What is Gout? Learn the Definition of Gout
Gout is a form of inflammatory arthritis. Gout is known to be one of the most painful forms of arthritis, characterized by excruciating attacks that occur suddenly in a single joint – frequently in the middle of the night. The most commonly affected joint is the big toe, but gout is also seen in the ankles, knees, wrists, and hands. Continue reading to better understand the gout definition.
Breaking Down the Biology of Gout
Gout is defined by the accumulation and crystallization of excess uric acid in the body. This excess of uric acid is referred to in the medical community as hyperuricemia. Uric acid is created when purines are metabolized, or broken down, by the body.
Purines are organic compounds that are primarily naturally produced in the body, with about 20% of purines being derived from diet. While they may get a bad reputation from their role in gout, they make up two of the four building blocks of DNA and RNA (adenosine and guanosine). Purines, and more specifically their uric acid by-product, only become a problem when the body begins to over produce the acid or loses the ability to adequately process the acid.
While hyperuricemia can occasionally occur without adverse symptoms, most commonly the uric acid begins to form the needle-like crystals inside of a joint which define gout.
Gout is one of the most recorded medical conditions throughout history, recognized and recorded as early as ancient Egyptian times. According to estimates from the Arthritis Foundation, gout affects roughly 4%, or 8 million individuals, in the United States – around 6 million men and 2 million women. These numbers are likely to rise even higher due to the United States’ aging population, the ever-rising obesity epidemic, and the increased incidence of other health conditions that increase the risk of gout, such as kidney disease.
Gout’s extensive history has been plagued by a common misconception – that gout only afflicts the lazy and rich – earning the nickname “Rich Man’s Disease” or the “Disease of Kings.” This misguided notion came about when the very wealthy were the only ones that could afford a regular diet of red meat and alcohol. We now know that this type of diet raises the level of purines in the body, thereby increasing uric acid and increasing the likelihood of gout. In today’s society, we see the opposite of the “Rich Man’s Disease” – gout is more often seen in lower socioeconomic groups that tend to have less healthy, varied diets.
In addition to meat and alcohol, other dietary and lifestyle conditions that increase the incidence of gout include:
- Foods and drinks that are high in fructose
- Certain seafood and oily fish, such as tuna, trout, scallops and mussels
- Obesity, or having too much body fat
- Certain medicines, such as diuretics (also known as water pills), which are commonly used for high blood pressure
- Certain diseases, such as kidney disease, diabetes, hypertension, and congestive heart failure
The Four Stages of Gout
There are four distinct stages that define gout that help determine your potential diagnosis and treatment plan:
- Asymptomatic hyperuricemia. Hyperuricemia refers to elevated levels of uric acid in the body. You can have hyperuricemia without having any symptoms of gout, also known as being asymptomatic, and in some cases gout will never develop. However, hyperuricemia is a necessary state for the development of gout, and is the main precursor to the development of the disease. In individuals who will go on to develop gout, although symptoms haven’t begun to show yet, the uric acid crystals are beginning to form in the joint.
- Acute gout. Acute gout, also known as a gout attack or episode, is the actual presentation of the symptoms of gout. The attack occurs when something happens that causes a jump in uric acid levels or disturbs the crystals that have formed in the joint. This may be due to a diet change, or a minor joint trauma, or a new medication. The affected joint will be extremely tender, swollen, red or purplish, shiny, and warm to the touch. After the attack sets in, the symptoms will likely intensify over the next eight to twelve hours. Once the symptoms have reached their peak, they will ease after a few days and ultimately resolve within a week to ten days. Initial attacks will generally resolve with or without treatment, but subsequent attacks tend to require dedicated treatment. It is recommended to seek treatment regardless though, because additional joint damage may be sustained if proper care isn’t taken.
- Interval gout. Interval gout refers to the asymptomatic period between gout attacks. While pain will likely not be present, there is still a risk of joint damage as there is usually sustained low-level inflammation. Sustained inflammation becomes increasingly common in recurrent gout attacks.
