Gout
By Dr. Kent Niss
Gout is an arthritic condition that affects many people in the United States. It affects men more than women. Gout is a unique arthritic condition that most commonly effects one joint at a time and often the same joint repeatedly. The definition of gout is deposits of uric acid crystals within the joint space. As you can imagine crystals within a joint space that was supposed to move freely result in pain. Also, this results in significant inflammation. Today I would like to go over some specifics about gout and how to manage it as well as how to prevent it both with medicines and without. This condition is rather common and seen quite often in the clinic.
Oftentimes gout can be diagnosed clinically rather than using any diagnostic tests, however, the gold standard for diagnosing gout is to aspirate fluid out of the joint space and then examine it under a microscope with specific dyes too illicit the presence of these uric acid crystals. As you can imagine, a needle placed into a joint space that is already very hot and painful would not be very pleasant. Therefore, most often this is a clinical diagnosis and only in very specific cases is joint aspiration performed. Gout presents as a single joint that is very warm, tender and often swollen. Usually, this joint is also rather red. This presentation is very similar to an infected joint as well as an inflamed joint due to other types of arthritis. The classic level of pain that correlates with gout is described as pain even with the touch of a feather. Therefore, it does not take a lot of pressure or movement to cause discomfort. There are several things that can cause uric acid to be in abundance, both genetic factors as well as environmental factors. Certainly, the genetic factors are difficult to modify, however, environmental factors are more easily modified. The most common environmental factors are foods and drinks that we intake. These are items that contain purine which is a common compound. The high-risk foods are red meat as well as seafood and shellfish. The most common drinks that cause gout or gout flares are alcohol and some sodas. Almost without a doubt most people who have a gout flare can recall eating or drinking one of the above within the previous 24 hours of the flare presenting.
Prevention of gout and gout flares is primarily due to avoiding these things. Some people are more sensitive to foods or drinks and therefore this can be identified over time and if able then trying to avoid intake of these specific things will help prevent flares. Shellfish is one of those items that almost always causes gout flares in those that have experienced gout in the past. Another way of preventing gout flares after diagnosis of gout has been made is the use of a medication called allopurinol. This is a medication that works at your kidneys to help you excrete additional uric acid. The use of allopurinol is based upon symptoms. If you continue to have gout flares, then increasing the dose of allopurinol is recommended. A blood test can be performed to look at the amount of uric acid within your blood, however, this does not directly coordinate with frequency or severity of gout flares. This is something to monitor if having repeated gout flares and taking a medication like allopurinol as this can help us titrate the dose of that allopurinol as well. A question that I get often is “why do we not screen for gout?” the easy answer to this is that it is not a cost-effective way of screening for gout. As stated above, uric acid testing does not correlate with frequency or severity of gout and has shown time after time to be a very poor screening test for gout as there is no specific cut off that would lead us to believe you are more likely to have gout or not.
The treatment of a gout flare is fairly straightforward albeit not always perfect. As gout causes pain by increasing inflammation within the joint space the treatment is to use an anti-inflammatory. Therefore, a mainstay of treatment or medication such as NSAIDs (naproxen, ibuprofen), colchicine and steroids such as prednisone or methylprednisolone. These are medications that are going to calm down the inflammation in the short term. And then steps need to be taken to help prevent recurrence of a flare. Sometimes these anti-inflammatory medications do not work as well as people would like them to, however, we also want to make sure we are mitigating risk with use of these medications as they are potentially harmful to the stomach as well as the kidneys. All of these things need to be kept in mind when managing gout. We discussed use of allopurinol above as a preventive medication and that is its sole purpose. It is not used in the setting of a gout flare as it can cause that flare to be worse.
In summary gout is an inflammatory condition of the joint where uric acid crystals are deposited within that joint. Decreasing uric acid is one way of managing gout and that is primarily done by changes in the diet as well as use of medications such as allopurinol. It is always important to keep in mind that there are several other factors both when diagnosing gout and managing gout that need to be assessed by a clinician. Therefore, if you do have symptoms that are concerning of gout you should seek medical help to determine the best path forward for you. Do not hesitate to reach out to your primary care provider to discuss this topic further.
