhaustion or illness can start an attack. Sometimes an operation (even a minor one like having a tooth out) can bring on an attack a few days later. The common factor here is probably dehydration. Excessive eating and drinking of alcohol can also make an attack more likely.
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What are the long-term risks?
The first few attacks of gout do no permanent damage to the joints and you can expect a complete recovery, leaving you with a normal joint. However, when a joint is repeatedly attacked by gout the urate crystals can damage the cartilage and bone of the joint and so start off long-term ('chronic') arthritis. But with modern treatments (and some modifications to your diet) this can usually be prevented. In mild cases the attacks are often so infrequent, with intervals of years between them, that permanent damage is unlikely ever to occur.
Gout is definitely associated with high blood pressure, diabetes, heart disease, and having too much fat in the blood ('hyperlipidaemia'). So if you have any of these conditions then gout is an additional possibility. Conversely, if you have had attacks of gout you should pay special attention to these other aspects of your health. You should also be aware that urate may form stones in the kidneys if gout is left untreated.
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How is gout diagnosed?
Your doctor may suggest the following tests ('investigations') but these are not always conclusive or practical:
A blood test This measures the amount of urate in the blood. A raised level of urate strongly supports the diagnosis of gout but cannot definitely confirm it. For one thing the urate level may be high in the other conditions already mentioned, and also in healthy people who do not have gout – especially if they are overweight. On the other hand, it is sometimes possible for the urate levels in the blood to be normal at the time of an acute attack – the level of urate in the blood does not always reflect the amount that has collected in the joint.
X-rays of joints X-rays might be taken, but x-ray results are usually normal in the early years of developing gout, so they are rarely helpful in confirming the diagnosis.
Examination of joint fluid Synovial fluid can be taken from a joint through a needle. It is then examined under a microscope, where any crystals of urate can be clearly seen. Gout is the only condition in which urate crystals can be found in the synovial fluid, so this test may clinch the diagnosis if there is doubt – for example where gout mimics another type of rheumatic disease such as rheumatoid arthritis. However it is more difficult, and more painful for the patient, to obtain fluid from a small joint, so unfortunately this test may not be practical in many cases of suspected gout, for example where the big toe joint is affected.
Because it is not always possible to confirm gout using these tests, the diagnosis may be based simply on the symptoms you describe together with an examination of the affected joints.
What treatments are there for an acute attack?
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Acute attacks of gout are usually treated with non-steroidal anti-inflammatory drugs (NSAIDs). These are tablets that relieve pain and help reduce inflammation. There are many NSAIDs that can be used. Examples include naproxen, diclofenac and indometacin. (See arc leaflet ‘Non-Steroidal Anti-Inflammatory Drugs’.) Aspirin, which is a type of NSAID, should usually be avoided if you have gout, along with medicines that contain aspirin. Not only can aspirin upset your stomach, but it can also increase the level of urate in the blood. However, if your doctor has prescribed low-dose aspirin to protect against heart disease or similar serious conditions then you should continue to take it.
Used for the short periods needed to treat an acute attack, NSAIDs are unlikely to cause side-effects. However, you may notice indigestion, a rash, headache, dizziness, or even asthma. Anything more serious – such as damage to the blood cells – is very rare. Unfortunately, there is always a risk of indigestion in some people; anyone who has had a stomach ulcer should be especially careful and should make sure that their tablets are taken either with a meal or straight after eating.
Colchicine
Colchicine is another medicine that has long been used to treat acute attacks. This is obtained from the meadow saffron – the autumn crocus – and it is safe and works well. A doctor usually prescribes one colchicine tablet (0.5 milligram (mg) strength) to be taken three times a day until the pain is relieved or for a limited number of doses. Some people cannot take colchicine because of diarrhoea or nausea.
If possible, colchicine tablets should be taken at the very beginning of an attack, and sometimes – if attacks are repeated – the doctor may give you tablets to keep by you so you do not have to wait for a doctor’s appointment, or for the chemist to open. By learning to recognize the symptoms, and by following your doctor’s instructions carefully and promptly, you can usually control an attack of gout quickly and effectively. Colchicine taken in a dose of 0.5 mg 1–3 times daily can be used to suppress the tendency to gout attacks. However, as with NSAID tablets, it has no effect on the level of urate in the blood, so it will not prevent joint damage.
Steroids
If an acute attack of gout does not improve with treatment using NSAIDs or colchicine, or if you have side-effects from these drugs, your doctor may have to prescribe a steroid-type drug (usually prednisolone). This can be injected into the joint or given as a short course of tablets (usually no more than a few days). (See arc leaflets 'Local Steroid Injections', 'Steroid Tablets'.)
