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Gout is a type of crystal-related inflammatory arthritis that mostly presents as an acute attack but can also cause chronic arthritis.
This condition is characterized by increased pain and swelling in the joints of your feet particularly the big toe, or your fingers, wrists, knees, ankles, and elbows.
Uric acid is the breakdown product when the body metabolizes the chemical compounds known as purines. Gout develops when there is an excess of uric acid in the bloodstream.
The surplus acid crystallizes to form needle-like deposits in and around the joints and bursae, which can trigger severe pain, swelling, redness, warmth, and at times limited mobility in the affected joint(s).
The gradual accumulation of the precipitated uric acid or urate crystals can render the affected joint extremely swollen and tender to the touch, making gouty arthritis a severely debilitating and deforming condition.
Gout affects people of both sexes, but it is more prevalent among men than women. It is only after menopause that women have an increased tendency to develop gout.
What Causes Gout?
Uric acid is a common metabolic waste product found in the blood, which is filtered out by the kidneys and eliminated through the urine.
Gout occurs when there is a buildup of uric acid in the body, which can happen due to an overproduction of the substance or the inability of the kidneys to get rid of it fast enough.
Over time, the excess uric acid becomes very saturated and forms sharp monosodium urate crystals, which are then deposited in the tissues of your joints.
The following factors can contribute to high uric acid levels in the body and can increase your chances of having a gout attack:
- Overconsumption of foods that are high in purines, such asred meat, fish, and shellfish (1)
- Drinking too much alcohol
- Excessive intake of sugary beverages and foods that contain a lot of fructose
Tissues That Can Be Affected by Gout
There is no joint in the body that is safe from gout symptoms, but the condition targets the joint at the base of the big toe more than any other. This is largely due to the location of the toe, which lies farthest from the heart.
Given this distance, the freshly pumped blood tends to lose its warmth by the time it reaches the extremities, making your feet naturally colder than the upper body.
Uric acid solidifies to form urate crystals when subjected to cool temperatures.
Gout mainly targets the following types of tissues:
Gout can occur in any joint including the spine. However, the joint that is most commonly affected by gout is the first metatarsophalangeal joint (1stMTP), which lies at the underside of the big toe. Gout that affects this joint is commonly known as podagra.
Bursae are thin fluid-filled sacs that lie at the juncture between the bones and the surrounding soft tissue.
This lubricating cushion allows the skin, muscles, ligaments, and tendons in the joint to slide smoothly over the bone and keeps them from rubbing against each other.
By minimizing the friction between the skeletal tissue and the opposing soft tissue, bursae help facilitate easy movement of the joint.
Although bursae are present all over the body, gout primarily targets the areas that cover the tip of the elbow and the front of the kneecap.
What are the Signs and Symptoms of Gout?
The following symptoms explain the progression of a gout attack:
- The symptoms of a gout attack come on suddenly and rapidly.
- Most gout attacks begin during nighttime or early in the morning and affect the big toe joint.
- At the onset of the attack, you may experience intense pain and swelling in the affected joint, which worsens over the next 12-24 hours.
- At the peak of the attack, the pain in the joint can get so extreme that even a slight brush against a soft, light fabric can be unbearable.
- The skin over the inflamed joint may become shiny, red, and warm to touch.
- The skin over the affected joint may even begin to peel after a point.
- As you avoid using the affected joint, it can become increasingly stiff with time, which can greatly hamper its range of motion as well as your overall movement.
- Gout attacks may involve only one joint initially, but subsequent attacks can affect multiple joints.
- The debilitating symptoms of a gout attack can last for a week or longer.
- In severe and long-term cases of gout, the progressive accumulation of urate crystals in the joints cancause joint erosion as well as bone and joint deformities.
Gout is diagnosed based on one’s medical history, a physical examination of the affected joint, and additional tests such as the following:
Uric Acid Test
The doctor will conduct a blood test or a urine test to evaluate your uric acid levels.
A uric acid blood test involves using a needle to draw a small amount of blood from a vein in your arm and then testing the blood sample to measure the uric acid content.
A uric acid urine test, on the other hand, requires the patient to collect his/her urine over the span of a day. The urine sample is then checked to determine the level of uric acid in it.
