Gout

From Wikipedia, the free encyclopedia

"Podagra" redirects here. For the moth genus, see Podagra (moth).
Gout

The Gout (James Gillray, 1799) depicts the pain of the artist's gout as
a demon ordragon.[1][2]
Classification and external resources
ICD-10

M10

ICD-9

274.00 274.1 274.8 274.9

OMIM

138900 300323

DiseasesDB

29031

MedlinePlus 000422
eMedicine

emerg/221 med/924med/1112 oph/506orthoped/124 radio/313

Patient UK

Gout

MeSH

D006073

Gout (also known as podagra when it involves the big toe)[3] is a medical condition usually characterized by
recurrent attacks of acute inflammatory arthritisa red, tender, hot, swollen joint. The metatarsal-phalangeal
joint at the base of the big toe is the most commonly affected (approximately 50% of cases). It may
also present as tophi, kidney stones, or urate nephropathy. It is caused by elevated levels of uric acid in
the blood. The uric acid crystallizes, and the crystals deposit in joints, tendons, and surrounding tissues.
Clinical diagnosis may be confirmed by seeing the characteristic crystals in joint fluid. Treatment
with nonsteroidal anti-inflammatory drugs (NSAIDs),steroids, or colchicine improves symptoms. Once the
acute attack subsides, levels of uric acid are usually lowered via lifestyle changes, and in those with frequent
attacks, allopurinol or probenecid provides long-term prevention.
Gout has become more common in recent decades, affecting about 12% of the Western population at some
point in their lives. The increase is believed to be due to increasing risk factors in the population, such
as metabolic syndrome, longer life expectancy, and changes in diet. Gout was historically known as "the
disease of kings" or "rich man's disease."

Signs and symptoms

Gout presenting in the metatarsal-phalangeal joint of the big toe: Note the slight redness of the skin overlying
the joint.
Gout can present in a number of ways, although the most usual is a recurrent attack of acute inflammatory
arthritis (a red, tender, hot, swollen joint).[4] The metatarsal-phalangeal joint at the base of the big toe is
affected most often, accounting for half of cases.[5] Other joints, such as the heels, knees, wrists, and fingers,
may also be affected.[5] Joint pain usually begins over 24 hours and during the night.[5] The reason for onset at
night is due to the lower body temperature then.[3] Other symptoms may rarely occur along with the joint pain,
including fatigue and a highfever.[3][5]
Long-standing elevated uric acid levels (hyperuricemia) may result in other symptomatology, including hard,
painless deposits of uric acid crystals known astophi. Extensive tophi may lead to chronic arthritis due to bone
erosion.[6] Elevated levels of uric acid may also lead to crystals precipitating in the kidneys, resulting
instone formation and subsequent urate nephropathy.[7]
Cause
The crystallization of uric acid, often related to relatively high levels in the blood, is the underlying cause of
gout. This can occur for a number of reasons, including diet, genetic predisposition, or underexcretion of urate,
the salts of uric acid.[4]Underexcretion of uric acid by the kidney is the primary cause of hyperuricemia in about
90% of cases, while overproduction is the cause in less than 10%.[8] About 10% of people
with hyperuricemia develop gout at some point in their lifetimes.[9] The risk, however, varies depending on the
degree of hyperuricemia. When levels are between 415 and 530 mol/l (7 and 8.9 mg/dl), the risk is 0.5% per
year, while in those with a level greater than 535 mol/l (9 mg/dL), the risk is 4.5% per year.[3]
Lifestyle
Dietary causes account for about 12% of gout,[4] and include a strong association with the consumption of
alcohol, fructose-sweetened drinks, meat, and seafood.[6][10] Other triggers include physical trauma and surgery.
[8]
Studies in the early 2000s have found that other dietary factors once believed associated are, in fact, not,
including the intake of purine-rich vegetables (e.g., beans, peas, lentils, and spinach) and total protein.[11]
[12]
With respect to risks related to alcohol, beer and spirits appear to have a greater risk than wine. [13]
The consumption of coffee, vitamin C, and dairy products, as well as physical fitness, appear to decrease the
risk.[14][15][16]This is believed partly due to their effect in reducing insulin resistance.[16]
Genetics
The occurrence of gout is partly genetic, contributing to about 60% of variability in uric acid level.
[8]
Three genes calledSLC2A9, SLC22A12, and ABCG2 have been found commonly to be associated with
gout, and variations in them can approximately double the risk.[17][18] Loss-of-function
mutations in SLC2A9 and SLC22A12 cause hereditary hypouricaemia by reducing urate absorption and
unopposed urate secretion.[18] A few rare genetic disorders, including familial juvenile hyperuricemic
nephropathy, medullary cystic kidney disease, phosphoribosylpyrophosphate synthetase superactivity,
andhypoxanthine-guanine phosphoribosyltransferase deficiency as seen in Lesch-Nyhan syndrome, are
complicated by gout.[8]
Medical conditions
Gout frequently occurs in combination with other medical problems. Metabolic syndrome, a combination
of abdominal obesity, hypertension, insulin resistance, and abnormal lipid levels, occurs in nearly 75% of
cases.[5] Other conditions commonly complicated by gout include: polycythemia, lead poisoning, renal
failure, hemolytic anemia, psoriasis, and solid organ transplants.[8][19] A body mass index greater than or equal
to 35 increases a male's risk of gout threefold.[12] Chronic lead exposure and lead-contaminated alcohol are