Protecting the joint
A painful joint such as the big toe may have to be protected during an attack of gout. For example, a 'cage' over it taking the weight of the bedclothes can help offer relief. Ice packs can also help but remember to protect the skin from direct contact with the ice itself by wrapping it in a cloth such as a tea towel.
What preventive treatment is there?
The drugs given to relieve an acute attack have no effect on the level of urate in the blood, so they do little to prevent further attacks, or to stop urate crystals being laid down in the joints. If your attacks become more frequent, or if blood tests show you are accumulating too much urate, your doctor may suggest one of the urate-lowering drugs. These have to be taken every day, whether you have an attack or not, as a preventive measure.
The aim of preventive treatment is to reduce urate levels in the blood. This will eventually deplete the deposits of urate in the joints and other parts of the body. Attacks of gout become less frequent and less severe because fewer urate crystals are deposited. You may be reluctant to take medication long term – in which case you might find the advice on diet and other measures particularly helpful (see 'What about diet?' and 'Complementary remedies' below). Even if you do take medication, you may find that you can reduce the dose you take by paying attention to your diet.
When you first begin taking one of the urate-lowering drugs you will remain at risk of acute attacks for at least 3 months and probably a lot longer. For this reason you should continue to take, in addition to the urate-lowering drug, the medication which you used to treat the acute attacks (e.g. an NSAID or colchicine). This will help to suppress gouty inflammation while the urate stores in your body become depleted. Drinking plenty of water during the early stages of treatment will also help by flushing out urate through the kidneys. Depending on the amount of urate you have it can take a long time (perhaps up to 2 years) to clear your body completely of urate crystals.
There are now several urate-lowering drugs that will satisfactorily prevent gouty attacks and gouty arthritis. Once started, the urate-lowering medication should be continued, unless of course side-effects develop. Interruptions in dosage, especially within the first few weeks or months of treatment, cause fluctuations in blood urate level and this appears to trigger attacks of gout.
Allopurinol
The most commonly used urate-lowering drug is allopurinol. This reduces the amount of urate made by the body. The chemical processes are altered so that purines are broken down not to urate but to a more soluble substance called hypoxanthine. Allopurinol is usually taken once a day. Your doctor will probably start you off on a dose of 100 mg a day, and then increase the dose gradually over a period of several weeks according to the level of urate in the blood. It is likely that you will have a repeat blood test after a month or so, to see whether your urate level has fallen sufficiently to reduce the risk of gout. Once the urate level has fallen to well within the normal range, you should continue on that dose of allopurinol.
Allopurinol is very safe even when taken for years. The most common side-effect is a rash. If you do develop a rash soon after starting allopurinol, you should stop taking the tablets and consult your General Practitioner for advice. It is possible that the rash might be due to something else, and your doctor will be able to advise whether you should re-start the tablets and what precautions you should take. It is important to realize that allopurinol can affect some other tablets, especially warfarin and azathioprine. If you have to take either of these drugs for any reason, you should tell the doctor who prescribes it that you are also taking allopurinol. The dose of the other drug may need to be adjusted.
Other urate-lowering drugs
Whereas allopurinol reduces the formation of urate in the body, other drugs work by 'flushing' out more urate than normal. These are the so-called 'uricosuric' drugs, which include probenecid, benzbromarone and sulfinpyrazone. Because they increase the amount of urate flushed through the kidneys, these drugs may not be appropriate if you have had kidney stones or similar disorders. They also have a rather higher risk of side-effects than allopurinol, so they are not widely used in the UK. However, one or other of them may be a useful alternative if allopurinol is not suitable for you.
Research has produced another drug, called febuxostat, for reducing urate levels. The use of this drug looks promising, although it has not yet been used in large numbers of patients.
Finally, there is a drug called uricase, which is given by a drip into a vein and dissolves stores of urate. This is usually reserved for situations where rapid accumulation of urate is interfering with kidney function.
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What about diet?
Weight
The most effective dietary treatment for gout is losing weight if you are overweight. This can significantly reduce urate levels in your body, but it must be done gradually. Extreme weight loss or 'starvation' diets (fasting) can actually raise urate levels, because they increase cell breakdown in the body. This cell breakdown releases a substance called lactate into the blood and a raised level of lactate interferes with urate excretion through the kidneys. Atkins-type diets that include lots of protein are probably unwise for people who are prone to gout, as proteins tend to be high in purines, which break down to produce urate.
Alcohol
The second most useful dietary change if you have gout is to cut down on alcohol. Excessive alcohol consumption has been associated with gout for centuries. Port used to be drunk quite widely and may have been especially risky, but nowadays beer is more likely than wines to lead to gout. If you have gout it is advisable to keep your alcohol intake well below the safe maximum levels recommended by the government. Currently this is 3–4 units a day for men and 2–3 units a day for women. Units are calculated from the strength of the drink as well as the quantity – and with wines and some of the stronger beers it is quite easy to consume all your 'daily units' (or more) in just one drink. Table 1 shows the number of units of alcohol in some of the most popular drinks. It is a very good idea to have at least 2 alcohol-free days a week – but without compensating over the remaining 5 days!
