Gouty Arthritis

Gouty arthritis, commonly known as gout, is one of the most painful yet treatable forms of arthritis. This condition occurs when sharp uric acid crystals build up in your joints, causing sudden and severe attacks of pain, swelling, and redness, most often in the big toe.

Table of contents

• What is gouty arthritis?
• What causes gout?
• Who is at risk of developing gout?
• Signs and symptoms
• Which joints are affected?
• The four stages of gout
• How is gout diagnosed?
• Treatment options
• Diet and lifestyle changes
• Preventing gout attacks

What is gouty arthritis?

Gout is a common and complex form of inflammatory arthritis that can affect anyone^[1]. It happens when there is a buildup of uric acid (a waste product your body makes when it breaks down certain chemicals) in your body^[2]. When uric acid levels become too high, sharp needle-like crystals can form in and around your joints, causing sudden episodes of severe pain and swelling.

Gout is one of the oldest diseases known to medicine, having been recognized since ancient times. The Egyptians identified specific foot pain in the big toe as a distinct disease as early as 2640 BCE^[8]. Despite being an ancient condition, gout remains the most common type of inflammatory arthritis in the United States, affecting approximately 1 to 2% of adults^[3].

The good news is that gout is one of the few rheumatic diseases that can be cured with proper treatment^[4]. With effective medications and lifestyle changes, most patients can manage their symptoms and prevent future attacks.

What causes gout?

Gout occurs when your body has too much uric acid in the blood, a condition called hyperuricemia^[4]. Your body naturally produces uric acid when it breaks down substances called purines, which are found in certain foods and drinks, as well as in your body’s own tissues^[2].

Normally, your kidneys filter uric acid out of your blood, and it leaves your body when you urinate. However, sometimes your body makes too much uric acid, or your kidneys don’t remove it from your blood fast enough^[2]. When uric acid levels rise above 6.8 mg/dL, it can no longer stay dissolved in the blood and begins to form sharp, needle-shaped crystals^[5].

These crystals settle into your joints and surrounding tissues, where they trigger sudden episodes of inflammation. The sharp crystals clump together and cause the intense pain, swelling, and other symptoms characteristic of a gout attack^[2].

It is important to note that having high uric acid levels doesn’t always mean you will develop gout. Many people with hyperuricemia never experience gout symptoms^[2]. Conversely, some people have signs and symptoms of gout without having unusual levels of uric acid in their blood^[11].

Who is at risk of developing gout?

Gout can affect anyone, but certain factors increase your likelihood of developing this condition^[3]. Men are three times more likely than women to develop gout^[2]. The disease tends to affect men after age 40, while women usually don’t experience gout until after menopause, when they lose the protective effects of estrogen^[6].

Several health conditions increase your risk of gout, including^[2]:

• Being overweight or having obesity
• Congestive heart failure
• Diabetes
• High blood pressure
• Kidney disease
• Blood cancer

Your lifestyle and diet also play important roles. You are more likely to experience gout if you^[2]:

• Have a parent or grandparent who has gout
• Eat a lot of animal proteins, especially red meat, organ meats, and shellfish
• Drink alcohol regularly, particularly beer
• Consume sugary drinks and foods with high fructose corn syrup
• Take certain medications, such as diuretics (water pills) or low-dose aspirin
• Take immunosuppressant drugs

Signs and symptoms

The signs and symptoms of gout almost always occur suddenly, often at night^[1]. Many people are awakened in the middle of the night by severe pain that feels like their affected joint is on fire^[1].

During a gout attack, symptoms in the affected joint may include^[2]:

• Intense pain that is likely to be most severe within the first four to 12 hours
• Discoloration or redness of the skin over the joint
• Stiffness and difficulty moving the joint
• Swelling
• Tenderness, even to a light touch such as a bedsheet covering your affected joint
• Warmth, or a feeling like the joint is burning

A vivid description of a gout attack was written in 1683 by Dr. Thomas Sydenham, who himself suffered from the condition. He described how the victim goes to bed in good health, only to be awakened around 2 o’clock in the morning by severe pain, most commonly in the great toe. He noted that the pain feels like a dislocation, with intense stretching and tearing sensations, and that the affected part becomes so sensitive that it cannot bear even the weight of bedclothes or the vibration of someone walking in the room^[10].

