Gout

Gout is a type of arthritis where swelling and severe pain develops in joints, especially at the base of the big toe.

Gout affects approximately 1 in 200 adults, most commonly men between 30-60 years of age. Gout less commonly affects women. Gout is one of a few types of arthritis where future damage to joints can be avoided by treatment.

Our bodies all have a breakdown product called urate (or uric acid). Most urate is produced by the body. It breaks down substances known as purines and usually passes out in our urine.

If urate does not pass out of the body, or if you produce too much, it can build up and form crystals. Gout is caused when these crystals build up and form around the body’s joints, causing inflammation and pain. 

Purines are found naturally in the body and also in some foods, such as shellfish, red meat and offal, and certain alcohols, such as beer and stout. Drinking a lot of alcohol can also cause dehydration, which makes gout more likely to occur. Dietary purines account for 5-10 per cent of total purines in the body. 

Urate builds up either because too much urate is being produced by the body or because not enough is being passed out in urine (which may indicate kidney disease). Some other diseases can also increase your likelihood of developing gout, including heart disease, psoriasis and the treatment of some blood disorders such as leukaemia.

Not everyone with high urate levels will develop gout. We do not know why some people develop it. However, if you are overweight you are more likely to develop it. A good diet and weight loss will reduce your chances of developing gout.

According to the latest research genes may play a part in increasing your risk of developing gout.

'I first had a gout attack when in my early 40s. It was very painful. I went to a specialist who prescribed me allopurinol.

I looked for a link with foods, but never found any correlation with purines or any other food. My job involved a lot of travel. Long aeroplane journeys and no exercise for a few days seemed to invite trouble. Hot climates too were a danger and I learnt to drink plenty of water.

One big toe has become very inflexible and the joints get a little painful after a long walk but otherwise I have no other problems.'

The following are risk factors for gout:

• if you are very stressed or have had an illness
• if you injure or bruise a joint. If you are prone to gout, and you have more pain in a joint than you would expect after a minor bump, it could be an attack coming on, so get treatment straight away
• by taking diuretics (water tablets) or low-dose aspirin. Some people take these for high blood pressure or to prevent heart disease
• dehydration

Pseudogout is a similar condition to gout, where sudden attacks of inflammation affect a joint. It is caused by calcium phosphate crystals, not urate crystals, and usually affects knees, shoulders or wrists, rather than toes. It is treated differently to gout, and is not covered here.

Gout usually affects the big toes. It can affect other joints such as ankles, knees, hands, wrists or elbows, especially in people who get gout when they are older.

A joint will start to ache, then swell up and become red, hot and extremely painful.  The joint may look as if it has a boil on it, or the skin can become shiny and peeling. The joint will be stiff.

You might also get a temperature and feel very tired. An attack of gout can last from 1-10 days, then die down, doing no permanent damage to the joint. There can be years between attacks.

However, if you get lots of attacks (which is rare), you can develop more permanent arthritis in the joint, which can damage it (chronic gout).

Chronic gout can also cause tiny white lumps (tophi) to appear under your skin, especially on your ears, fingers or elbows. This is where urate crystals form under the skin. They can be painful.

If your urate levels are especially high, it can build up in the kidneys as stones, so you will need treatment to reduce the levels.

Non-steroidal anti-inflammatory drugs (NSAIDs).

Very bad (acute) attacks of gout are usually treated with NSAIDs. These help reduce inflammation and so cut down the pain. Indometacin (Indocid) and diclofenac (Voltarol) are examples of NSAIDs. You must always take NSAIDs with or straight after food to prevent stomach problems. NSAIDs can be taken at the first sign of an attack.

Cortisone type drugs

Corticosteroids might be given to you as tablets or an injection, if an acute attack does not respond to other drugs.

Colchicine

This drug could be an option if you cannot take NSAIDs. Colchicine is obtained from the meadow saffron. It is used in low doses because it can cause diarrhoea and nausea at higher doses.

Allopurinol

If you have more than two or three attacks, your doctor may prescribe a preventative drug to stop urate building up in your body. The most common of these drugs is allopurinol.

Never start taking this during an acute attack of gout. These medicines have to be taken every day, possibly for the rest of your life. This can cause an allergic rash. Contact your doctor if this happens.

Febuxostat

Febuxostat is a new drug which has recently been approved by the National Institute for Health and Clinical Excellence (NICE) for use by people who cannot take allopurinol. 

How to help yourself during an attack of gout

• An ice-pack (or pack of frozen peas), wrapped in a cloth, can be put on the sore joint for 30 minutes, several times a day, to bring relief and reduce inflammation.
• A frame over your foot to keep bedclothes off it can relieve pain at night.

How to manage the effects on your life

If you are overweight, losing weight very gradually can help reduce the amount of urate in your blood. Do not go on a starvation diet. That can make gout worse.

Moderate exercise is very important for keeping your joints moving. A physiotherapist can give you exercises that are right for you.

Reduce the amount of alcohol you drink as dehydration can trigger gout. Alcohol, especially beer, can make it more likely for gout to flare up.

Drink lots of water – between 1.5 and 2.5 litres a day (six to eight glasses) to help prevent kidney stones. This can stop urate forming into crystals. Drinking five or more cups of coffee daily has been shown to increase the amount of uric acid that is excreted. For the best advice on how much water you should drink, talk with your doctor.

While it is helpful to cut down on foods which contain purines, 90 per cent of purines are produced in the body. The foods with the highest amounts of purines are:

• liver
• offal
• oily fish (herring, mackerel, sardines, fish roe, anchovies)
• beer
• yeast and yeast extracts (like Marmite)

There are other foods with purines in them – ask your doctor or nurse for a full list. Find out more about eating well.

If you think you have gout (or any kind of arthritis), see your GP.

An infected joint can look the same as gout, so the doctor will need to rule that out. They might do a blood test to measure the amount of urate in your blood. They might also take some of the fluid from around a joint and get it tested to see if it contains any crystals. 

It is important to discuss with your doctor not only how to treat an acute attack of gout, but also how to prevent another attack and manage the condition.

If your gout is severe and keeps flaring up, your doctor may suggest you see a rheumatologist – a specialist or consultant based at a hospital. They may be able to advise on taking stronger drugs like corticosteroids.

Rheumatologists work with a healthcare team which could include:

• a nurse practitioner who can help you learn about the condition and how to live with it
• an occupational therapist who can assess whether you need any extra equipment to cope at home
• a podiatrist who can assess whether you need special foot care, and advise on the right shoes or insoles.

This information comes from our factsheet on gout which was last reviewed in 2011. It will be next reviewed in 2013.