Ouch!!!!! That joint bloody hurts……is it GOUT?
What is Gout?
Gout is a painful condition that develops in some people who have chronically high blood levels of uric acid (hyperuricemia).
Not everyone with high uric acid levels develops gout. Generally up to two-thirds of individuals with hyperuricemia never develop symptoms. The symptoms of gout result from the body’s reaction to deposition of these uric acid crystal in our bodies.
Uric acid crystals have a tendency in deposit themselves in joints hence joints are the most commonly affected part of the body. The crystals however can also form in the kidney or other parts of the urinary tract where they can impair kidney function or cause kidney or urinary tract stones and the severe pain that is associate with it.
Having experienced one gout attack and having overcomed it DOES NOT mean that you will never get another attack again. Gout is in fact a chronic disease. Hence it is VERY IMPORTANT that your gout is managed and followed up by a good GP with adequate experience in treating chronic gout. This is imperative because gout, if not managed well can be a debilitating condition causing joint deformities and affecting your mobility and impairing your daily function.
Who is at risk of Gout?
Gout usually develops in adulthood and is rare in children.
It commonly develops earlier in adult men (often at ages 30 to 45 years) than in women (usually after age 55), and is particularly common in people older than 65 regardless of gender.
Factors that increase the risk of developing gout, include:
- High blood pressure
- Chronic kidney disease
- Consuming excessive amounts of alcohol (particularly beer, whiskey, gin, vodka, or rum) on a regular basis
- Consuming large amounts of meat (particularly red meat), seafood like ikan bilis, or beverages containing high fructose corn syrup (such as non-diet sodas)
- Taking medications that affect blood levels of urate (especially diuretics or “water pills”)
What causes the Gout pain?
Gout attacks (also called flares) are sudden episodes of SEVERE joint pain, usually with redness, swelling, and tenderness of the joint. Although an attack typically affects a single joint, some people develop a few inflamed joints at the same time. Attacks start more often overnight and in the early morning hours than during the day, but they can occur at any time. The pain and inflammation usually reach their peak intensity within 12 to 24 hours and generally improve completely within a few days to several weeks, even if untreated. It is not clear how the body “turns off” a gout attack.
The characteristic pain and inflammation of gout develop when white blood cells and cells in the joint linings attempt to surround and digest urate crystal deposits. These cells recognize the crystal deposits as foreign material and release chemical signals that contribute to the pain, swelling, and redness associated with a gout attack.
Different phases of gout
There are 3 phases of gout:
- acute gouty arthritis
- intercritical gout
- chronic tophaceous gout
Acute gouty arthritis:
I call this the “CRAP IT’S PAINFUL” Phase
- Initial gout flares usually involve a single joint, most often the BIG TOE or the KNEE . This attack is known as acute gouty arthritis. Over time, the attacks can begin to involve multiple joints at once and may be accompanied by fever
I call this the “SNEAKILY QUIET” Phase
- The time between gout attacks is known as an intercritical period. A second attack usually occurs within two years of the first. If gout is untreated over a period of several years, the time between attacks may shorten. Each subsequent attack can become more painful, last for longer and even involve more than one joint.
Chronic tophaceous Gout
I call this the “YUCKY BULGY” Phase
- Many years of repeated attacks of gout or persistent hyperuricemia can result in tophceous gout. The accumulation of large numbers of uric acid crystals in masses can be seen as eruptions or unsightly bulges of the joint also known as tophi. People with this form of gout develop tophi in joints, bursae (the fluid-filled sacs that cushion and protect tissues), bones, and cartilage, or under the skin. Tophi may cause erosion of the bone and eventually joint damage and deformity (called gouty arthropathy).
- The presence of tophi near the knuckles or small joints of the fingers can be a distressing cosmetic problem. Tophi are usually not painful or tender. However, they can become inflamed and can cause symptoms like those of an acute gouty attack. Tophi can also get infected and required surgical removal in that event.
- Since the improved use of uric acid lowering medications, there has been a reduction in the number of chronic tophaceous gout. Nonetheless this condition is still seen.
- It takes MANY YEARS of gout to develop debilitating tophi and it will also take over just as many years to reverse tophaceous gout and to get rid of the bulky uric acid deposits in the joints. Hence the constant emphasis on the importance of early treatment and good compliance to treatment for gout.
How do you treat an acute gout attack?
The goal of treatment of flares of gouty arthritis is to reduce pain, inflammation, and disability QUICKLY AND SAFELY. Antiinflammatory medications are the best treatment for acute gout attacks and are best started early in the course of an attack.
People with a history of gout should keep medication on hand to treat an attack because early treatment is an important factor in determining how long it takes to decrease the pain, severity, and duration of an attack.
Nonsteroidal antiinflammatory drugs — Nonsteroidal antiinflammatory drugs (NSAIDs) work to reduce swelling in a joint and include ibuprofen (sample brand names: Advil,Neurofen), naproxen (sample brand names: Aleve, Anaprox), indomethacin (brand name: Indocin), and etoricoxib/ celecoxib(brand name: Celebrex). NSAIDs are generally recommended for people who have no history of kidney or liver disease, who have no bleeding problems, who do not use anticoagulant medications such as warfarin, and who have no history of a stomach or duodenal ulcer.
NSAID treatment is withdrawn within a day or two of the resolution of the acute flare.
Aspirin use is NOT RECOMMENDED.
