Date:
Gout
- Gout is an ancient and common form of inflammatory arthritis, and is the most common inflammatory arthritis
among men. Gout may remit for long periods, followed by flares for days to weeks, or can become chronic.
- Gout is a chronic disease caused by an uncontrolled metabolic disorder, hyperuricemia, which leads to the deposition of monosodium urate crystals in tissue. Hyperuricemia means too much uric acid in the blood. Uric acid is a metabolic product resulting from the metabolism of purines (found in many foods and in human tissue). 1, 2
- Hyperuricemia is caused by an imbalance in the production and excretion of urate, i.e., overproduction, underexcretion or both. Underexcretion is the most common cause, thought to account for 80-90% of hyperuricemia. 3
- Hyperuricemia is not the same as gout. Asymptomatic hyperuricemia does not need to be treated.
- Risk factors for gout include being overweight or obese, having hypertension, alcohol intake (beer and spirits more than wine), diuretic use, and a diet rich in meat and seafood. 4,5,6
- Gout can be viewed in four stages:
o Asymptomatic tissue deposition occurs when people have no overt
symptoms of gout, but do have hyperuricemia and the asymptomatic
deposition of crystals in tissues. The deposition of crystals, however,
is causing damage.
o Acute flares occur when urate crystals in the joint(s) cause acute
inflammation. A flare is characterized by pain, redness, swelling, and
warmth lasting days to weeks. Pain may be mild or excruciating. Most
initial attacks occur in lower extremities. The typical presentation
in the metatarsophalageal joint of the great toe (podagra) is the
presenting joint for 50% of people with gout. About 80% of people with
gout do have podagra at some point. Uric acid levels may be normal in
about half of patients with an acute flare. Gout may present
differently in the elderly, with many joints affected.
o Intercritical segments occur after an acute flare has subsided, and a
person may enter a stage with clinically inactive disease before the
next flare. The person with gout continues to have hyperuricemia, which
results in continued deposition of urate crystals in tissues and
resulting damage. Intercritical segments become shorter as the disease
progresses.
o Chronic gout is characterized by chronic arthritis,
with soreness and aching of joints. People with gout may also get tophi
(masses of urate crystals deposited in soft tissue) usually in cooler
areas of the body (e.g., elbows, ears, distal finger joints).7,8
- Gout is also associated with an increased risk of kidney stones.9,10
- The gold standard for diagnosing gout is aspiration and microscopic analysis for urate crystals in joint fluid or a tophus. Urate crystals are negatively birefringent under polarized light. Infection must be ruled out.7,11
- The goals of treatment are to end the pain of acute flares, and to prevent future attacks and the formation of tophi and kidney stones. Therapy for acute flares consists of nonsteroidal anti-inflammatory drugs, steroids, and colchicine. Diet and lifestyle (weight loss, avoiding alcohol, reducing dietary purine intake) modifications may help prevent future attacks. Changing medications (e.g., stopping diuretics) associated with hyperuricemia may also help. Therapy for persons with recurrent acute flares or chronic gout usually involves allopurinol.
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