Gout

Gout is a painful form of arthritis that strikes suddenly, causing severe joint pain and swelling when tiny needle-shaped crystals of uric acid build up in the joints.

Table of contents

• What is gout?
• Symptoms and attacks
• Causes and risk factors
• How gout is diagnosed
• Treatment options
• Prevention and lifestyle changes
• Possible complications

What is gout?

Gout is a common and complex form of arthritis (inflammation of the joints) that can affect anyone^[1]. It happens when there is too much uric acid in your blood. Uric acid is a waste product that your body normally makes when it breaks down substances called purines, which are found naturally in your body and in certain foods^[2].

When uric acid levels get too high, sharp, needle-like crystals can form in your joints and surrounding tissues. These crystals cause sudden episodes of severe pain, swelling, and inflammation^[3]. Gout is the most common type of inflammatory arthritis^[4].

Nearly 10% of people aged over 65 years report having gout, and the overall number of people affected in the United States approaches 4%^[2]. The condition has become more common in recent decades, likely due to factors such as longer life expectancy, increasing rates of obesity, and changes in diet^[9].

Symptoms and attacks

The signs and symptoms of gout almost always occur suddenly, and often at night^[1]. During a gout attack, you may experience intense pain and swelling in one or more joints. Gout most commonly affects the big toe, but it can occur in other joints including the ankles, knees, elbows, wrists, and fingers^[2].

During an attack, the affected joint becomes hot, swollen, red, and extremely tender. Even the weight of a bedsheet on the joint may seem unbearable^[1]. The pain is likely to be most severe within the first four to 12 hours after it begins^[1].

After the most severe pain subsides, some joint discomfort may last from a few days to a few weeks. Later attacks are likely to last longer and affect more joints^[1]. A gout attack usually lasts about one to two weeks if left untreated^[3].

Gout symptoms come and go in episodes called flares or gout attacks^[2]. Between attacks, you might not experience any symptoms. Months or even years can pass between attacks, though they may become more frequent over time if gout is not treated^[3].

Causes and risk factors

Gout develops when there is too much uric acid in your blood, a condition called hyperuricemia^[2]. Your kidneys normally filter uric acid out of your blood and remove it when you urinate. Sometimes your body makes too much uric acid, or your kidneys don’t remove it from your blood fast enough^[2].

Having high uric acid levels does not always mean you will develop gout. Many people with hyperuricemia never get gout. It is estimated that only about one in three people with high uric acid levels actually develop the condition^[3].

Men are three times more likely to develop gout than women. Women usually don’t experience gout until after menopause (when monthly periods stop)^[2]. Older males are most commonly affected^[9].

People with certain health conditions are more likely to develop gout, including those with overweight or obesity, congestive heart failure (when the heart cannot pump blood effectively), diabetes, high blood pressure, kidney disease, or blood cancer^[2].

You are more likely to experience gout if you have a biological parent or grandparent who has gout, eat a lot of animal proteins (especially animal flesh, shellfish, and organ meats), drink alcohol regularly, take diuretic medications (water pills), or take drugs that suppress the immune system^[2].

Certain foods and drinks high in purines can trigger gout attacks. These include sugary drinks and sweets, high fructose corn syrup (a sweetener in many packaged foods), alcohol (especially beer), organ meats like liver, and game meats such as goose and venison^[2].

Other factors that can trigger a gout attack include having an illness that causes a high temperature, drinking too much alcohol or eating a very large meal, becoming dehydrated, injuring a joint, or taking certain medicines^[6].

How gout is diagnosed

It is important to be diagnosed with gout early so you can start treatment quickly^[5]. A doctor will take your medical history and ask about your diet and whether you drink alcohol^[6]. They will do a physical exam, including examining the affected joints.

Several tests may be ordered to confirm the diagnosis. A sample of fluid may be taken from inside the affected joint using a thin needle. This fluid is examined under a microscope to check for uric acid crystals^[6]. The presence of crystals in the joint fluid or in a deposit outside the joint can confirm the diagnosis^[9].

Blood tests can measure the levels of uric acid in your blood. However, blood test results can be misleading. Some people have high uric acid levels but never experience gout, and some people have signs and symptoms of gout but don’t have unusual levels of uric acid in their blood^[10]. Blood uric acid levels may even be normal during an attack^[9].

Joint X-rays can be helpful to rule out other causes of joint inflammation^[10]. Ultrasound or a special CT scan may be used to look for uric acid crystal buildup in the affected joint and check for other conditions that may be causing the symptoms^[10].

Treatment options

Gout treatment has two main goals: relieving the pain and inflammation caused by acute attacks, and lowering uric acid levels over the long term to prevent future attacks^[12].

