Gout

Introduction

  • Gout is a type of inflammatory arthritis caused by the deposition of uric acid crystals in joints, leading to severe pain, swelling, and redness.
  • It is associated with hyperuricemia, where excess uric acid builds up in the blood.
  • While often episodic, recurrent gout attacks can lead to chronic joint damage and tophi (uric acid crystal deposits under the skin).
  • Effective management includes lifestyle changes, medications to treat acute attacks, and long-term uric acid control.

Causes of Gout

  1. Increased Uric Acid Production
    • Purine-rich foods: Red meat, shellfish, organ meats.
    • Excessive alcohol intake, particularly beer.
  2. Decreased Uric Acid Excretion
    • Kidney dysfunction.
    • Certain medications (e.g., diuretics, aspirin).
  3. Medical Conditions
    • Obesity, hypertension, diabetes, metabolic syndrome.
  4. Genetic Predisposition
    • Family history of gout increases risk.

Symptoms of Gout

  1. Acute Gout Attack
    • Sudden, intense joint pain, often at night.
    • Affected joint: Most commonly the big toe (podagra).
    • Redness, warmth, swelling, and tenderness in the joint.
  2. Intercritical Period
    • Symptom-free interval between attacks.
  3. Chronic Gout
    • Persistent joint inflammation.
    • Development of tophi: Firm, yellowish-white nodules under the skin, often on fingers, elbows, or ears.

Complications of Gout

  • Chronic Arthritis: Joint damage and deformity from repeated attacks.
  • Tophi Formation: Deposits of uric acid crystals causing visible lumps.
  • Kidney Stones: Uric acid crystals in the urinary tract.
  • Cardiovascular Disease: Increased risk of heart disease and stroke.

Diagnosis of Gout

  1. Clinical Assessment
    • History of acute joint pain and swelling.
    • Risk factors such as diet, alcohol intake, and comorbidities.
  2. Laboratory Tests
    • Serum Uric Acid: Elevated levels (>6.8 mg/dL).
    • Synovial Fluid Analysis: Presence of needle-shaped monosodium urate crystals.
    • Inflammatory Markers: Elevated ESR or CRP during acute attacks.
  3. Imaging
    • X-rays: Chronic joint changes like bone erosion.
    • Dual-Energy CT: Identifies urate deposits.
    • Ultrasound: Double contour sign indicating urate crystal deposition.

Treatment Options for Gout

1. Acute Attack Management

MedicationBrand NameManufacturerCost Range
NSAIDsIndomethacinIndocinMerck
NaproxenAleveBayer
ColchicineColcrysTakeda$50–$150 per course
CorticosteroidsPrednisoneDeltasonePfizer
  • NSAIDs: First-line treatment for pain and inflammation.
  • Colchicine: Effective if taken early during an attack; reduces inflammation by inhibiting neutrophil activity.
  • Corticosteroids: Used when NSAIDs and colchicine are contraindicated.

2. Long-Term Uric Acid Control

MedicationBrand NameManufacturerCost Range
Xanthine Oxidase InhibitorsAllopurinolZyloprimGlaxoSmithKline
FebuxostatUloricTakeda
Uricosuric AgentsProbenecidBenemidMerck
PegloticaseKrystexxaHorizon Therapeutics$10,000–$20,000 per dose
  • Allopurinol: Reduces uric acid production; start at a low dose to avoid acute flare-ups.
  • Febuxostat: Alternative for those intolerant to allopurinol.
  • Probenecid: Increases uric acid excretion through urine.
  • Pegloticase: Used for severe or refractory gout; enzymatically breaks down uric acid.

3. Lifestyle Modifications

  • Dietary Adjustments
    • Avoid purine-rich foods (red meat, shellfish) and high-fructose corn syrup.
    • Increase intake of low-fat dairy, fruits, and vegetables.
  • Hydration
    • Drink 2–3 liters of water daily to prevent kidney stones.
  • Weight Management
    • Losing excess weight reduces uric acid levels and joint stress.
  • Limit Alcohol
    • Particularly beer and spirits.

Monitoring Parameters

  • Regular monitoring of serum uric acid levels (<6 mg/dL is the target).
  • Frequency and severity of gout attacks.
  • Renal function tests during urate-lowering therapy.

Patient Counseling Points

  • Educate on the importance of adherence to urate-lowering therapy, even when asymptomatic.
  • Emphasize early treatment during acute attacks for best outcomes.
  • Discuss dietary triggers and the importance of hydration.
  • Warn about the potential for gout flares when starting urate-lowering therapy and the need for prophylaxis.

Use in Children

  • Rare; often secondary to underlying metabolic conditions.

Use in Pregnancy

  • NSAIDs are contraindicated in the third trimester; corticosteroids may be safer for acute attacks.

Use in Elderly

  • Adjust dosing for renal function and monitor for drug interactions.

FAQs About Gout

Q1: What causes gout?

  • Excess uric acid in the blood leads to crystal formation in joints.

Q2: Can gout be cured?

  • It cannot be cured, but proper management prevents attacks and complications.

Q3: What foods should I avoid with gout?

  • Red meat, organ meats, shellfish, alcohol, and sugary beverages.

Q4: How is gout treated during an attack?

  • With NSAIDs, colchicine, or corticosteroids to reduce inflammation.

Q5: How is chronic gout managed?

  • With medications like allopurinol or febuxostat to lower uric acid levels.

Q6: Are there natural remedies for gout?

  • Cherry juice and vitamin C may help lower uric acid, but they are not substitutes for medical treatment.

Q7: Can dehydration trigger gout?

  • Yes, inadequate hydration increases uric acid concentration, triggering attacks.

Q8: Is gout hereditary?

  • Genetic factors can increase susceptibility.

Q9: Can I drink coffee with gout?

  • Yes, moderate coffee consumption may reduce uric acid levels.

Q10: How long does a gout attack last?

  • Untreated attacks typically resolve in 7–10 days; treatment shortens duration.

Q11: Can exercise help with gout?

  • Yes, but avoid strenuous activity during acute attacks.

Q12: What are tophi?

  • Hard deposits of uric acid crystals under the skin, common in chronic gout.

Q13: How often should I check my uric acid levels?

  • Every 6–12 months or more frequently during treatment initiation.

Q14: Can gout affect other parts of the body?

  • Yes, including the kidneys (stones) and soft tissues (tophi).

Q15: When should I see a doctor for gout?

  • If attacks become more frequent, severe, or do not respond to standard treatments.