Gout

Attacks usually start at night, often in the big toe. Any contact is painful, where even the weight of bedclothes can cause pain. The symptoms develop over a few hours. The swelling can look like a boil and the skin may peel.

Other joints – the knee, the elbow or the wrist, for example – can also be affected by gout. This is more likely in older people. If several joints are inflamed at once this is called polyarticular gout.

Similar attacks can be caused by calcium crystals being deposited in joints. This type of crystal arthritis (termed pseudogout or pyrophosphate arthritis) affects the knee and other joints more than the big toe and is linked with osteoarthritis.

However, if the body is unable to remove urate effectively it builds up and may form crystals in the joints or under the skin.

There are several factors that can affect how well the body processes urate.

• An inherited (genetic) tendency may cause the kidneys to retain more urate than normal. 
• Kidney disease may mean that your kidneys are unable to process urate as well as they should.
• In blood disorders where the body produces too many blood cells, urate produced by the breakdown of those cells may be more than the kidneys can cope with (sometimes called secondary gout).
• Tablets such as diuretics, which drain water from the body, may increase urate to a level that the kidneys cannot handle effectively.
• Diabetes, heart disease and high blood pressure are associated with a raised level of urate, though the reasons for this aren’t fully understood.

Where a definite cause can be identified the condition may be described as secondary gout. However, gout is usually due to a combination of factors.

If you are prone to gout, several things can trigger an acute attack:

• a bruise or injury to a joint
• exhaustion or illness
• an operation or tooth extraction
• excessive eating and drinking of alcohol
• dehydration.

What are the long-term risks?

The first few attacks of gout do no permanent damage to the joints and you can expect a complete recovery. However, repeated attacks can damage the cartilage and bone and start off long-term (chronic) arthritis. With modern treatments and some changes to your diet damage can usually be prevented.

Gout is associated with high blood pressure, diabetes, heart disease, and having too much fat in the blood (hyperlipidaemia) so these factors must to be considered in all gout patients. Urate may form kidney stones if gout is left untreated, so tests may be needed to check how well the kidneys are working.

• A blood test to measure the amount of urate in the blood. A raised level of urate strongly supports a diagnosis of gout but can't confirm it. For one thing the urate level may be high in other conditions such as diabetes and heart disease, but it's also possible for urate levels in the blood to be normal at the time of an acute attack.
• X-rays of joints – X-rays are rarely helpful in confirming the diagnosis because they are usually normal in the early years of having gout. However, they will reveal joint damage in long-standing poorly-controlled gout.
• Examination of joint fluid – Synovial fluid can be taken from a joint through a needle and examined under a microscope, where any urate crystals can be clearly seen. This test can confirm the diagnosis but isn’t always practical. In particular it is difficult, and painful for the patient, to obtain fluid from a small joint such as the big toe.

Drug treatment for acute attacks of gout

Non-steroidal anti-inflammatory drugs (NSAIDs)

Acute attacks of gout are usually treated with non-steroidal anti-inflammatory drugs (NSAIDs). They relieve pain and reduce inflammation. Examples include naproxen, diclofenac and indometacin. Avoid aspirin – unless it is low-dose aspirin prescribed to protect against heart disease or similar conditions – as it can increase the level of urate in the blood.

NSAIDs are unlikely to cause serious side-effects when used for the short periods needed to treat an acute attack of gout, although there is a risk of indigestion. If you've had a stomach ulcer make sure you take the tablets with a meal or straight after eating.

Colchicine

Colchicine can be taken either until the pain is relieved or for a limited number of doses. Some people can’t take colchicine because of diarrhoea or nausea. As with NSAIDs, colchicine tablets should be taken at the very beginning of an attack, and your doctor may let you keep a supply so you can start taking them at the first signs of an attack. Colchicine can also be taken at a dose of 0.5 mg 1–3 times a day to suppress the tendency to gout attacks. Like NSAIDs, this will not reduce urate blood levels, so will not prevent long term joint damage.

Steroids

If an acute attack of gout doesn’t improve with NSAIDs or colchicine, or if you have side-effects from these drugs, your doctor may prescribe a steroid injection into the joint or a short course of steroid tablets (usually no more than a few days).

Ongoing treatments to reduce urate

The drugs given to relieve an acute attack don’t reduce the level of urate in the blood. If attacks become more frequent, or if blood tests show that urate is high, your doctor may prescribe one of the urate-lowering drugs to be taken every day.

You may still have acute attacks of gout when you first begin taking one of the urate-lowering drugs, so you’ll still need to take NSAIDs or colchicine to suppress gouty inflammation while your urate level is brought down. You’ll be at risk of acute attacks for at least three months and probably longer. It can take as long as two years to clear your body completely of urate crystals.

Urate-lowering drugs should be continued indefinitely – unless you have side-effects. Interruptions in dosage, especially in the early stages, cause fluctuation in the urate level, which seems to trigger acute attacks.

