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Gout

Read in Hindi

Dr Samarth Desai
Orthopedist

verified

Miss Anjali (name changed) went to a coastal area for a family vacation for a week. As coastal areas are famous for their non-vegetarian food, especially seafood such as crabs, prawns, and oysters, they had a wonderful time eating these delicacies every day (almost at every meal). However, on the last day, Anjali experienced stiffness in her fingers along with pain in her joints. The condition was so severe that she could not hold her bag/bottle. When she finally arrived at her place, she visited her doctor only to know that she was suffering from gout.

Gout is a type of rheumatic disease caused by the high levels of uric acid in the blood. However, not everybody with increased blood levels of uric acid gets gout. It occurs when uric acid levels in the blood are extremely high, which in turn leads to the deposition of hard crystals in the joints. Gout is also known as inflammatory arthritis and causes sudden and severe episodes of pain and swelling in the joints.

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Stages

Gout is a common form of inflammatory arthritis, particularly in men. It may remit for long time periods, followed by flare-ups for days to weeks or can become chronic. Gout is classified into four different stages:

Asymptomatic stage – In this stage, there is the deposition of uric acid crystals in the tissue; however, people do not show any symptoms. This indicates that hyperuricemia is causing the damage.

Acute stage – This is the second stage in which people suffering from gout experience acute flares. It is characterized by mild or excruciating pain, redness, swelling and warmth in the affected area.

Interval stage – It is the stage between two subsequent attacks of gout. Although you may not experience pain, it does not signify that the condition is treated. In fact, this is the right time to manage your condition with medications and lifestyle changes to prevent future attacks.

Chronic stage – If your uric acid levels in blood remain high for a long time period, it signifies chronic gout. The symptoms become more frequent with severe and sudden pain (which usually lasts for few days or weeks). In rare cases, joint damage can lead to loss of mobility. You can prevent this condition with proper treatment and effective management.

Symptoms

Gout is detected once you experience the first attack; however, there are few signs that can help you to identify the condition in its initial stage:



  • Peeling of skin

  • Tophi

  • Fever


Moreover, gout is characterized by a sudden attack of burning pain, stiffness and swelling in the joints. In addition to big toes, it can attack the ankles, heels, knees, fingers, elbows and wrists. Here are six warning signs to differentiate arthritis from usual joint pain.

Causes And Risk Factors

Uric acid is a by-product of protein metabolism, which is excreted from the body through urine. However, in certain cases, there is an imbalance in the excretion and production of uric acid in the body – a condition known as hyperuricemia. This in turn leads to the deposition of urate crystals in the tissue and between the joints because of--


  • Overproduction of uric acid or

  • Decreased excretion by the kidneys or

  • Both


Here are certain common causes for elevated uric acid levels.

Risk Factors

There are several factors that place you at risk of suffering from gout:

Gender: Gout is common in men as compared to women (till they reach menopause). It is believed that oestrogen hormone protects women from gout.

Age: There is a high risk of getting gout if you are above 60 years. This is attributed to various functional changes that occur with age.

Genes: If you have a family history of gout, the chances of you suffering from this disease is comparatively high.

Overweight: In case you are overweight or obese, you are more likely to suffer from gout because of the excess production of uric acid in the body.

Medications: Medications such as diuretics or those taken by people suffering from rheumatoid arthritis and psoriasis or patients who underwent a transplant, increase your uric acid levels, thereby elevating your risk of gout.

Purine-rich foods: Eating considerable amount of meat and fish that are high in chemicals called purines increases your chances of getting gout.

Artificial fruit juices and soft drinks: They contain artificial sweeteners and citric acid, which in turn places you at risk of gout. They not only increase your uric acid levels but also worsen symptoms.

Certain diseases: If you are suffering from hypertension, diabetes, heart disease or kidney diseases, your chances of developing gout are quite high.

Excessive drinking: Although alcohol has multiple side-effects, one more reason to cut down your intake of alcohol is that it places you at risk of gout.

Other medical conditions - Various medical conditions can cause an increased urate acid level, which may mimic gout: type 2 diabetes, osteoarthritis, high blood pressure, high cholesterol and fat levels in the blood, and chronic kidney disease.

Prevention

To lead a healthy life with gout, here is what you should remember.


  • Avoid eating foods that are rich in purines such as meat and fish

  • Lower your intake of alcohol

  • Eat foods that are low in fat content

  • Follow your doctor’s instructions

  • Take medications regularly

  • Include cherries in your diet (as it can lower the risk of gout attacks)

  • Individuals with gout should avoid dehydration. So, increase water intake to maintain optimal kidney function.

  • Increase in weight causes an increase in uric acid, which adds more strain on the joints. Therefore, regular exercise is essential to maintain optimal weight.

  • Avoid medications that increase urine output and medicines that suppress your immune system.

Diagnosis

Diagnosis of gout is based on the symptoms that you experience. Your doctor might enquire about family history and medical background. Depending on the symptoms, you might be recommended a blood test to detect the presence of uric acid crystals in the synovial fluid. A high level of uric acid level in the blood does not necessarily indicate gout; thus, tests to exclude other potential causes of inflammation might be recommended. These include –

X-ray, ultrasound, and MRI – This is used to detect inflammation of soft tissue and bone. Here is everything you should know about MRI.

Microscopic analysis – It involves the examination of fluid from the affected joint for uric acid crystals under a microscope. Positive results indicate gout.

Here are seven diagnostic tests to identify if your joint pain is caused by arthritis.