risk factors for gout due to the harmful effect of lead on kidney function.[20] Lesch-Nyhan syndrome is often
associated with gouty arthritis.
Medication
Diuretics have been associated with attacks of gout. However, a low dose of hydrochlorothiazide does not
seem to increase the risk.[21] Other medicines that increase the risk include niacin and aspirin (acetylsalicylic
acid).[6] The immunosuppressive drugs ciclosporin and tacrolimus are also associated with gout,[8] the former
more so when used in combination with hydrochlorothiazide.[22]
Pathophysiology

Uric acid
Gout is a disorder of purine metabolism,[8] and occurs when its final metabolite, uric acid, crystallizes in the
form of monosodium urate, precipitating and forming deposits (tophi) in joints, on tendons, and in the
surrounding tissues.[6] Microscopic tophi may be walled off by a ring of proteins, which blocks interaction of the
crystals with cells, and therefore avoids inflammation.[23] Naked crystals may break out of walled-off tophi due
to minor physical trauma to the joint, medical or surgical stress, or rapid changes in uric acid levels. [23] When
they breach the tophi, they trigger a localimmune-mediated inflammatory reaction,[23][6] with one of the key
proteins in the inflammatory cascade being interleukin 1.[8] An evolutionary loss of urate oxidase(uricase),
which breaks down uric acid, in humans and higher primates has made this condition common.[8]
The triggers for precipitation of uric acid are not well understood. While it may crystallize at normal levels, it is
more likely to do so as levels increase.[6][24] Other factors believed important in triggering an acute episode of
arthritis include cool temperatures, rapid changes in uric acid levels, acidosis,[25][26] articular hydration,
and extracellular matrix proteins, such asproteoglycans, collagens, and chondroitin sulfate.[8] The increased
precipitation at low temperatures partly explains why the joints in the feet are most commonly affected.[4] Rapid
changes in uric acid may occur due to a number of factors, including trauma, surgery, chemotherapy, diuretics,
and stopping or starting allopurinol.[3] Calcium channel blockers and losartan are associated with a lower risk of
gout compared to other medications for hypertension.[27]
Diagnosis

Gout on X-rays of a left foot. The typical location is the big toe joint. Note also the soft tissue swelling at the
lateral border of the foot.