The results of these tests alone cannot specify whether you have gout or not, but they can determine an elevated uric acid level, which is a crucial precondition for the onset of gout.
That said, it is also likely that some people with high uric acid levels may never develop gout.
The presence of urate crystals in the affected joint conclusively establishes whether you have gout or not.
To that end, the doctor will extract fluid from the joint through a needle, which is then examined under a microscope for traces of uric acid-based crystals.
If gout is left untreated for a long time, the crystallized uric acid may accumulate to form a mass under the skin.
Such condensed deposits of urate crystals are referred to as tophi and usually, appear in the late stages of gout.
In such a case, the doctor will use a special procedure called arthrocentesis to draw fluid from the swollen joint.
The need for an X-ray may arise in advanced cases of gout to determine the extent of damage. In the initial stages of gout, the urate deposition is too minimal to be captured by these imaging techniques.
Thus, an x-ray of the joint will rarely be useful in catching the condition early.
A majority of patients with gout seek medical help for their joint pain much before the urate crystals and physical deformity become visible on an X-ray.
Nevertheless, an x-ray can help the doctor identify any other factor that may be responsible for your arthritis.
Additional imaging modalities useful for detecting gout include musculoskeletal ultrasound of the affected joint(s).
Musculoskeletal ultrasound may reveal a double contour sign on the involved cartilage and a snowstorm appearance suggesting the presence of floating or accumulated monosodium urate crystals within the joint or along the tendons. Both these markers can indicate tophi formation in the X-rayed site. (14)
MRI and CT scans are rarely used but are useful in long-standing but rare cases of gout involving the spine.
Gout patients are usually prescribed a two-pronged treatment plan. One aspect of the treatment deals with relieving the symptomatic pain and swelling brought on by a gout attack, andthe other is concerned with preventing future attacks by lowering the uric acid in the body.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
NSAIDs refer to a class of anti-inflammatory medications that are used as the preliminary treatment option for curbing an ongoing gout attack.
NSAIDs help reduce the inflammation in the joint and relieve the pain associated with gout.
Certain NSAIDs can easily be purchased over-the-counter, such as ibuprofen and naproxen. However, you will most likely need a doctor’s prescription to get the stronger ones.
Colchicine is yet another anti-inflammatory medicine that works best when taken during the initial phase of the gout flare-up.
Colchicine is also given daily as a maintenance medication until the goal uric acid value of less than 6 mg/dl is achieved in patients with chronic gouty arthritis.
If used incorrectly, mainly taking too high a dose or too frequent dosing, can lead to adverse effects of nausea, diarrhea, and vomiting.
Aspirin, on the other hand, is strictly ill-advised as it can raise your uric acid levels and make your condition worse. (8)
Corticosteroids are used to provide quick relief from the inflammation and pain induced by an active gout attack. They should not be used long-term because of their adverse effects.
In severe cases of gout, the doctor may prescribe oral corticosteroids or administer them through an intramuscular (IM) or intravenous (IV) injection.
Corticosteroids are usually prescribed in the following cases:
- If nonsteroidal anti-inflammatory drugs or colchicine fail to address the gout flare-up
- If NSAIDs or colchicine are considered unsafe for the patient, due to active kidney disease or a history of ulcer formation and gastrointestinal bleeding
- In patients with a severe acute attack involving a single joint or multiple joints
Uric Acid Reducer Drug
Preventative medical care may be warranted to bring down consistently high uric acid levels, particularly if you are prone to frequent gout attacks and you have long-term gout.
Your doctor will delineate a treatment plan to reduce the buildup of excess uric acid in the bloodstream, which can lead to the formation of tophi or kidney stones if left unchecked.
This kind of preventative therapy includes prescriptions drugs including allopurinol, febuxostat, and pegloticase and aims to reduce uric acid production in the body.
Other drugs that may help improve the removal of uric acid from the body include probenecid and lesinurad.
Self-Care Tips and Home Remedies
1. Self-Care Tips
Lifestyle changes cannot cure gout, but they can help control uric acid levels in the blood.
Lifestyle recommendations to manage gout include:
- Rest: The first thing to do when dealing with a gout attack is to rest the affected joint. Exerting undue strain or pressure on an already painful joint only aggravates and prolongs your symptoms.