A gout attack usually lasts about one to two weeks if left untreated^[7]. After the most severe pain subsides, some joint discomfort may persist from a few days to a few weeks. Later attacks are likely to last longer and affect more joints^[1].

Which joints are affected?

Gout most commonly affects the big toe joint, a condition called podagra^[10]. However, any joint can be involved in a gout attack, and it may affect more than one joint at the same time^[2].

Other joints frequently affected by gout include^[2]:

• Feet and ankles
• Knees
• Hands and wrists
• Elbows

People with osteoarthritis in their fingers may experience their first gout attack in their finger joints^[6].

The four stages of gout

Gout is best understood by viewing it as having four distinct phases or stages^[8]:

Stage 1: High uric acid (Asymptomatic hyperuricemia)

In this stage, you have elevated uric acid levels in your blood but no symptoms. Although most patients will have elevated levels of uric acid in the blood for many years before having their first gout attack, not everyone with high uric acid will develop gout^[10]. This stage generally is not treated, and there is no current recommendation for treatment during this period in the absence of clinical signs or symptoms^[10].

Stage 2: Acute gout attacks

This stage is marked by sudden gout attacks that cause severe pain and inflammation in one or more joints. These attacks come and go in episodes called flares^[2].

Stage 3: Period between attacks (Intercritical periods)

These are periods of time between acute attacks when you feel normal but remain at risk for another attack^[8]. Some patients may have only one or two gout attacks in their lifetime, while others experience attacks at short intervals^[10].

Stage 4: Advanced gout (Chronic tophaceous gout)

If gout is left untreated over long periods, you may develop tophi, which are hard lumps of uric acid deposits under the skin^[8]. Tophi are usually found on the ears, fingers, elbows, or around joints. While they start out painless, over time they can become painful and damage bones and soft tissue, leading to misshapen joints^[3]. With proper treatment, tophi can be dissolved and will completely disappear over time^[10].

How is gout diagnosed?

It is important to be diagnosed with gout early so you can start treating it quickly^[3]. Since gout symptoms can look like other diseases, a healthcare provider should make the diagnosis.

A diagnosis of gout can be made through several methods^[3]:

Physical examination and medical history: Your doctor will examine the affected joint and ask about your symptoms, diet, alcohol consumption, medications, and family history^[3].

Joint fluid test: The definitive way to diagnose gout is by examining fluid from the affected joint. Your doctor may use a needle to draw fluid from your swollen joint. When examined under a special polarized light microscope, needle-shaped, negatively-birefringent uric acid crystals can be seen^[10]. Crystals inside white blood cells are particularly characteristic during an acute attack.

Blood test: A blood test 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, while others have signs and symptoms of gout without unusual levels of uric acid in their blood^[11].

Imaging tests: X-rays can help rule out other causes of joint inflammation^[11]. Ultrasound can detect urate crystals in joints or in tophi. A specialized scan called dual-energy computerized tomography combines X-ray images taken from many different angles to visualize urate crystals in joints^[11].

Treatment options

Gout is managed in three main stages: treating acute attacks, preventing future flares, and lowering excess uric acid in the body^[9]. A healthcare provider will suggest medications and changes to your diet that will lower your uric acid levels and minimize how often you experience gout attacks in the future^[2].

Treatment during an acute attack:

The goal during an acute gout attack is to reduce inflammation and control pain^[13]. Several types of medications can help:

• Nonsteroidal anti-inflammatory drugs (NSAIDs): These include over-the-counter options such as ibuprofen and naproxen sodium, as well as prescription NSAIDs like indomethacin^[11]. Treatment should be started as soon as possible and discontinued when symptoms resolve.
• Colchicine: This medication can effectively reduce gout pain, especially when taken soon after symptoms begin^[11]. Low-dose colchicine is better tolerated than high doses and may be used in combination with NSAIDs^[13].
• Corticosteroids: These can be given as pills, injected into the affected joint, or given as an injection into the muscle^[11]. They are particularly useful for patients who cannot take NSAIDs.

Long-term treatment to prevent attacks:

Treatment with uric acid-lowering medications is recommended for patients with two or more gout flare-ups per year, tophi, or damage visible on X-rays^[18]. The goal is to lower uric acid levels to 6 mg/dL or below to dissolve or prevent crystals^[13].

