About Gout

Kimberly Madison, BSN, MSN

Inflammatory Arthritis

According to the Centers for Disease Control and Prevention (CDC) National Statistics, around 58.5 million people in the United States (U.S.) have a form of arthritis¹. Non-inflammatory and inflammatory are the two major categories of arthritis². Gout is a common form of inflammatory arthritis¹.

What is gout?

Gout is a type of inflammatory arthritis. Intense pain, along with red, hot, swollen joints, characterizes the condition. Stiffness and immobility can also occur in the affected joints. Unlike other forms of inflammatory arthritis, an acute gout attack or gout flare will initially affect a single, unilateral joint¹.

Hyperuricemia, or high levels of uric acid, causes gout. However, not all people with hyperuricemia will develop gout. Uric acid, or urate, is the waste product of purine. Our bodies produce the organic compound, purine². Red meats, organ meats, shellfish, fructose, and alcoholic beverages, especially beer, also contain purines.

The kidneys excrete urate through urine. If the kidneys cannot filter enough urate, the excess builds up and continues to circulate through the body. About one-third of uric acid breaks down in the intestines³.

The under excretion of uric acid by the kidneys is the most common cause of hyperuricemia. Monosodium urate (MSU) deposits form in the presence of hyperuricemia⁶. These needle-like crystals can settle in any area of the body, particularly in joints, bursa, tendon sheaths, and kidneys.

Phases of gout

Gout progresses through the following three phases if not treated^4,5.

Acute gout

A gout attack, or flare, is a sudden onset of excruciating pain and swelling of the joints. Commonly, starting in the big toe, gout flares affect a single joint of the lower extremities at a time. However, gout can show up in other joints, too.

Without treatment, a gout flare can last for days, or possibly weeks. A gout flare happens suddenly, usually at night when a person is lying down. Because fluid leaves joints faster than uric acid while lying flat, acute pain episodes occur at bedtime. An intercritical period, or time in between flare-ups, usually follows an acute gout attack.

Recurrent gouty arthritis

Over time, acute attacks increase in frequency. At this phase, there is bilateral joint involvement. Gouty arthritis can be mistaken for rheumatoid arthritis because smaller joints are involved with some joint deformity.

Tophaceous gout

Tophi are stone-like masses in the soft tissues and joints. They can appear anywhere in the body and bring about destruction of the joints, bones, and surrounding tissue. Tophaceous gout is the most chronic form of the disease.

Who gets gout?

Risk Factors

Men between the ages of 30 to 40 years old account for over half of the cases in the U.S. Women's risk increases after menopause¹.

Genetics

The risk for gout also increases if a person has a family history or the disease.

Diet

High purine foods can trigger a gout attack. Foods such as certain meats, shellfish, fructose, and alcohol are high in purines that break down to uric acid.

Preexisting Conditions

Health issues like chronic kidney disease, type 2 diabetes, obesity, hypertension, and some cancers put a person at risk for gout.

Medications

Certain medications, such as loop diuretics, ethambutol, low-dose aspirin, pyrazinamide and cyclosporine, can increase a person's risk for gout.

How is gout diagnosed?

Gout can be difficult to diagnose because the symptoms are like those of other diseases. Your primary healthcare provider or rheumatologist will want to know your symptoms, complete a medical history and physical exam. The provider may also order lab tests and imaging¹.

Signs and Symptoms

Most people who seek treatment for gout usually do so while experiencing an acute pain crisis. The excruciating pain starts in one or more joints and worsens with movement or when touched. Some people experience chills, fever, and feel ill. A person with gout may report pain with warmth, redness, swelling, and stiffness of the joint.

Laboratory tests and imaging

A healthcare provider may order the following tests to help diagnose gout⁵:

blood test to measure uric acid level
aspiration of synovial fluid for laboratory analysis
ultrasound or Xray of affected joints

How is gout treated?

A rheumatologist or other healthcare provider will treat gout with medical interventions and recommended self-management strategies. The first concern for treatment is pain management during an acute flare.

To manage pain and inflammation, a healthcare provider may prescribe non-steroidal anti-inflammatory (NSAIDS) medications like ibuprofen, corticosteroids, or colchicine. A person can take corticosteroids orally or by injection in the affected joint¹.

Besides pain management interventions, a healthcare provider will prescribe medication to reduce uric acid. Allopurinol is the gold standard uric acid-reducing medication. Healthcare providers may also prescribe febuxostat, probenecid, or pegloticase. These medications lower or prevent urate formation.

By lowering uric acid, medications also decrease damage to the joints by reducing tophi formation. A healthcare provider can aspirate excess synovial fluid to decrease swelling of the joint. In some cases, a surgeon will remove larger tophi¹.

Self-management activities, such as lifestyle changes, can also help reduce painful flares. These activities include¹:

consuming a healthy diet and limiting purine-rich foods
decreasing alcohol consumption
drinking enough water
engaging in physical activity
changing medications that provoke gout attacks

Unfortunately, many people with gout wait until they have an acute pain crisis before seeking medical attention.

Final thoughts

If you or someone you know has gout, it's important to follow a plan of treatment. Medications and self-management activities help reduce acute pain crises and reduce further destruction to involved joints. The following steps can help a person live better with gout⁶:

Join an online support group. People with gout can feel isolated, especially during a pain crisis. Making connections in a supportive environment with others who share your experience can boost your emotional well-being. The Alliance for Gout Awareness is a non-profit organization with a community of people living with gout⁶.
Schedule routine appointments with your healthcare provider. Routine follow-up is important to ensure you receive proper treatment. Your healthcare provider can monitor your symptoms and make adjustments to your treatment plan if necessary.
Manage your pain and uric acid levels. Manage your gout by taking prescribed medications to prevent flares and destruction of your joints, bones, and surrounding tissues. Remember, if uric acid levels remain elevated over a long period, tophi can form, leading to immobile joints and disability.
Adopt lifestyle changes to reduce your gout flares. Physical activity, maintaining a healthy weight and eliminating purine-rich foods from your diet can prevent flare-ups. Understandably, if you need to lose weight, changing your diet while managing your weight loss can be hard to do on your own. Be sure to let your provider know you would like to lose weight so they can help you¹.

Have you cared for patients during an acute gout attack?

What pain management strategies worked best for them?

Share your stories in the comments.

References

¹ CDC: Gout

²Inflammatory Arthritis, Purine

³Urinary excretion of uric acid is negatively associated with albuminuria in patients with chronic kidney disease: a cross-sectional study

⁴Clinical manifestations and diagnosis of gout

⁵Gout and Hyperuricemia

⁶Alliance for Gout Awareness: Gout Guides