Because the big toe joint is the most frequent target of a gout attack, it may be wise to stay off your feet for the majority of the time that the condition persists.
- Apply an ice pack: You can treat the affected joint with a bit of cold therapy to temporarily relieve the symptoms of a gout attack. It may prove an effective home remedy to lower inflammation and soothe the ache. Simply wrap a few ice cubes in a kitchen towel and apply it on the painful site for 10 minutes at a time.
Do not apply the ice directly onto the skin as it can lead to frostbite. Placing the ice pack on the skin for too long is also strictly ill-advised.
- Elevate your leg: You may register some degree of relief from the gout symptoms by placing your leg at a raised position.
Leg elevation can help enhance the flow of blood to the affected site and thereby reduce the intensity of the gout attack.
- Increase your fluid intake: You must consume ample amounts of fluids daily to keep your body sufficiently hydrated.
Water is your best bet, but you can also supplement your fluid needs through healthy juices and succulent fruits or vegetables.
It is also important to limit your intake of alcohol and sweetened beverages such as sodas, which have a diuretic effect on the body.
- Maintain a healthy body weight: It is absolutely essential for gout patients to maintain their body weight within a healthy range to reduce the burden on their joints.
As obesity is a contributing factor to increased uric acid levels, the need for weight management is even more pressing. (2)
- Exercise regularly and properly: Engage in a moderate form of exercise that does not push your body too much but keeps it active enough to avoid unnecessary weight gain.
As gout can render your joints achy and feeble, subjecting them to a rigorous workout will only add to the strain and will worsen your condition.
Ask your doctor to recommend exercises that are appropriate for your condition. (2)
- Drink alcohol in moderation: Overconsumption of alcohol can contribute to the development of gout and must be avoided.
For someone who is already diagnosed with this condition, it is even more important to exercise moderation when it comes to alcohol intake.
Men should not exceed their daily intake to more than 2 drinks, while women should stick to only 1 drink or less per day.
Giving up alcohol completely is ideal, but if you must drink, it has to be in limited amounts. Besides, it may serve you well to steer clear of beer and other spirits. (2)
- Drink lemon juice: Gout patients may benefit from drinking lemon water every morning, but it is best to take your doctor’s approval before adding it to your daily routine.
The findings of a 2017 study published in Scientia Horticulturae showed that the juice or the water-soluble extracts derived from the lemon fruit may help reduce the serum uric acid levels in both human and rodent subjects. (10)
- Consume anti-inflammatory foods: Anti-inflammatory foods such as ginger and turmeric may help reduce the intensity of gout symptoms.
Increase your intake of such foods, which can help your body fight the gout-induced inflammation from within. (3)(6)(9)
- Some Chinese plants: There are certain chinese plants that block xanthine oxidase and may also help treat gout. (15)(16)
- Add magnesium-rich foods to your diet: Magnesium has been found useful in lowering elevated uric acid levels in the body.
This beneficial effect was highlighted by a study that found a link between increased magnesium intake and reduced hyperuricemia. (7)
- Cut back on purine-rich foods and drinks: Foods and beverages that are rich in purines contribute to an increased buildup of uric acid in the body.
If you wish to keep your uric acid levels in check, it is essential that you minimize your intake of the following:
- Organ meats, which includes liver, kidney, and sweetbreads
- Red meat, particularly lamb and beef
- Certain vegetables including mushrooms, asparagus, and cauliflower
- Seafood and shellfish, such as crabs, lobster, and sardines
- Foods with high sodium content, specifically sauces, and gravies
These dietary inclusions should be accompanied by proper dietary additions which essentially includes foods that are low in purines, such as cereals, vegetable, soya bean-based foods as well as dairy products.
Including antioxidant-rich cherries in your diet may help with the management of gout by reducing the number of recurrent attacks.
According to a 2012 case-crossover study that included 633 patients with gout, the consumption of cherry fruit and its extract is associated with a lower risk of gout flare-ups. (11)
Another 2019 study conducted on 24 subjects with gout suggested that long-term intake of cherry juice concentrate may reduce the number and risk of recurrent gout attacks. (9)
Even though cherries exhibit considerable therapeutic potential in reducing the intensity and frequency of gout flares, there is still a need for further large-scale randomized controlled trials to conclusively establish these claims.
