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What Is It?
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Gout is a disorder characterized by too much uric acid in the blood and tissues. In gout, crystals of uric acid are deposited in the joints, where they cause a type of arthritis called gouty arthritis. They also can be deposited in the kidneys, where they can cause kidney stones.
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There are three main causes of the high levels of uric acid that lead to gout:
• A diet rich in chemicals called purines, because purines are broken down by the body into uric acid. Foods that contain purines include anchovies, nuts and organ foods such as liver, kidney and sweetbreads. In some people, a diet high in purines can lead to high levels of uric acid in the body.
• The body produces too much uric acid regardless of diet. This can happen for unknown reasons. It can occur in certain inherited genetic metabolic disorders, leukemia and during chemotherapy for cancer.
• The kidneys do not excrete enough uric acid. This can be caused by kidney disease, starvation and alcohol use, especially binge drinking. This also can occur in people taking medications called thiazide diuretics, which are used to treat high blood pressure.
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In addition, obesity or sudden weight gain can cause high uric acid levels because the body's tissues break down more purines.
In some people, gout is caused by a combination of these factors. People with a family history of gout are more likely to develop the condition.
About 90 percent of patients with gout are men older than 40. Gout is quite rare in younger women and typically occurs in women many years after menopause.
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Symptoms
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The first attack of gouty arthritis usually involves only one joint, most commonly the big toe. However, it sometimes affects a knee, ankle, wrist, foot or finger. In gouty arthritis, the affected joint can become red, swollen and extremely tender to the touch. Typically, even a bed sheet cannot brush against it without triggering intense pain. After the first attack of gout, later episodes are more likely to involve several joints. Sometimes, if gout lasts for many years, uric acid crystals can collect in the joints or tendons, under the skin or on the outside the ears, forming a whitish deposit called a tophus.
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Diagnosis
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Your doctor will ask you about your medications, diet, alcohol use and about any family history of gout. Your doctor will examine you, and will look at your painful joints and search your skin for tophi.
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Your doctor may use a sterile needle to remove a sample of fluid from your inflamed joint. This joint fluid will be examined in a laboratory for microscopic uric acid crystals, which confirm the diagnosis of gouty arthritis. Your doctor also may order blood tests to measure the level of uric acid in your blood. Depending on your history and symptoms, you may need additional blood tests and urine tests to check how well your kidneys are working.
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Expected Duration
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Without treatment, the pain of gouty arthritis usually lasts for several days, but it is most intense within the first 24 to 36 hours. The interval between attacks varies a lot. Some people have them every few weeks, while others go years between attacks. After several gout attacks, a joint may take longer to improve or even become chronically inflamed and painful.
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Prevention
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To help prevent gout:
• Follow a healthy diet.
• Avoid alcohol use, especially binge drinking.
• Avoid dehydration.
• Lose weight if you are obese.
• Avoid diuretics (water pills) if possible.
For most people with gout, dietary restrictions do not seem to help much, but you should avoid any foods that seem to trigger gout attacks.
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Treatment
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To treat an attack of gouty arthritis, your doctor usually will begin by prescribing a nonsteroidal anti-inflammatory drug (NSAID), such as indomethacin (Indocin), ibuprofen (Advil, Motrin and others) or naproxen (Aleve, Anaprox, Naprosyn and others). Aspirin should be avoided because it can raise the level of uric acid in your blood. If you cannot tolerate an NSAID, or if these drugs don't work for you, your doctor may suggest a corticosteroid. Corticosteroids can be given orally or injected directly into the affected joint. Another option is an injection of a compound called adrenocorticotrophic hormone, which directs your adrenal gland to make more cortisone. A drug called colchicine sometimes is used, but it tends to cause unpleasant side effects (nausea, vomiting, cramps, diarrhea) and causes side effects in about 80 percent of patients.
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To prevent attacks of gout from happening in the first place, your doctor may prescribe allopurinol (Aloprim, Zyloprim) to make your body produce less uric acid. If attacks are rare and respond well to treatment, this approach is not necessary. It usually is recommended when:
• Gout attacks are frequent.
• Gout attacks do not respond promptly to treatment.
• Gout attacks affect more than one joint at a time.
• There is a history of kidney stones and previous gout.
• A tophus has developed.
Uric-acid levels usually begin to drop within 24 hours after the first dose of allopurinol. The full effect occurs after two weeks of daily treatment.
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Another treatment approach is to make your kidneys release more uric acid by taking probenecid (Benemid, Probalan) or sulfinpyrazone (Anturane). These drugs work well in 70 percent to 80 percent of patients. But they should not be taken by people who have significant kidney disease or who have had a kidney stone.
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Medications to lower uric acid — allopurinol, probenecid or sulfinpyrazone — usually are taken indefinitely. If discontinued, the uric acid level can be expected to rise again and attacks of gout are likely to resume.