Spiked rods of uric acid crystals from a synovial fluid sample photographed under a microscope withpolarized
light. Formation of uric acid crystals in the joints is associated with gout.
Gout may be diagnosed and treated without further investigations in someone with hyperuricemia and the
classic podagra. Synovial fluid analysis should be done, however, if the diagnosis is in doubt.[3] X-rays, while
useful for identifying chronic gout, have little utility in acute attacks.[8]
Synovial fluid
A definitive diagnosis of gout is based upon the identification of monosodium urate crystals in synovial fluid or
a tophus.[5] All synovial fluid samples obtained from undiagnosed inflamed joints should be examined for these
crystals.[8] Underpolarized light microscopy, they have a needle-like morphology and strong
negativebirefringence. This test is difficult to perform, and often requires a trained observer.[28] The fluid must
also be examined relatively quickly after aspiration, as temperature and pH affect their solubility.[8]
Blood tests
Hyperuricemia is a classic feature of gout, but it occurs nearly half of the time without hyperuricemia, and most
people with raised uric acid levels never develop gout.[5][29]Thus, the diagnostic utility of measuring uric acid
level is limited.[5] Hyperuricemia is defined as a plasma urate level greater than 420 mol/l (7.0 mg/dl) in males
and 360 mol/l (6.0 mg/dl) in females.[30] Other blood tests commonly performed are white blood cell
count, electrolytes, renal function, and erythrocyte sedimentation rate(ESR). However, both the white blood
cells and ESR may be elevated due to gout in the absence of infection.[31][32] A white blood cell count as high as
40.0109/l (40,000/mm3) has been documented.[3]
Differential diagnosis
The most important differential diagnosis in gout is septic arthritis.[5][8] This should be considered in those with
signs of infection or those who do not improve with treatment.[5] To help with diagnosis, a synovial fluid Gram
stain and culture may be performed.[5] Other conditions that look similar include pseudogout and rheumatoid
arthritis.[5] Gouty tophi, in particular when not located in a joint, can be mistaken for basal cell carcinoma,[33] or
otherneoplasms.[34]
Prevention
Both lifestyle changes and medications can decrease uric acid levels. Dietary and lifestyle choices that are
effective include reducing intake of food such as meat and seafood, consuming adequate vitamin C,
limiting alcohol and fructoseconsumption, and avoiding obesity.[4] A low-calorie diet in obese men decreased
uric acid levels by 100 mol/l (1.7 mg/dl).[21] Vitamin C intake of 1,500 mg per day decreases the risk of gout by
45%.[35] Coffee, but not tea, consumption is associated with a lower risk of gout.[36] Gout may be secondary
to sleep apnea via the release of purines from oxygen-starved cells. Treatment of apnea can lessen the
occurrence of attacks.[37]
Treatment
The initial aim of treatment is to settle the symptoms of an acute attack.[38] Repeated attacks can be prevented
by different drugs used to reduce the serum uric acid levels.[38] Ice applied for 20 to 30 minutes several times a
day decreases pain.[4][39] Options for acute treatment include nonsteroidal anti-inflammatory
drugs (NSAIDs), colchicine, and steroids,[4]while options for prevention include allopurinol, febuxostat,
and probenecid. Lowering uric acid levels can cure the disease.[8] Treatment of associated health problems is
also important.[8] It is unclear if dietary supplements have an effect in people with gout.[40]
NSAIDs
NSAIDs are the usual first-line treatment for gout, and no specific agent is significantly more or less effective
than any other.[4] Improvement may be seen within four hours, and treatment is recommended for one to two

weeks.[4][8] They are not recommended, however, in those with certain other health problems, such
as gastrointestinal bleeding, renal failure, or heart failure.[41] While indomethacin has historically been the most
commonly used NSAID, an alternative, such as ibuprofen, may be preferred due to its better side effect profile
in the absence of superior effectiveness.[21] For those at risk of gastric side effects from NSAIDs, an
additional proton pump inhibitor may be given.[42]
Colchicine
Colchicine is an alternative for those unable to tolerate NSAIDs.[4] At high doses, side effects (primarily
gastrointestinal upset) limit its usage.[43] At lower doses, which are still effective, it is well tolerated.[21]
[44]
Colchicine may interact with other commonly prescribed drugs, such as atorvastatin and erythromycin,
among others.[43]
Steroids
Glucocorticoids have been found as effective as NSAIDs[45][46] and may be used if contraindications exist for
NSAIDs.[4] They also lead to improvement when injected into the joint; a joint infection must be excluded,
however, as steroids worsens this condition.[4]
Pegloticase
Pegloticase was approved in the USA to treat gout in 2010.[47] It is an option for the 3% of people who are
intolerant to other medications.[47] Pegloticase is administered as an intravenous infusion every two weeks,
[47]
and has been found to reduce uric acid levels in this population.[48] It is likely useful for tophi but has a high
rate of side effects.[49]
Prophylaxis
A number of medications are useful for preventing further episodes of gout, including xanthine oxidase
inhibitor (includingallopurinol and febuxostat) and uricosurics (including probenecid and sulfinpyrazone). They
are not usually started until one to two weeks after an acute flare has resolved, due to theoretical concerns of
worsening the attack,[4] and are often used in combination with either an NSAID or colchicine for the first three
to six months.[8] They are not recommended until a person has had two attacks of gout,[4] unless destructive
joint changes, tophi, or urate nephropathy exist,[7] as medications have not been found cost-effective until this
point.[4] Urate-lowering measures should be increased until serum uric acid levels are below 300360 mol/l
(5.06.0 mg/dl), and are continued indefinitely.[4][8] If these medications are being used chronically at the time of
an attack, discontinuation is recommended.[5] If levels cannot be brought below 6.0 mg/dl and there are
recurrent attacks, this is deemed treatment failure or refractory gout.[50] Overall, probenecid appears less
effective than allopurinol.[4]
Uricosuric medications are typically preferred if undersecretion of uric acid, as indicated by a 24-hour collection
of urine results in a uric acid amount of less than 800 mg, is found.[51] They are, however, not recommended if
a person has a history of kidney stones.[51] In a 24-hour urine excretion of more than 800 mg, which indicates
overproduction, a xanthine oxidase inhibitor is preferred.[51]
Xanthine oxidase inhibitors (including allopurinol and febuxostat) block uric acid production, and long-term
therapy is safe and well tolerated, and can be used in people with renal impairment or urate stones, although
allopurinol has causedhypersensitivity in a small number of individuals.[4] In such cases, the alternative drug,
febuxostat, has been recommended.[52]
Prognosis
Without treatment, an acute attack of gout usually resolves in five to seven days; however, 60% of people have
a second attack within one year.[3] Those with gout are at increased risk of hypertension, diabetes
mellitus, metabolic syndrome, and renal and cardiovascular disease, and thus are at increased risk of death.[8]
[53]
This may be partly due to its association withinsulin resistance and obesity, but some of the increased risk
appears to be independent.[53]
Without treatment, episodes of acute gout may develop into chronic gout with destruction of joint surfaces, joint
deformity, and painless tophi.[8] These tophi occur in 30% of those who are untreated for five years, often in
the helix of the ear, over the olecranon processes, or on the Achilles tendons.[8] With aggressive treatment,
they may dissolve. Kidney stones also frequently complicate gout, affecting between 10 and 40% of people,
and occur due to low urine pH promoting the precipitation of uric acid.[8] Other forms of chronic renal
dysfunction may occur.[8]