Cherries maybe a favorable addition to the diet of patients with gout. However, cherry intake is recommended as an adjunctive measure only for lowering the risk of gout attacks rather than as a standalone treatment. You cannot expect your uric acid levels to decrease simply by consuming cherries.
This healthful fruit has to be incorporated in an otherwise gout-appropriate diet, and you must strictly follow your doctor-recommended treatment plan for the effective management of gout.
Speak with your doctor about the correct dosage to avoid any undue side-effects.
Drinking coffee may help bring down the elevated uric acid levels in your body and delay or prevent the onset of gout.
This positive effect can be traced back to caffeine, which is the predominant alkaloid found in coffee.
Caffeine may help reduce the risk of gout by inhibiting the release of xanthine oxidase, an enzyme that aids in the formation of uric acid.
According to a 2010 study conducted over a 26-year period on 89,433 female subjects, long-term intake of coffee may help reduce the incidence of gout in women. (4)
Another 2014 review found coffee to be a more helpful diuretic than green tea for improving blood uric acid levels, possibly by enhancing the excretion of uric acid through increased urine output.
Thus, the beverage need not contain high amounts of caffeine to engender the desired result.
Given the conflicting data, there is a need for more extensive and rigorous research to establish the exact mechanism thatmakes coffee useful for gout relief.
It is best to confer with your doctor before increasing your coffee consumption. Generally, people are advised to keep their coffee intake down to two cups a day.
Excessive consumption of coffee is to be avoided in the interest of your overall health.
Coffee may be a beneficial dietary aid in reducing the buildup of excess uric acid in the body but only when consumed in moderation or according to your doctor’s advice. Coffee is a known diuretic, which means that it can stimulate your kidneys to produce more urine. The best way to eliminate uric acid from the body is through urinary excretion, and coffee may help in that regard.
What are the Complications of Gout?
Gout, when not managed properly, can lead to the following complications.
If gout is left untreated for a long time, the urate crystal may clump together to form a hardened mass under your skin known as tophi.
This type of enhanced consolidation of urate salts is largely due to the persistently high levels of uric acid in the body.
Tophi formation typically occurs in advanced stages of gout and can affect almost any joint in the body.
The development of tophi is largely painless, but the damage it causes is significant enough to permanently deform the affected joint.
Joint Damage and Deformity
Chronic gout can lead to sustained inflammation in the joints, which can render them increasingly stiff and immobile over time.
This is only made worse by the formation of tophi on the affected joint, which is also a common occurrence in long-term gout patients.
In some cases of chronic gout, the joint is so severely affected that you may need surgery to repair the damage or replace the joint altogether.
Kidney Stones and Kidney Disease
Elevated levels of uric acid, particularly in chronic gout, can lead to the formation of kidney stones.
The urate crystals can get deposited in your urinary tract overtime, which can scar or damage the kidneys and gradually lead to the onset of kidney disease.
Psychological and Emotional Problems
People with chronic gout struggle with constant or long-term pain and inflammation in their joints, which can take a serious toll on their mental and emotional health as well.
If the condition advances to a severe degree, it can make joint movement increasingly painful.
You may find it difficult to walk or perform the most basic everyday tasks, which can lead to frustration and emotional distress.
Living with pain can be hard, and you need professional guidance from your doctor or a mental health expert to come up with healthy coping mechanisms.
Risk Factors for Gout
The following factors can increase your likelihood of developing gout:
- Gender: Gout is more prevalent among men than women. Moreover, the condition typically affects men between the ages of 30 and 50 years, while it has a relatively late onset among the female population.
A woman is most likely to develop gout once she has crossed menopause.
- Obesity: People who are overweight or obese have an increased tendency to develop gout.
- Diet: Poor dietary choices can raise your uric acid levels and make you more susceptible to gout.
People who eat too much of fructose-containing foods, meats that are high in purines such as organ meat or red meat, and specific varieties of seafood, as well as those who indulge in excessive alcohol consumption, are at an increased risk of gout.
- Metabolic Syndrome: People who have metabolic syndrome, which includes hyperlipidemia, hypertension, or late-onset (type 2) diabetes, tend to have elevated urate levels as their kidneys fail to filter out the urate from the blood efficiently enough.