Treatment

Medications form the first line of treatment to deal with gout. If the symptoms are present for many years, it leads to the formation of tophi (chalky substances); surgical intervention might be required. The common medications that are prescribed are listed below:

NSAIDs (Non-steroidal anti-inflammatory drugs): These drugs are used to treat acute attacks and prevent you from future attacks of gout. Pain and swelling can be reduced with NSAIDs. Certain examples of NSAIDs are ibuprofen, naproxen sodium, indomethacin, and celecoxib.

Steroids: If you cannot take either NSAIDs or pain relievers, your doctor might recommend corticosteroids to ease your pain and inflammation. These are available in the pill form and in the form of an injection.

Moreover, your doctor might recommend medications that lower your risk of future attacks and/complications associated with this condition. These include

Medications for individuals who produce increased amounts of uric acid - These medicines, e.g. allopurinol and febuxostat, help in reducing the amount of uric acid produced by individuals.

Medications to help in eliminating excess uric acid - These medications, e.g. probenecid and pegloticase, are used in individuals who have difficulty in eliminating excess uric acid. They help in removing the excess uric acid via the urine.. Here is how you can naturally reduce uric acid levels.

 

In case an individual gets an attack of gout at home, certain points should be remembered.


  • Cool the affected area - This cooling can be performed with a bag of frozen peas wrapped in a towel if an ice pack is not available. This helps in pain and swelling reduction.

  • Rest - The joints that are involved should be rested to reduce the pain.


Bed cage - This is a cage-like structure that supports the bedsheets and keeps them off the feet, particularly toe joints. This helps in resting the joints affected by minimizing the stress of the sheets on them.

Lifestyle/management

Managing one’s lifestyle can prevent flare-ups and attacks of gout. The following can be adopted as lifestyle modifications.


  • Exercise - It helps maintain optimum weight, which reduces stress on the joints. Moreover, it helps in overall health and well-being. 

  • Diet - A healthy diet high in fibre and vegetables and low in added sugars and fats should be consumed. Avoid fad diets as this can cause excess cell breakdown, which can result in increased urate levels. Foods that can be consumed in moderation are red meat, seafood, predominantly oily fish and shellfish and processed foods and drinks.

  • Fluids - Increase water intake to ~2 l per day in case of kidney stones. Avoid sweet soft drinks as the high sugar content can predispose you to gout. Limit alcohol intake to only wine. This should be consumed not more than 14 units a week, which equates to six glasses of wine per week.

Prognosis And Complications

Prognosis


  • If prompt treatment is received, individuals can progress on to live normal, productive lives. For individuals who present with symptoms at a younger age and have a more severe form of the disease. For individuals who do not carry out lifestyle modifications, flare-ups occur recurrently and frequently.


Complications

Certain common health complications caused because of gout are as follows:

Joint damage – Some people might experience symptoms of gout quite frequently and thus require proper medical treatment. If left untreated, such recurrent attacks of gout can cause joint damage because of the constant erosion of joints and inflammation.

Tophi – If you are suffering from gout for a year or your condition is not treated, uric acid crystals tend to deposit, leading to the formation of tophi (clustered granules of urate). They can develop under the skin or in the joints of your hands, elbow or ankles. Although they are not painful, they become swollen.

Kidney stones – There are high chances that urinate crystals might get collected in the urinary tract, leading to the formation of kidney stones. Hence, you require to take medications to treat gout and lower your risk of kidney stones.

Increased possibility of getting cancer, particularly prostate cancer

Constriction and narrowing of the arteries - This can cause heart issues such as heart attack or even stroke.

Thyroid issues such as an underactive thyroid.

Sexual problems - In men, erectile dysfunction may be observed.

Alternative Treatments

Here are certain remedies that may ease pain and swelling, common in gout patients


  • Cherries - Studies revealed that intake of cherries can decrease the chances of getting a gout attack. 

  • Apple cider vinegar - The acidity in this vinegar helps in reducing the pain associated with gout.

  • Banana - They are a rich source of potassium, which is essential in preventing uric acid crystals.

  • Ginger - Because of its anti-inflammatory properties, ginger helps in reducing pain associated with inflamed joints.

  • Vitamin C - Studies revealed that including vitamin C rich foods such as citrus fruits, strawberries and broccoli in one’s diet can help in the reduction of uric acid levels. However, remember that vitamin C might interfere with other drugs. Therefore, it is imperative to consult a physician before starting with vitamin C supplements. 

  • Low-fat yoghurt and skimmed milk – The incorporation of low-fat yoghurt and skimmed milk in one’s diet been proven to reduce gout-related attacks.

References


  1. Gout. Versus Arthritis. Available at: https://www.versusarthritis.org/about-arthritis/conditions/gout/. (https://www.versusarthritis.org/about-arthritis/conditions/gout/)

  2. Treatment for Gout. American Kidney Fund. Available at: https://www.kidneyfund.org/kidney-disease/chronic-kidney-disease-ckd/complications/gout/treatments-for-gout/.  (https://www.kidneyfund.org/kidney-disease/chronic-kidney-disease-ckd/complications/gout/treatments-for-gout/.)

  3. Gout. NCBI. Available at: https://www.ncbi.nlm.nih.gov/books/NBK546606/. (https://www.ncbi.nlm.nih.gov/books/NBK546606/)

  4. 8 Gout Home Remedies. Kidney Atlas. Available at: https://www.kidneyatlas.org/gout-home-remedies/.. (https://www.kidneyatlas.org/gout-home-remedies/)

  5. Feig DI, et al. New England Journal of Medicine. 2008;359(17):1811–1821.

  6. Hsu C, et al. European Journal of Internal Medicine. 2015;26(9):691-5.

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