What is gout?

Gout is the commonest inflammatory arthritis of men above 40 years of age. It belongs to a major category of arthropathies that are called ‘crystal-deposition arthritis’. This group is one of the 3 important causes of inflammatory arthropathies (the other 2 being immunoinflammatory category – rheumatoid arthritis belongs to that group; and infection that cause septic arthritis).

The majority of the patients with gout are men above the age of 40 years. A gouty attack usually starts in the middle of the night after a big party where the patient might have indulged in heavy eating and drinking. There is a sudden acute severe painful swelling of any of the joints in the ankle-feet region, but most often in the joint at the base of the big toe. In its acute stage, usually a single joint is affected. The joint swells up with acute tenderness to touch. The overlying skin becomes severely inflamed with dusky reddish-brown discolouration. Over a period of a few days, scaling and peeling of the overlying skin is commonly seen. Initially, the episodes are infrequent and may last for a week, with no symptoms between episodes.

The patients with gout have been found to be more prone to develop blood lipid abnormalities that would make them more prone to heart disease. Also, most of them are obese and often more prone to high blood pressure that further increases the chance of a heart attack.

How is it caused?

In gout, joint inflammation is triggered by the deposition of crystals of uric acid. Uric acid is a waste product produced in the body that passes through the kidneys into the urine. Some people, due to their genetic makeup, do not excrete adequate amounts of uric acid from their kidneys. This leads to a slow but steady increase in the uric acid content of their body that may also cause a high blood uric acid level in their blood. In a majority of such individuals, high uric acid in the blood (and the other body fluids) does not directly cause any health problem.

However, in a small number of such individuals, persistently high levels of uric acid in the body fluids lead to the deposition of uric acid crystals. Two main sites where uric acid crystal deposition causes problems include:
the musculoskeletal system (joints, bursae, tendons, ligaments), and

Most individuals who have had a few attacks of gout have high blood uric acid levels. But, interestingly, blood uric acid levels generally falls during acute attack of gout. However, people with a high percentage of uric acid crystals in their body are more prone to obesity, hypertension and many other heart problems. Such individuals must therefore be advised to restrict their dietary caloric intake and carry out regular aerobic workout exercises to keep their weight under control, get their blood pressure regularly checked and get it properly treated if it is high.

How is an attack triggered?

An acute attack may be set off by any of the following:
Excessive alcohol intake
Eating prohibited foods like meats
Any stress of illness or surgery
Medicines that are often given for making a person pass more urine (e.g., lasix) and anti-cancer drugs, ingestion of drugs that are often used to lower blood levels of uric acid (e.g., allopurinol).

How is it diagnosed?

Gout can be diagnosed by the symptoms and medical history. Classical symptoms of gout make diagnosis easier since it is the most probable diagnosis in a middle aged male, who has a recent history of heavy eating and drinking and who complains of painful joints. The history usually reveals a similar problem in the patient's other male relatives.

Blood tests may be performed to check for uric acid levels. The diagnosis may be confirmed by withdrawing a sample of the joint fluid using a small needle from the affected joint. This fluid is full of tiny uric acid crystals that look like small needles. It is useful to remember that a high level of uric acid in the blood does not necessarily mean gout, nor does a normal level exclude the possibility of gout.

What is the treatment?

Treatment of acute gouty attack requires immediate control of the acute joint symptoms followed by strategies to prevent future possible attacks, and joint and tissue damage due to the deposition of uric acid crystals in the long run. Acute attack is treated with the use of fast acting anti-inflammatory drugs. Commonly used drugs belong to the category of so-called non-steroidal anti-inflammatory drugs (NSAIDs). There are several of them like ibuprofen, diclofenac, naproxen, indomethacin . However, most of them have a major side-effect i.e. severe irritation of the gastrointestinal tract (stomach, duodenum and often small intestines as well).

In those patients who cannot take NSAIDs (due to allergy or GI disease), one of the best methods of the control of acute gouty attack is to inject depot-preparations of corticosteroids (e.g. triamcenalone acetonide ) in the joint itself.

After the acute attack subsides, the person must be investigated to find out if has any underlying disease (especially some renal disease) for uric acid crystal formation, he has a family history of gout, is ingesting some drugs etc. Then if no obvious underlying cause is found then the person is diagnosed as ‘primary gout’ and advised:

General positive health practices: dietary control of total caloric intake, with special precaution against items that cause increased production of uric acid in the body (red meat, wines, fermented food, sprouts of all varieties), regular fitness workouts especially aerobic exercises, control of cholesterol, high blood pressure. It is important to reduce weight very gradually as sudden weight loss can also precipitate an acute attack of gout.
Plenty of fluid intake on a regular basis.
Avoid all the drugs that can cause acute gouty attack or raise the blood uric acid levels (aspirin is one of them).
If these measures do not prevent further attacks of gout and blood uric acid remains persistently high, then, under careful guidance of the doctor, uric acid lowering drugs can be instituted. These include allopurinol, sulfinpyrazone, and probenecid. They may often precipitate an acute attack of gout when they are started. Therefore, it is necessary to take these drugs under the guidance of the doctor who may prescribe some additional drugs to prevent acute attack of gout during the initiation period with these drugs.