Treating acute attacks

Several medications can help treat the pain and inflammation during a gout attack. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, are commonly used to reduce pain and swelling^[10]. NSAIDs are the most commonly used drugs in acute gout^[16].

Colchicine is another medication that can ease pain and swelling during an attack. Low-dose colchicine is generally better tolerated than high doses^[13].

Corticosteroids (steroid medications) can be given as pills or injected directly into the affected joint to reduce inflammation. These are useful for people who cannot take NSAIDs^[10].

Treatment should start as soon as possible. Getting treatment within the first 24 hours of the start of a flare can lessen its length and severity^[20]. Low-dose colchicine, NSAIDs, and glucocorticoids delivered orally, by injection into muscle, or into the joint are similarly effective during acute flare-ups^[17].

Long-term treatment to prevent attacks

If you have frequent attacks or high levels of uric acid in your blood, you may need to take uric acid-lowering medicine^[6]. These medications work to prevent future gout attacks and complications by reducing the amount of uric acid in your blood.

Allopurinol is the preferred first-line therapy for lowering uric acid^[17]. It blocks the production of uric acid in your body. Treatment typically starts at a low dose (100 mg or less daily) and is increased gradually every two to five weeks to reach a target blood uric acid level of 6 mg per dL or less^[17].

Febuxostat is another medication that blocks uric acid production. However, it may be limited by increased cardiovascular and all-cause mortality seen in studies^[17].

Probenecid is a medication that helps the kidneys remove uric acid from your blood^[7].

Pegloticase is an intravenous medication given by infusion that helps break down uric acid. Because of its high cost and side effects, it is considered for patients who have lumps of uric acid crystals or more than one flare per year despite other treatments^[17].

It is important to take uric acid-lowering medicine regularly, even when you no longer have symptoms^[6]. The medication may need to be continued for life^[17]. Anti-inflammatory medications such as colchicine or NSAIDs should be continued for three to six months after starting uric acid-lowering therapy to prevent flares^[17].

Prevention and lifestyle changes

Making healthy lifestyle choices can help prevent gout attacks and slow damage to the joints^[6]. Diet and lifestyle modification can help control gout and prevent attacks^[7].

Weight management

Being overweight may raise the risk of getting gout. Losing weight may lower the risk and reduce the number of gout attacks. This is true even without strictly restricting purines in the diet^[19]. Try to lose weight if you are overweight, but avoid crash diets^[6].

Dietary changes

Eating a healthy diet is an important factor in managing gout^[18]. Focus on eating fruits, vegetables, whole grains, low-fat dairy products, and lean proteins like fish and chicken in moderation (around 4 to 6 ounces per day)^[13].

Avoid or limit foods high in purines, including shellfish, red meat, organ meats (such as liver), and certain seafood like anchovies, sardines, mussels, scallops, trout, and tuna^[7]. Limit alcohol, especially beer, and avoid drinks high in sugar or fructose like concentrated juices and sodas^[7].

Low-fat dairy products may be beneficial. Multiple studies have found lower uric acid levels among people who consume low-fat dairy products^[18]. Some evidence suggests that eating cherries or drinking cherry juice can reduce gout attacks and improve pain^[18]. Vitamin C may lower uric acid levels, so consuming citrus fruits and other foods rich in vitamin C (such as strawberries and peppers) may be helpful^[18].

Fluid intake and other lifestyle factors

Drink plenty of fluids to avoid getting dehydrated, especially water. Aim for eight to 16 cups of fluids a day, at least half of them water^[20]. Have some alcohol-free days each week, and try not to drink more than 14 units of alcohol a week^[6].

Exercise regularly, but avoid intense exercise or putting lots of pressure on joints^[6]. Try to quit smoking^[6]. A doctor may suggest vitamin C supplements^[6].

Possible complications

Gout that goes untreated can lead to worsening pain and joint damage^[1]. Over time, if left untreated, gout can become chronic, with joints remaining slightly inflamed all the time. They may become misshapen over the long term, making it harder to move them^[3].

Some people develop tophi, which are hard lumps of uric acid crystals that form in soft tissues or bones around joints. Tophi start out as painless, but over time they can become painful and damage bone and soft tissue^[8]. They often appear on the ears, fingers, or elbows^[6].

High uric acid levels can also lead to kidney stones, which are painful deposits that form in the kidneys^[9]. In rare cases, chronic gout that is not treated can lead to kidney damage or chronic arthritis^[6].

If you experience sudden, intense pain in a joint, contact your doctor. If you have a fever, feel sick, or cannot eat along with joint pain and swelling, seek urgent medical help, as these symptoms could mean you have an infection inside your joint^[6].