This leads to the buildup of excess uric acid in the body, paving the way for gout.
- Family History: Some people are genetically predisposed to developing gout when the condition runs in their family.
- Medications: Certain medications can also put you at an increased risk of gout by increasing your uric acid levels.
These medications include diuretic drugs or “water pills” for the management of high blood pressure and some immunosuppressants taken by people with rheumatoid arthritis, psoriasis, and transplant recipients.
Myths About Gout
1. Gout only affects wealthy and obese people.
Gout affects people of all sizes but is more prevalent among those who figure on the heavier side.
Being overweight or obese can put you at an increased risk of developing other weight-related health concerns such as diabetes, high blood pressure, and elevated cholesterol levels.
These problems are collectively termed as metabolic syndrome and can make you more vulnerable to gout.
The claim that gout affects people of the higher income bracket more than those in the middle and lower classes is entirely unfounded.
2. Gout pain only attacks the big toe.
The joints of the big toe are the most commonly affected by gout, but that doesn’t mean that the condition is limited to the big toe alone. A gout attack can involve almost any joint of the body, whether big or small.
In fact, if you are a woman with a preexisting osteoarthritis, it is very likely that the gout pain will first manifest in the small joints of the hands before progressing to the other joints.
The initial few episodes of gout flare-ups usuallyaffect only one or two joints, but the condition can become more widespread as it reaches a more advanced stage.
It is not uncommon for chronic gout patients to experience pain and inflammation in multiple joints at once.
3. Gout is an uncommon disease.
Gout is not a rare disorder as the data points otherwise. This inflammatory condition affects over 8 million people in America alone, which shows its overwhelming prevalence.
Moreover, men who are past the age of 40 are more likely to develop gout than any other form of arthritis.
When to See the Doctor
Anyone diagnosed with gout and has recurrent flare-ups should seek regular care from their physician.
Your doctor may refer you to a rheumatologist in order to avoid tophi formation and subsequent permanent joint damage and deformity.
Early treatment and monitoring your uric acid levels to see how well you are responding to the current treatment are important for optimal control of the disease.
What your doctor may ask you?
- Are the affected joint(s) painful and swollen?
- What activities make your symptoms worse?
- How long does the gout attack last?
- Are you on any other medications or diuretics?
- What kind of diet do you follow?
What you may want to ask your doctor?
- Is gout hereditary?
- How can I keep my uric acid level under control?
- How to manage the pain during a gout attack?
- What lifestyle changes do I need to take up?
- Does gout increase my risk for any other conditions?
- How can I prevent it from getting worse?
- How long do I have to take these medications?
Expert Answers (Q&A)
Answered by Dr. Hai-En Peng (Podiatrist)
The food items to avoid in gout or to be consumed in strict moderation are: alcohol, especially beer and hard liquor, red meat/organ meat like liver and kidneys, seafood, sugary drinks/foods high in fructose, processed foods and refined carbohydrates.
It has been recently shown that tomatoes are bad for gout and there’s been some recent study linking it to high urate crystals.
It is always possible, but it’s more of a lifestyle change. Sometimes our bodies can’t clear or make too much uric acid.
So, we always need to help ourselves out by having the right diet and taking the appropriate medication to keep the levels at bay and reducing the frequency of the attacks.
A gout attack can happen at any time but yes, if the uric acid levels are too high, then you wake up the next morning with an acute gouty attack.
It all depends on how our body uses sleep and rest to heal itself, which in turn affects the uric acid levels.
Not so much as bone cancer itself, but patients with gout have been shown to have an increased risks of certain cancers.
Gout is all about diet modification and moderation. As long as you follow it strictly, you can help eliminate a lot of frequent attacks and the pain associated with it.
If the diet is not enough, please see your nearest rheumatologist to get a proper medication to help keep the uric acid levels down.
About Dr. Hai-En Peng, Podiatrist: Dr. Peng was born in Nyack, NY, and went to California College of Podiatric Medicine in San Francisco, CA. He spent the next 4 years there and graduated in the top 15% of his class.
Dr. Peng also completed a 3-year advanced surgical residency in reconstructive foot and ankle surgery.