Table 1. Approximate units of alcohol in some popular drinks |
|---|
Beer, lager, stout |
Lager |
Cider |
Wine, red or white |
Gin, rum, vodka, whisky (40% abv) |
Sherry, port (20% abv) |
'Alcopops' (5% abv) |
NOTE: These figures are based on typical strengths for the drinks shown; actual strengths vary from one brand to another. Bear in mind also that 'measures' poured at home are often much larger than the standard pub measures shown. |
Fluids
To reduce the risk of urate crystallizing in the joints it is important to drink plenty of water. If you have kidney stones you may need to drink as much as 3.5 litres (6 pints) a day. If you do not have stones you may not need to drink quite so much, though this depends, for instance, on how much you perspire. However, to be on the safe side, drink at least 1 litre (2 pints) of fluid a day. At least half of this should be water – you can include some other fluids in this total, but not beer or other alcoholic drinks. Bear in mind that many soft drinks such as colas contain large amounts of sugar, in the form of fructose, and should be avoided. This is because, apart from the calorific content, fructose sugar is likely to increase the level of uric acid in the blood. 'Diet' colas are probably a reasonable substitute, water better still! As with anything, be moderate. Large quantities of strong tea or coffee are also unwise, as they can actually dehydrate you and may contain purines, which are converted into urate.
Complementary remedies
Many natural or herbal remedies for gout are available. These include celery seeds, cherries, garlic, artichokes, and combinations of these and others. Saponins (natural compounds found in peas, beans and some other vegetables) are claimed to reduce cholesterol levels and to help prevent gout. There is little or no scientific evidence for most of these, with the exception of cherries, which do seem to be beneficial – either as fruit or as juice, fresh or preserved.
Food
Urate is produced from purines, which are chemicals resulting from the breakdown of cells. But purines can also come from the foods we eat. So cutting down on foods which are high in purines can be helpful if you have gout. These foods are shown in Table 2. Note that urate levels are not affected by 'acidic' foods like oranges or grapefruit, so you can eat these safely. You should aim to reduce the amount of protein you obtain from meat and increase the amount you get from vegetable sources. Skimmed milk and yogurt are not high in purines and should probably be part of your diet for reducing the risk of gout.
Table 2. Foods which are high in purines | ||
|---|---|---|
Meat |
Fish |
Other |
Kidneys |
Anchovies |
Beer |
Please note: Oily fish such as herring, mackerel and sardines may be beneficial if you have heart disease and may also be helpful for some forms of arthritis. However, they are high in purines so large quantities are not recommended if you have gout. (See arc booklet 'Diet and Arthritis'.)
Some more questions answered
Do women get gout?
Rarely. The disease is very occasionally found in older women, particularly if they are taking diuretics (water tablets which are used in the treatment of high blood pressure or heart disease). This is because these drugs can cause the body to retain urate. Gout in young women is extremely rare and needs special investigation, as it can be a sign of kidney disorders.
Can gout cause serious joint disease?
Yes, but this is only likely to happen if the condition is left untreated. In untreated gout the attacks will initially last only a few days, with the joint returning to its normal state afterwards. However, eventually the deposits of urate can cause damage to the lining and cartilage of the joint, resulting in deformity and disability. But the urate-lowering medications referred to earlier, combined with attention to diet, can prevent this joint damage.
Is urate deposited at places other than in joints?
Yes. As mentioned, it can be deposited under the skin – for example, on the ears, fingers and toes. It can also be deposited in internal organs, particularly the kidneys. For this reason it is usual for doctors investigating someone with gout to carry out a test to check how well the kidneys are working. A specimen of urine may be needed for this.
Can it be harmful to take the drugs that lower urate over a long period?
The drugs in question are usually very safe. They sometimes have to be discontinued because of an adverse effect such as a rash or indigestion (dyspepsia), but usually this type of drug treatment can be taken indefinitely without side-effects. It is important to realize, however, that no drug can be said to be completely free from possible side-effects. This makes it all the more important to consider other ways of managing your health – by losing weight and altering your diet.
What is 'secondary' gout?