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When your doctor prescribes a medication to reduce uric acid in your blood, he or she also should prescribe a second medication to prevent a gout attack. That's because any change in uric acid levels, up or down, can trigger an attack. These preventive medications can include a low dose of colchicine or a low dose of an NSAID. Once the uric acid is lowered enough, the preventive medication can be stopped.
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When To Call A Professional
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Call your doctor whenever you have pain and swelling in a joint. If you have had gout in the past, your doctor may suggest you have NSAIDs available so you can take them at the earliest sign of an attack.
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Prognosis
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During the first few attacks of gouty arthritis, drug treatment started early in the attack usually will relieve symptoms within 48 hours or less. Without drug treatment, gout symptoms may go away on their own, but this usually takes several days.
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More than 50 percent of patients who have had one attack of gouty arthritis will have a second, usually within six months to two years. If your disease is severe enough to require long-term preventive medication, such treatment is highly effective at lowering uric acid, which can prevent attacks and, over months to years, cause tophi to go away.
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Pseudogout (CPPD)
What Is It?
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Pseudogout is a form of arthritis triggered by deposits of calcium crystals (calcium pyrophosphate dehydrate) in the joints. It is also called calcium pyrophosphate deposition disease (CPPD). This disease can cause short-term or long-term joint swelling, most frequently in the knee, wrist, shoulder, ankle, elbow or hand. As the name suggests, this condition can appear similar to gout, another arthritic condition caused by another type of crystal that commonly causes the sudden pain and swelling in a single joint. However, gout is caused by uric acid crystals, and gout tends to occur in the big toe or midfoot. Pseudogout also can resemble osteoarthritis or rheumatoid arthritis.
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Pseudogout most commonly affects the elderly. It occurs in about 3 percent of people in their 60s and as many as half of people in their 90s. The cause is unknown. Because many people affected by this disease already have joint damage from other conditions, it is probable that the physical and chemical changes of aging make them more susceptible to crystal formation. One theory is that an injury to cartilage allows calcium crystals to be released into the joint space, and these crystals trigger an inflammatory response.
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In some cases, other medical conditions can make people more susceptible to pseudogout. These include an underactive thyroid (hypothyroidism), a genetic disorder of iron overload (hemochromatosis) or excessive blood levels of calcium (hypercalcemia). Pseudogout also can be triggered by joint injury, such as joint surgery or a sprain or the stress of a medical illness. Frequently, however, nothing can be identified that might have triggered the disease.
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Symptoms
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Symptoms include:
• Pain, swelling and stiffness around a single joint, especially the knee. Occasionally, more then one joint is affected at the same time.
• Fever, usually low-grade
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Diagnosis
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Diagnosing pseudogout can be tricky because it can resemble gout, infection or other causes of joint inflammation. Also, pseudogout commonly is associated with other joint problems. Therefore, it is important that even when pseudogout is identified, other causes of joint trouble also are considered.
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X-rays may reveal calcium deposits along the affected joints, although many healthy elderly people have similar findings on X-rays without the inflammation of pseudogout. Because a joint infection or other joint disease can cause similar symptoms and findings, doctors often will recommend that joint fluid be removed from an inflamed joint and analyzed for CPPD crystals, as well as for evidence of gout crystals, inflammation or infection. Your doctor also may want to do tests for other conditions that can trigger pseudogout. These may include tests of iron, calcium and thyroid function.
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Expected Duration
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Attacks of pseudogout can last for days or weeks. If the condition is not diagnosed, it can lead to joint degeneration.
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Prevention
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There is no way to prevent pseudogout from developing. If a medical condition is discovered that can lead to pseudogout, treatment of that condition may prevent future attacks of pseudogout. For people with frequent attacks, medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or colchicines, may prevent future attacks.
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Treatment
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Fluid can be removed from the joint to ease the pressure. In this procedure, called joint aspiration, a needle is inserted into the joint after the area is numbed, to withdraw fluid. Treatment usually also includes nonsteroidal anti-inflammatory drugs (NSAIDs) or glucocorticoid injections to keep the swelling down. The combination of joint aspiration and medication usually eliminates symptoms after a few days.
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Treatment with oral corticosteroids over a short period of time also may be necessary. Daily use of a low dosage of colchicine, a medicine that is also used in the treatment of gout, may help to prevent acute attacks. Occasionally, people with recurrent or chronic pseudogout may develop degenerative joint disease. In this case, surgery (such as joint replacement) may become the only effective treatment.
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When To Call A Professional
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If you experience significant joint pain, especially if the joint is swollen, contact your doctor.
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Prognosis
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With treatment, the outlook for pseudogout is usually good. Joint pain and swelling usually go away promptly. Recurrent attacks are common, but usually can be controlled with repeated treatment.
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