Colchicine — Colchicine may be prescribed instead of an NSAID. Colchicine does not increase the risk of ulcers, has no known interaction with anticoagulants, and, in controlled doses, does not affect kidney function.
Colchicine can have the following side effects, including diarrhoea, nausea, vomiting, and crampy abdominal pain.
Colchicine seems to be most effective when given at the first symptoms of an acute attack.
Corticosteroids — Commonly used oral corticosteroids include prednisolone, and triamcinolone.
Corticosteroids may be used if NSAIDs and colchicine cannot be used.
They can even be injected directly into the affected joint or they can be given as pills or by intramuscular injection. People who have multiple affected joints or who cannot take NSAIDs or colchicine may be given oral steroids.
There may be an increased risk of recurrent gout attack (called a rebound attack) in people taking oral corticosteroids for severe attacks but reducing the dose too quickly. For this reason we taper corticosteroid dosing over a period of at least 10 to 14 days before completely discontinue the course of steroids.
After my acute gout attack has resolved, do I then need to go on to long term treatment to control my uric acid levels?
You will only need long term treatment if you meet the following criteria:
- Evidence of gout tophi
- More than or equal to 2 gout attacks per year
- Chronic kidney disease
- History of kidney or urine tract stones
What are the uric acid lowering therapies available?
Therapy to prevent progression of gout may include medications and lifestyle changes that can be used long-term to lower urate levels and thus prevent or reverse the urate crystal deposits that cause worsening of gout.
Progressive gout can cause severe gouty arthropathy, disability, kidney stone formation, and possibly kidney damage.
Uric acid-lowering medications lower urate levels in one of three ways:
- they increase uric acid elimination by the kidneys, or
- they decrease production of urate, or
- they convert urate to the more readily excreted allantoin.
Examples of Uric acid lowering therapy include:
- Allopurinol – most porpulary used
- Losartan – used more commonly to reduce blood pressure but has also been shown to have a uric acid lowering effect
Very rapid urate lowering can cause more frequent acute flares of gout. Aim is to achieve GRADUAL reduction in Uric acid level to the TARGET of 6 mg/dl. Increased fluids are recommended during this time (at least two liters per day are recommended).
When started Uric acid lowering treatment, drugs used to treat acute gout, like colchicine and NSAID are CONCURRENTLY given as a PROPHYLAXIS to PREVENT A GOUT FLARE.
The antiinflammatory prophylactic therapy (colchicine or NSAIDs) can usually be safely discontinued when blood levels of urate are normal and have been in the goal range for about six months. Longer prophylactic therapy may be needed in some patients, especially those with tophi.
Dietary changes — Changing your diet may reduce the frequency of gout attacks. Because obesity is a risk factor for gout, as well as for many other health conditions, losing weight is an important goal.
You are encouraged to eat and drink:
- Low-fat dairy products
- Foods made with complex carbohydrates (whole grains, brown rice, oats, beans)
- Only a moderate amount of wine. THAT MEANS CUT DOWN OTHER ALCOHOL. (about 300 mL of wine per day may be acceptable. Quantities higher than this can cause gout flares)
- Vitamin C (500 mg per day has a mild urate-lowering effect)
Changes in diet are often recommended along with medications. Diet change alone is unlikely to lower blood urate levels by more than about 15 percent, even if the diet is severely restricted. On the other hand, when diet control is accompanied by weight loss (often with increased exercise), improvements in urate control can be more impressive.
Is there a specific level of uric acid to achieve?
YES THERE IS of course! And the MAGIC Number is <6mg/dl.
BIGGEST misconceptions with Gout treatment?
The medications given for the acute gout flare are not only for pain management BUT they’re really an ANTIINFLAMMATORY, there to control the angry milieu of substances creating havoc and pain in your joint.
SO TAKE THEM AS INSTRUCTED!
No such thing as ”Oh I’m afraid of getting dependent on the pain medication” or “if I can tolerate the pain I don’t want to take the pankillers”.
Treating a gout attack is about managing the inflammation and by doing that we at the same time manage the pain.
If you have been put on uric acid lowering treatment eg Allopurinol, TAKE THEM EVERYDAY and DO NOT STOP IT even if you have a gout flare. ALSO DO NOT TAKE EXTRA TABLETS when you have a gout flare.
If you have never taken allopurinol regularly, IT SHOULD NEVER BE STARTED during a gout flare. Ideally it is started once symptoms of pain resolve. This is around 2 weeks after a gout flare.
Everyones optimal dose of allopurinol or Uric acid lowering therapy is DIFFERENT so what is critical here is regular follow up and monitoring of uric acid levels so your GP can adjust your medication doses to place you on the best platform to avoid further Gout attacks.
Cos REMEMBER GOUT CAN PERMANENTLY DESTROY YOUR JOINTS!
When allopurinol is newly started, it . Your GP will give you instructions as to when it is safe to stop the colchicine or the NSAIDs.
What we offer at our clinic for gout and inflamed joints:
– Joint fluid testing
– Blood test
– X-rays of joints
– Joint steroid injections
– Follow up for medication adjustment and monitoring of complications
SORT OUT, THAT DAMN GOUT! See us in one of our clinics!
Need more advice?
Come down to our Katong Clinic, call us at +65 6635 2551
Dr Tan and Partners @Katong (GP and Chronic Disease Management)
184 East Coast Road
+65 6635 2551
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and 4.30pm to 9pm
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