- Chronic gout. Chronic gout is characterized by repeated gout attacks, and can sometimes be mistaken for rheumatoid arthritis as it begins to spread to additional joints. A small number of individuals will only experience gout once in their lifetime, but an estimated 60% of people who have a gout attack will have a second one within a year. Estimates also show that 84% of individuals will have another attack within three years. Chronic, untreated or improperly managed gout can turn into tophaceous gout, characterized by the presence of tophi or clumps of uric acid crystals. This extremely painful condition is only caused by untreated mismanaged gout over a period of several years, making it even more important to seek medical treatment if you suspect that you have been suffering from gout attacks.
In order to obtain a diagnosis of gout, your primary care physician will begin by taking a medical history. The two primary factors to be evaluated are which joint or joints are involved (e.g. the big toe) and whether the episode began explosively or developed slowly over time. If the joint pain developed over days or weeks, it is unlikely to be gout.
In terms of diagnostic tests, the most accurate test examines the synovial fluid of the affected joint through a procedure known as arthrocentesis. Your physician will use a needle to extract a sample of your synovial fluid, and then it will be sent to a laboratory to be examined for the presence of uric acid crystals, alternatively referred to as monosodium urate (MSU) crystals. If these crystals are found, there is a very high likelihood that you have gout. The removal of fluid and crystals, known as aspiration, may also temporarily reduce some of the painful symptoms of gout.
A less accurate, but also less invasive, diagnostic tool that may be used by your physician is a blood test to examine the levels of uric acid in the blood. This is a less accurate diagnostic tool because the level of uric acid in the blood can fluctuate throughout a gout attack. It is more often done after an attack has passed, when the levels of uric acid are more likely to be stable and therefore a high level will be more indicative of gout.
Imaging tests, such as x-rays, can also be used as a diagnostic tool when chronic gout is suspected. If you are having your first suspected gout attack, it is unlikely that any indicators will be found on an x-ray. X-rays are particularly useful in identifying tophi before they are visible to the naked eye, allowing treatment to begin before the tophi becomes severe.
Treatments for Gout
There are several stages of treatment that vary depending on acute gout vs. chronic gout, as well as how individual patients tolerate and respond to treatment.
- NSAIDs. NSAIDs, or non-steroidal anti-inflammatory drugs, are the first line of defense when it comes to treating gout. By reducing the level of inflammation in the joint, they not only protect against joint and bone damage, they also assist with pain relief. You can find some NSAIDs, such as ibuprofen (Advil or Motrin) or naproxen (Aleve) as over the counter medications. Your doctor can prescribe a higher strength dose of these NSAIDs, or other NSAIDs such as Celecoxib (Celebrex) or Indomethacin (Indocin), among others.
- Corticosteroids. When NSAIDs are not well tolerated, cannot be taken with other medications that you are on, or are not effective in relieving symptoms, corticosteroids may be used. These can be administered orally (commonly prednisone) or through an injection directly into the joint. Injections are only used if the gout is contained to one or two joints, and they must be done by a trained physician. These injections tend to only provide short term relief.
- Gout-specific medications. In the case of recurrent symptoms, or chronic gout, your physician may prescribe gout-specific medications, such as allopurinol (Aloprim or Zyloprim) or colchicine (Colcrys), which help to manage and control the levels of uric acid within the body. In the most severe cases, when no other treatment has been successful, your physician may administer pegloticase (Krystexxa) intravenously.
- Low purine diet. In addition to medicinal treatment, sticking to a low purine diet can contribute to lowering uric acid levels in the body. This primarily means avoiding high purine foods and drinks, as mentioned above, however adding cherries, lemons, apples, and/or baking soda to your diet can assist in lowering uric acid levels further. It is also important to stay well hydrated! Dehydration can contribute to an excess of uric acid.
When to Contact a Doctor
You should contact your doctor at the first sign of a gout attack because leaving the condition untreated will only prolong symptoms and increase the risk of damage to the joint. In addition, the longer that gout goes untreated, the higher your risk of developing chronic tophaceous gout. If you are having repeated attacks that respond poorly to treatment, you should ask your primary care physician to refer you to a rheumatologist – a doctor that specializes in diseases of the joints and muscles.
If the affected joint becomes hot to the touch and you develop a fever, this may be a sign that the joint has become infected, and you should seek medical care immediately.
If you or a loved one are experiencing gout-like symptoms, call or book online with PlushCare to set up a phone appointment with a top U.S. doctor today.