Can you take urate-lowering drugs over a long period?

The drugs in question are usually very safe. They sometimes have to be discontinued because of an adverse effect such as a rash or indigestion (dyspepsia), but usually this type of drug treatment can be taken indefinitely without side-effects. It is important to realize, however, that no drug can be said to be completely free from possible side-effects. This makes it all the more important to consider other ways of managing your health – by losing weight and changing your diet.

Allopurinol

Allopurinol is the most commonly used urate-lowering drug. It alters the chemical processes so that less urate is produced in the body. Allopurinol is usually taken once a day. Your doctor will probably start you off on a dose of 100 mg a day, and increase the dose gradually if necessary. You’ll probably have a repeat blood test after a month or so, to see whether your urate level has fallen sufficiently to reduce the risk of gout. Once the urate level is well within the normal range, you should continue on that dose of allopurinol. The commonest cause for ‘failure’ of allopurinol is the patient not taking the drug in the correct dose regularly.

The most common side-effect is a rash. If you do develop a rash soon after starting allopurinol, you should stop taking the tablets and see your doctor, who will advise whether you should re-start the tablets and what precautions you should take.

Allopurinol can affect some other tablets, especially warfarin and azathioprine. If you have to take either of these drugs for any reason, you must tell the doctor who prescribes it that you’re also taking allopurinol. The dose of the other drug may need to be adjusted.

Other urate-lowering drugs

Uricosuric drugs, which include probenecid, benzbromarone and sulfinpyrazone, work by flushing out more urate than normal through the kidneys. These drugs may not be suitable if you’ve had kidney stones or similar disorders. They’re not widely used in the UK, but may be a useful alternative if allopurinol isn’t suitable for you.

Febuxostat is another drug that looks promising for reducing urate levels, though it hasn’t so far been used in large numbers of patients. Other drugs for gout will be developed in due course.

Diet and nutrition

Losing weight, if you need to, is the most effective dietary treatment for gout because it can significantly reduce the urate levels in your body. This needs to be done sensibly – extreme weight loss or starvation diets increase cell breakdown in the body, which can raise urate levels.

We don't recommend Atkins-type diets for people who are prone to gout. Such diets are high in proteins and so contain a lot of purines, which break down to produce urate. Aim to reduce the amount of protein you obtain from meat and increase the amount you get from vegetable sources. Skimmed milk and yogurt are not high in purines, and urate levels are not affected by acidic foods like oranges or grapefruit.

Avoiding foods that are particularly high in purines may be helpful, whether or not you need to lose weight. These include:

• meat: kidneys, liver, offal
• fish: anchovies, fish roes, herring, mackerel, sardines
• other: beer or foods high in yeast extracts.

Oily fish such as herring, mackerel and sardines may be beneficial if you have heart disease and for some forms of arthritis. However, because they are high in purines large quantities of oily fish are not recommended for gout.

Read more general advice on diet, nutrition and nutritional supplements.

Alcohol

Excessive alcohol consumption is associated with gout, and beer is more likely than wines to lead to gout. Keep your alcohol intake well below the levels recommended by the government: 3–4 units a day for men and 2–3 units a day for women. Remember that units are calculated from the strength of the drink as well as the quantity. (See Table 1 for approximate units of alcohol in some popular drinks.) It’s a good idea to have at least two alcohol-free days a week – but without compensating over the remaining five days.

Table 1. Approximate units of alcohol in some popular drinks

NOTE: These figures are based on typical strengths for the drinks shown; actual strengths vary from one brand to another. Bear in mind also that ‘measures’ poured at home are often much larger than the standard pub measures shown.

Fluids

Drinking plenty of water reduces the risk of urate crystallizing in the joints. If you have kidney stones you may need as much as 3.5 litres (6 pints) a day. If you don’t have kidney stones you may not need to drink quite so much, but aim for at least 1 litre (2 pints) of fluid a day. You can include some other fluids besides water in this total, but not beer or other alcoholic drinks. Basically, all patients with gout, no matter what gout drugs they’re taking, should similarly increase their water intake.

Many soft drinks contain large amounts of sugar, in the form of fructose. Keep these to a minimum as fructose sugar is likely to increase the level of urate in the blood. Diet soft drinks are probably a reasonable substitute. Large quantities of strong tea or coffee are also unwise, as they can dehydrate you and may contain purines, which are converted into urate.

Complementary therapies

Cherries seem to be beneficial – either the fruit or the juice, fresh or preserved. However, there’s little evidence for many of the other natural or herbal remedies available for gout. These include celery seeds, garlic, artichokes, and saponins (natural compounds found in peas, beans and some other vegetables).

Protecting the joint

A painful joint may have to be protected during an attack of gout. A cage over it taking the weight of the bedclothes can help.

Ice packs can help to soothe the painful joint – but remember to protect the skin from direct contact with the ice.