Nodules of the finger and helix of the ear representing gouty tophi

Tophus of the knee

Tophus of the toe, and over the external malleolus

Gout complicated by ruptured tophi (exudate tested positive for uric acid crystals)
Epidemiology
Gout affects around 12% of the Western population at some point in their lifetimes, and is becoming more
common.[4][8]Rates of gout have approximately doubled between 1990 and 2010.[6] This rise is believed due to
increasing life expectancy, changes in diet, and an increase in diseases associated with gout, such as
metabolic syndrome and high blood pressure.[12]A number of factors have been found to influence rates of
gout, including age, race, and the season of the year. In men over the age of 30 and women over the age of
50, prevalence is 2%.[41]
In the United States, gout is twice as likely in African American males as it is in European Americans. [54] Rates
are high among the peoples of the Pacific Islands and the Mori of New Zealand, but rare in Australian
aborigines, despite a higher mean concentration of serum uric acid in the latter group.[55] It has become
common in China, Polynesia, and urban sub-Saharan Africa.[8] Some studies have found attacks of gout occur
more frequently in the spring. This has been attributed to seasonal changes in diet, alcohol consumption,
physical activity, and temperature.[56]
History

Antonie van Leeuwenhoekdescribed the microscopic appearance of uric acid crystals in 1679.[57]
The word "gout" was initially used by Randolphus of Bocking, around 1200 AD. It is derived from
the Latin word gutta, meaning "a drop" (of liquid).[57] According to the Oxford English Dictionary, this is derived
from humorism and "the notion of the 'dropping' of a morbid material from the blood in and around the joints".[58]
Gout has, however, been known since antiquity. Historically, it has been referred to as "the king of diseases
and the disease of kings"[8][59] or "rich man's disease".[60]The first documentation of the disease is from Egypt in
2,600 BC in a description of arthritis of the big toe. The Greek physician Hippocrates around 400 BC
commented on it in his Aphorisms, noting its absence in eunuchs and premenopausalwomen.[57][61] Aulus
Cornelius Celsus (30 AD) described the linkage with alcohol, later onset in women, and associated kidney
problems:
Again thick urine, the sediment from which is white, indicates that pain and disease are to be apprehended in
the region of joints or viscera... Joint troubles in the hands and feet are very frequent and persistent, such as
occur in cases of podagra and cheiragra. These seldom attack eunuchs or boys before coition with a woman,
or women except those in whom the menses have become suppressed... some have obtained lifelong security
by refraining from wine, mead and venery.[62]
In 1683, Thomas Sydenham, an English physician, described its occurrence in the early hours of the morning,
and its predilection for older males:
Gouty patients are, generally, either old men, or men who have so worn themselves out in youth as to have
brought on a premature old ageof such dissolute habits none being more common than the premature and
excessive indulgence in venery, and the like exhausting passions. The victim goes to bed and sleeps in good
health. About two o'clock in the morning he is awakened by a severe pain in the great toe; more rarely in the
heel, ankle or instep. The pain is like that of a dislocation, and yet parts feel as if cold water were poured over
them. Then follows chills and shivers, and a little fever... The night is passed in torture, sleeplessness, turning
the part affected, and perpetual change of posture; the tossing about of body being as incessant as the pain of
the tortured joint, and being worse as the fit comes on.[63]
The Dutch scientist Antonie van Leeuwenhoek first described the microscopic appearance of urate crystals in
1679.[57] In 1848, English physician Alfred Baring Garrod realized this excess uric acid in the blood was the
cause of gout.[64]
Other animals
Gout is rare in most other animals due to their ability to produce uricase, which breaks down uric acid.
[65]
Humans and othergreat apes do not have this ability, thus gout is common.[3][65] Other animals with uricase
include fish, amphibians, and most non primate mammals.[66] The Tyrannosaurus rex specimen known as
"Sue", however, is believed to have suffered from gout.[67]
Research