Medications used to lower uric acid include:

• Allopurinol: This is the first-line medication for lowering uric acid. It works by blocking uric acid production^[13]. Treatment typically starts at 100 mg or less daily and can be increased every two to five weeks to reach the target uric acid level^[15].
• Febuxostat: Another medication that blocks uric acid production. It is an alternative for those who cannot take allopurinol^[13].
• Probenecid: This helps your kidneys remove uric acid more effectively^[13].
• Pegloticase: This is an intravenous medication reserved for patients with severe gout who have not responded to other treatments^[13].

When starting uric acid-lowering treatment, there is a risk of triggering a gout flare. To prevent this, your doctor may prescribe low-dose colchicine, NSAIDs, or steroids for three to six months after starting uric acid-lowering therapy^[13].

It is important to continue taking uric acid-lowering medicine regularly, even when you no longer have symptoms^[7]. In a study of patients with low uric acid levels, 87% had flare-ups within five years of stopping their medication^[15].

Diet and lifestyle changes

Adopting a healthy diet is one of the most important factors in managing gout^[19]. Making changes to what you eat and drink can help reduce gout symptoms and prevent future attacks.

Foods and drinks to limit or avoid:

Certain foods and beverages high in purines are more likely to lead to high uric acid levels^[2]:

• Alcohol: Especially beer and hard liquor. Even though not all alcoholic drinks are high in purines, alcohol prevents your kidneys from eliminating uric acid^[2].
• Sugary drinks and sweets: Foods and drinks with high sugar content, particularly those containing high fructose corn syrup, can trigger gout^[2].
• Red meat and organ meats: These include liver, kidneys, tripe, and sweetbreads^[3].
• Certain seafood: Including anchovies, sardines, mussels, scallops, trout, and tuna^[3].

Foods and drinks to include:

• Low-fat dairy products: Studies show that drinking low-fat milk and eating low-fat dairy can reduce your uric acid levels and risk of a gout attack^[21].
• Coffee: Long-term coffee drinkers (4-6 cups per day) have less risk of developing gout^[21].
• Citrus fruits and foods rich in vitamin C: Vitamin C may help lower uric acid levels. Grapefruit, oranges, pineapples, and strawberries are high in vitamin C but lower in fructose^[21].
• Cherries: Some evidence suggests that eating cherries or drinking cherry juice can reduce gout attacks and improve pain^[19].
• Plenty of water: Drink at least 8 glasses of water a day. Staying hydrated helps flush out uric acid and prevent kidney stones^[21]. During a flare, increase your intake to 16 glasses a day.

A recent study suggests that the DASH diet (Dietary Approaches to Stop Hypertension) or a similar dietary pattern emphasizing plant-based foods, vegetables, fruits, whole grains, and non-meat proteins may help lower uric acid levels^[20].

Other lifestyle recommendations:

• Maintain a healthy weight. Being overweight increases your risk of gout^[3]. Weight loss may lower uric acid levels and reduce the number of gout attacks, but avoid crash diets^[7].
• Be physically active for at least 150 minutes per week at moderate intensity^[3].
• Try to quit smoking^[7].
• Have some alcohol-free days each week^[7].

Preventing gout attacks

If you are experiencing a gout attack, there are things you can do to relieve the pain^[7]:

• Take any medicine you have been prescribed as soon as possible. It should start to work within 2 days.
• Rest and elevate the affected limb with pillows so it is higher than your chest.
• Keep the joint cool by applying an ice pack or a bag of frozen peas wrapped in a towel for up to 20 minutes at a time.
• Drink lots of water unless your doctor tells you not to.
• Try to keep bedclothes off the affected joint at night.
• Do not put pressure on the joint, as this can make the pain worse.

Get treatment immediately if you feel an attack starting^[7]. Getting treatment within the first 24 hours of the start of a flare can lessen its length and severity^[27].

Between attacks, making healthy lifestyle choices can help prevent or reduce future gout attacks^[3]. Regular follow-up with your healthcare provider and consistent use of uric acid-lowering medications as prescribed are essential for long-term gout management.

If you experience sudden pain and swelling in a joint along with fever, feeling sick, or inability to eat, seek urgent medical help. These symptoms could mean you have an infection inside your joint and need immediate treatment^[7].