This is gout that is predominantly due to a specific underlying cause. Diuretics (water tablets) have already been mentioned. It is rare that diuretics alone would cause gout; people who take diuretics do so because of heart disease or raised blood pressure – conditions which themselves are known to increase the risk of developing gout. The diuretic may be a necessary part of the treatment for heart disease or raised blood pressure. In this case the effect of the diuretic on urate levels may have to be accepted and managed with appropriate treatments and dietary measures. Other causes of secondary gout include certain rare blood disorders. Low-grade lead poisoning was once a cause of secondary gout – this was seen in plumbers and painters during the 19th century and in people making 'moonshine' whisky in the 20th century. Usually, however, it is not possible to identify any such cause, and the condition is then referred to as 'primary' gout.
Are there any other types of crystal – apart from urate – that can cause joint disease?
The only other common kind of 'crystal arthritis' is caused by a certain type of calcium crystal, which is deposited in the joints in a similar way to urate. It may cause acute attacks rather like gout, but this tends to affect the knee more often than the big toe. (See arc booklet 'Pseudogout and Calcium Crystal Diseases'.)
Is gout equally common in all countries?
There are certain races (such as some of the Pacific peoples) who have high urate levels and who are therefore especially susceptible to gout. They are also prone to diabetes and heart disease – more evidence of the links between gout and these conditions. The prevalence of gout can also vary at different times – it became rare in Europe, for example, during the period of deprivation and hardship caused by the Second World War.
Glossary
Asthma – a condition that affects the airways which carry air in and out of the lungs. The muscles around the walls of the airways tighten and the lining of the airways becomes inflamed and starts to swell, causing breathing difficulties.
Azathioprine – a drug used to help prevent rejection of transplanted organs and also in the treatment of rheumatoid arthritis. It works by suppressing the body’s immune system so it will not attack the transplanted organ or the joints.
Cartilage – a layer of tough, gristle-like tissue which covers the ends of the bones in a joint. Its smooth, slippery surface allows the bones to glide over each other without friction.
Dehydration – a condition where the normal water content of your body is reduced. The human body is about two-thirds water. The amount of water in the body only has to be reduced by a few per cent before the chemical balance within the body is affected. Dehydration can result from illness or exhaustion, or from not drinking enough (non-alcoholic) fluids.
Diabetes – a medical condition which interferes with the body’s ability to use glucose (sugar) for energy. The body needs insulin, which is normally produced in the pancreas, in order to use glucose. In diabetes the body may stop producing insulin, produce too little insulin, or become resistant to insulin. If the body is unable to use the glucose obtained from foods the amount of sugar in the blood increases; if untreated, raised blood sugar can have wide-ranging effects on a person’s health.
Inflammation – living tissue’s reaction to injury or infection. The flow of blood increases, resulting in heat and redness in the affected tissues, and fluid and cells leak into the tissue, causing swelling.
Lactate – a chemical compound produced in the body during normal metabolism or during exercise. Production of lactate increases with strenuous exercise or as a result of the rapid cell breakdown caused by severe dieting. Raised lactate is thought to increase the risk of gout attacks by 'competing' with urate for excretion via the kidneys.
Stomach ulcer – a sore or hole in the lining of the stomach. During digestion, the stomach produces acid to break down food. The stomach has a lining of mucus to protect the tissues from this acid, but if this lining is damaged the acid may irritate the sensitive tissue underneath and may eventually cause an ulcer to form. People who have had stomach ulcers should take special care when taking NSAIDs as these can sometimes cause damage to the stomach lining.
Synovial fluid – fluid produced within the joint capsule which helps to nourish the cartilage and lubricate the joint.
Warfarin – a drug used to prevent blood clots from forming or growing larger. It works by 'thinning' the blood, making it less 'sticky' and reducing the blood’s ability to clot.
Further reading
Gout: The 'At Your Fingertips' Guide by Rodney Grahame, Anne Simmonds and Elizabeth Carrey. Class Publishing 2003. ISBN 9781859590676.
Contains advice on all aspects of living with gout. The book is available from libraries and bookshops. (It is not available from arc.)
Useful addresses
The Arthritis Research Campaign (arc)
PO Box 177
Chesterfield
Derbyshire S41 7TQ
Phone: 0870 850 5000
www.arc.org.uk
As well as funding research, we produce a range of free information booklets and leaflets. Please contact the address above for a list of titles or, on this website, see Publications for people with arthritis.
Arthritis Care
18 Stephenson Way
London NW1 2HD
Phone: 020 7380 6500
Helpline (freephone): 0808 800 4050
www.arthritiscare.org.uk
Offers self-help support, a helpline service, and a range of leaflets on arthritis.
UK Gout Society
PO Box 527
London WC1V 7YP
www.ukgoutsociety.org
Produces an information booklet 'All About Gout: A Patient Guide to Managing Gout', which can also be downloaded from the website.
Information on drugs
Separate arc leaflets are available on many of the drugs used for arthritis and related conditions. We would recommend that you read the relevant leaflets for more detailed information about your medication.