A number of new medications are under study for treating gout, including anakinra, canakinumab,
and rilonacept.[68]Canakinumab may result in better outcomes than a low dose of a steroid but costs five
thousand times more.[69] Arecombinant uricase enzyme (rasburicase) is available; its use, however, is limited,
as it triggers an autoimmune response. Less antigenic versions are in development.[3]
Questions and Answers about Gout

This booklet contains general information about gout. It describes what gout is and how it develops. It also
explains how gout is diagnosed and treated. At the end is a list of key words to help you understand the terms
used in this booklet. If you have further questions after reading this booklet, you may wish to discuss them with
your doctor.
What Is Gout?
Gout is a painful condition that occurs when the bodily waste product uric acid is deposited as needle-like
crystals in the joints and/or soft tissues. In the joints, these uric acid crystals cause inflammatory arthritis,
which in turn leads to intermittent swelling, redness, heat, pain, and stiffness in the joints.
In many people, gout initially affects the joints of the big toe (a condition called podagra). But many other joints
and areas around the joints can be affected in addition to or instead of the big toe. These include the insteps,
ankles, heels, knees, wrists, fingers, and elbows. Chalky deposits of uric acid, also known as tophi, can appear
as lumps under the skin that surrounds the joints and covers the rim of the ear. Uric acid crystals can also
collect in the kidneys and cause kidney stones.
Information Boxes
What Is Uric Acid?
Uric acid is a substance that results from the breakdown of purines. A normal part of all human tissue, purines
are found in many foods. Normally, uric acid is dissolved in the blood and passed through the kidneys into the
urine, where it is eliminated.
If there is an increase in the production of uric acid or if the kidneys do not eliminate enough uric acid from the
body, levels of it build up in the blood (a condition called hyperuricemia). Hyperuricemia also may result when
a person eats too many high-purine foods, such as liver, dried beans and peas, anchovies, and gravies.
Hyperuricemia is not a disease, and by itself it is not dangerous. However, if excess uric acid crystals form as a
result of hyperuricemia, gout can develop. The crystals form and accumulate in the joint, causing inflammation.
What Are the Four Stages of Gout?
Gout can progress through four stages:
1. Asymptomatic (without symptoms) hyperuricemia. In this stage, a person has elevated levels of
uric acid in the blood (hyperuricemia), but no other symptoms. Treatment is usually not required.
2. Acute gout, or acute gouty arthritis. In this stage, hyperuricemia has caused the deposit of uric acid
crystals in joint spaces. This leads to a sudden onset of intense pain and swelling in the joints, which
also may be warm and very tender. An acute attack commonly occurs at night and can be triggered by
stressful events, alcohol or drugs, or the presence of another illness. Attacks usually subside within 3 to
10 days, even without treatment, and the next attack may not occur for months or even years. Over
time, however, attacks can last longer and occur more frequently.
3. Interval or intercritical gout. This is the period between acute attacks. In this stage, a person does
not have any symptoms.
4. Chronic tophaceous gout. This is the most disabling stage of gout. It usually develops over a long
period, such as 10 years. In this stage, the disease may have caused permanent damage to the
affected joints and sometimes to the kidneys. With proper treatment, most people with gout do not
progress to this advanced stage.
When Its Not Gout, It May Be Pseudogout
Gout is sometimes confused with other forms of arthritis because the symptomsacute and episodic attacks
of joint warmth, pain, swelling, and stiffnesscan be similar. One form of arthritis often confused with gout is
called pseudogout. The pain, swelling, and redness of pseudogout can also come on suddenly and may be
severe, closely resembling the symptoms of gout. However, the crystals that irritate the joint are calcium
phosphate crystals, not uric acid. Therefore, pseudogout is treated somewhat differently and is not reviewed in
this booklet.
What Causes Gout?
A number of risk factors are associated with hyperuricemia and gout. They include:

Genetics. Many people with gout have a family history of the disease. Estimates range from 20 to 80
percent.

Gender and age. It is more common in men than in women and more common in adults than in
children.

Weight. Being overweight increases the risk of developing hyperuricemia and gout because there is
more tissue available for turnover or breakdown, which leads to excess uric acid production.

Alcohol consumption. Drinking too much alcohol can lead to hyperuricemia, because alcohol
interferes with the removal of uric acid from the body.

Diet. Eating too many foods that are rich in purines can cause or aggravate gout in some people.

Lead exposure. In some cases, exposure to lead in the environment can cause gout.

Other health problems. Renal insufficiency, or the inability of the kidneys to eliminate waste products,
is a common cause of gout in older people. Other medical problems that contribute to high blood levels of uric
acid include:
o

high blood pressure

hypothyroidism (underactive thyroid gland)

conditions that cause an excessively rapid turnover of cells, such as psoriasis, hemolytic anemia, or some
cancers
o

Kelley-Seegmiller syndrome or Lesch-Nyhan syndrome, two rare conditions in which the enzyme that helps
control uric acid levels either is not present or is found in insufficient quantities.
o

Medications. A number of medications may put people at risk for developing hyperuricemia and gout. They
include:
Diuretics, which are taken to eliminate excess fluid from the body in conditions like hypertension, edema,
and heart disease, and which decrease the amount of uric acid passed in the urine
o
o

Salicylate-containing drugs, such as aspirin

Niacin, a vitamin also known as nicotinic acid

Cyclosporine, a medication that suppresses the bodys immune system (the system that protects the body
from infection and disease). This medication is used in the treatment of some autoimmune diseases, and to
prevent the bodys rejection of transplanted organs.
o

Levodopa, a medicine used to support communication along nerve pathways in the treatment of
Parkinsons disease.
o

Who Is Likely to Develop Gout?

Scientists estimate that 6 million adults age 20 and older report having had gout at some time in their lives.1 It
is rare in children and young adults. Men, particularly those between the ages of 40 and 50, are more likely to
develop gout than women, who rarely develop the disorder before menopause. People who have had an organ
transplant are more susceptible to gout.
1

According to the National Arthritis Data Workgroup, this estimate is based on self-reports, which may produce
an overestimation of prevalence, as cited in Helmick CG, Felson DT, Lawrence RC, Gabriel S, Hirsch R, Kwoh
CK, et al.; National Arthritis Data Workgroup. Estimates of the prevalence of arthritis and other rheumatic
conditions in the United States. Part 1. Arthritis and Rheumatism 2008;1:15-25.
How Is Gout Diagnosed?
Gout may be difficult for doctors to diagnose because the symptoms can be vague, and gout often mimics
other conditions. Although most people with gout have hyperuricemia at some time during the course of their
disease, it may not be present during an acute attack. In addition, having hyperuricemia alone does not mean
that a person will get gout. In fact, most people with hyperuricemia do not develop the disease.
To confirm a diagnosis of gout, a doctor may insert a needle into an inflamed joint and draw a sample of
synovial fluid, the substance that lubricates a joint. The joint fluid is placed on a slide and examined under a
microscope for uric acid crystals. Their absence, however, does not completely rule out the diagnosis.

