Gout is the number one arthritic mononeuropathy diagnosed in the world and the most common arthropathy diagnosed in the United States. There are over 8.3 million people in the US alone that are affected by the disease. That would be 1 in 25 adults. Yet few understand the cause of the disease, the importance of recognition and the consequences of neglecting treatment. If left untreated, gout can complicate your health and lead to joint deformity and more severe problems including kidney stones, cardiovascular disease , cataracts and permanent disability.
A Disorder of Metabolism
Gout is a type of arthritis typically characterized as a mononeuropathy (one joint) that results from the build-up of uric acid in the tissues or a joint, most often the metatarsal phalangeal joint (MPJ) of the big toe. A disorder of metabolism allows uric acid to accumulate in the blood and tissues. When the tissues become supersaturated, crystalline deposits form causing inflammation, severe pain and destruction of the joint.
Gout occurs most commonly in the big toe because uric acid is sensitive to temperature changes. At cooler temperatures, uric acid turns into needle-like crystals. Since the toe is the part of the body that is furthest from the heart, it’s also the coolest part of the body and the most likely target of gout. However gout can affect other peripheral areas of the body such as the knees, elbows, fingertips or wrists with signs that present as hard nodules that cause the joint to be bulbous and disfigured. Gout can also occur as a polyneuropathy affecting more than one joint.
An attack of gout can be miserable, marked by the following symptoms:
Intense pain that comes on suddenly often in the middle of the night or upon rising.
Red, tender, hot area with swelling over the joint, all of which are signs of inflammation.
Gout attacks are caused by deposits of uric acid in the joint. Uric acid is the result of the breakdown of purines, chemicals that are found naturally in our bodies and in food.
Uric acid is present in the blood and eliminated in the urine, but in people who have gout, uric acid accumulates and crystallizes in the joints. Joint destruction is caused by these crystalized deposits called trophi from the Latin trophus meaning "stone". A tophus around a joint can cause it to become swollen and misshapen and the skin that covers it to become stretched and taut, sometimes to the point of ulceration. Trophi crystallization in the joints erodes bone and destroys cartilage, leading to chronic inflammation and debilitating pain.
Causes of and Misconceptions about Gout
There is a correlation between certain foods and beverages (red meat, red wine, beer and shellfish) that contain high levels of purines resulting in gout flare-ups and attacks. However other variables can contribute to the disease and exacerbation of symptoms.
Some people develop gout because their kidneys have difficulty eliminating normal amounts of uric acid, while others produce too much uric acid. The tendency to accumulate uric acid is often inherited. There are certain genes that control how much uric acid gets “reabsorbed” by the kidneys, which leads to higher levels of uric acid in the blood. Other biological influences that put a person at risk for developing gout include: high blood pressure, diabetes, obesity, metabolic syndrome and certain medications and vitamins. For example, the body’s ability to remove uric acid can be negatively affected by taking aspirin, some diuretic medications (water pills) and the vitamin niacin (also called nicotinic acid). There is a prevalent age range. While gout is more common in men aged 40 to 60 years, it can occur in younger men and also occurs in women.
There is a general misconception about gout that has given it the reputation of being a disease of gluttons and kings. The ancient Greeks called the gouty toe podagra, foot grabber, ruled over by child of Dionysus (god of wine) and Aphrodite (goddess of love). The term "gout" comes from the Latin word gutta or "drop", podagra being thought to arise as a "constitutional disease", a result of "bodily humours falling to the affected body part". Romans used this symbolism to say that gout was a disease of revelry caused by too much food, wine and excess. During the 19th century the disease was portrayed in a series of cartoon-like images used for political and social discontent that generated a particular set of jibes at the "gouty elite". Because of this there was and still is a tendency to trivialize the impact of the disease despite its severity and lack of class distinction. A recent survey conducted by the Alliance for Gout Awareness revealed very interesting insights:
● 52% of people with gout feel embarrassed of their condition so they don’t talk about it. ● 40% of people look down on people with gout. ● 93% say they didn’t know that gout is actually a form of arthritis. ● 46% of gout patients believe that diet alone causes gout.
Diagnosing and Medical Management of Gout
In diagnosing gout, laboratory tests and x-rays are often ordered to determine if the inflammation is caused by something other than gout. If confirmed initial treatment of an attack of gout typically includes the following:
Medications. Prescription medications or injections are used to treat the pain, swelling, and inflammation.
Dietary restrictions. Foods and beverages that are high in purines should be avoided, since purines are converted in the body to uric acid.
Fluids. Drink plenty of water and other fluids each day, while also avoiding alcoholic beverages, which cause dehydration.
Immobilize and elevate the foot. Avoid standing and walking to give your foot a rest. Also, elevate your foot (level with or slightly above the heart) to help reduce the swelling.
Because high levels of uric acid (hyperuricemia) are a significant marker of gout it is important to recognize that periodic evaluation as part of an annual screening can avoid disease progression and joint destruction. A healthy benchmark for control of gout is a serum uric acid level (SUA) of 6.0 mg/dL or below.
The symptoms of gout and the inflammatory process usually resolve in three to ten days with treatment. If gout symptoms continue despite the initial treatment, or if repeated attacks occur you may be placed on a maintenance treatment that may involve daily medication. If diagnosed early, most people with gout can live a normal life. Lowering urid acid levels can improve joint function and resolve tophi. Medication, lifestyle and dietary changes can also help ease symptoms and reduce the frequency and severity of gout attacks.
Self-Management of Gout
Medicine is an important tool for managing gout but lifestyle and fitness changes can significantly contribute to the long-term success of managing gout. Since diet plays a role in the management of gout, patients should be advised to avoid high-purine foods as they can increase the amount of uric acid in the blood and may trigger an attack of gout. Also foods containing high fructose corn syrup, which are also associated with gout flare should be eliminated. Fructose is a naturally occurring simple sugar found in fruits, vegetables and honey. In the form of high fructose corn syrup, it has become an additive in many foods and drinks. There is a correlation between a diet high in fructose content and gout. In the typical American diet, high-fructose corn syrup is added to many foods. All sweetened soft drinks, juices and foods with added high fructose corn syrup on the label, especially sodas, fruit drinks, many breakfast cereals, many store-bought baked goods, many ice creams and candy and processed foods such as those found at “fast food” restaurants should be kept under control.
High-purine foods to avoid include
organ meats, such as brain, sweetbreads, heart, kidney, and liver
herring, anchovies, smelt, and sardines
mackerel, tuna, trout, haddock, and codfish
mussels and scallops
beer, wine, and liquor
The Impact of Gout on People and Society
Not treating gout can result in attacks that are more frequent or longer in duration with implications to the cost in community health and quality of life.
According to a 2013 study from the Arthritis Research Centre of Canada, the University of British Columbia and Boston University, there is a $2,021 annual work productivity loss per gout patient suffering from more than 3 gout attacks per year. For those patients that suffer 6 or more gout attacks per year, direct gout-related health care costs top $12,020. Patients with gout who fail to achieve optimal levels of serum uric acid are at increased risk for premature mortality with a risk twice as high in patients with serum uric acid levels of 6 mg/dL or higher than in those with levels below 6 mg/dL (Fernando Pérez-Ruiz, MD, PhD, from Hospital Universitario Cruces in Vizcaya, Spain, reported during a news conference here at the American College of Rheumatology 2018 Annual Meeting)