The doctor also may find it helpful to look for uric acid crystals around joints to diagnose gout. Gout attacks
may mimic joint infections, and a doctor who suspects a joint infection (rather than gout) may also culture the
joint fluid to see whether bacteria are present.
Signs and Symptoms of Gout

hyperuricemia

presence of uric acid crystals in joint fluid

more than one attack of acute arthritis

arthritis that develops in a day, producing a swollen, red, and warm joint

attack of arthritis in only one joint, often the toe, ankle, or knee.
How Is Gout Treated?
With proper treatment, most people who have gout are able to control their symptoms and live productive lives.
Gout can be treated with one or a combination of therapies. The goals of treatment are to ease the pain
associated with acute attacks, to prevent future attacks, and to avoid the formation of tophi and kidney stones.
Successful treatment can reduce discomfort caused by the symptoms of gout, as well as long-term damage to
the affected joints. Treatment will help to prevent disability due to gout.
The most common treatments for an acute attack of gout are nonsteroidal anti-inflammatory drugs
(NSAIDs)2 taken orally (by mouth), or corticosteroids, which are taken orally or injected into the affected joint.
NSAIDs reduce the inflammation caused by deposits of uric acid crystals, but have no effect on the amount of
uric acid in the body.
2

Warning: NSAIDs can cause stomach irritation or, less often, they can affect kidney function. The longer a
person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many
other drugs cannot be taken when a patient is being treated with NSAIDs because NSAIDs alter the way the
body uses or eliminates these other drugs. Check with your health care provider or pharmacist before you take
NSAIDs. Also, NSAIDs sometimes are associated with serious gastrointestinal problems, including ulcers,
bleeding, and perforation of the stomach or intestine. People age 65 and older and those with any history of
ulcers or gastrointestinal bleeding should use NSAIDs with caution.
Corticosteroids are strong anti-inflammatory hormones. The most commonly prescribed corticosteroid is
prednisone. Patients often begin to improve within a few hours of treatment with a corticosteroid, and the
attack usually goes away completely within a week or so.
When NSAIDs or corticosteroids do not control symptoms, the doctor may consider using colchicine. This drug
is most effective when taken within the first 12 hours of an acute attack.
For some patients, the doctor may prescribe either NSAIDs or oral colchicine in small daily doses to prevent
future attacks. The doctor also may consider prescribing other medicines to treat hyperuricemia and reduce
the frequency of sudden attacks and the development of tophi.
People who have other medical problems, such as high blood pressure or high blood triglycerides (fats), may
find that the drugs they take for those conditions can also be useful for gout.
The doctor may also recommend losing weight, for those who are overweight; limiting alcohol consumption;
and avoiding or limiting high-purine foods, which can increase uric acid levels.
What Can People With Gout Do to Stay Healthy?
Fortunately, gout can be controlled. People with gout can decrease the severity of attacks and reduce their risk
of future attacks by taking their medications as prescribed. Acute gout is best controlled if medications are
taken at the first sign of pain or inflammation. Other steps you can take to stay healthy and minimize gouts
effect on your life include the following:

Tell your doctor about all the medicines and vitamins you take. He or she can tell you if any of them
increase your risk of hyperuricemia.

Plan followup visits with your doctor to evaluate your progress.

Drink plenty of nonalcoholic fluids, especially water. Nonalcoholic fluids help remove uric acid from the
body. Alcohol, on the other hand, can raise the levels of uric acid in your blood.

Exercise regularly and maintain a healthy body weight. Lose weight if you are overweight, but avoid lowcarbohydrate diets that are designed for quick weight loss. When carbohydrate intake is insufficient, your body
cant completely burn its own fat. As a consequence, substances called ketones form and are released into the
bloodstream, resulting in a condition called ketosis. After a short time, ketosis can increase the level of uric
acid in your blood.

Avoid foods that are high in purines.

High-Purine Foods

anchovies

asparagus

beef kidneys

brains

dried beans and peas

game meats

gravy

herring

liver

mackerel

mushrooms

sardines

scallops

sweetbreads
Research Highlights
Because uric acids role in gout is well understood and medications to ease attacks and reduce the risk or
severity of future attacks are widely available, gout is one of the mostif not the mostcontrollable forms of
arthritis. But researchers continue to make advances that help people live with gout. Perhaps someday these
advances will prevent this extremely painful disease.
Some areas of gout research include the following:

Refining current treatments. Although many medications are available to treat gout, doctors are trying to
determine which of the treatments are most effective and at which dosages. Recent studies have compared
the effectiveness of different NSAIDs in treating the pain and inflammation of gout and have looked at the
optimal dosages of other treatments to control and/or prevent painful attacks.

Evaluating new therapies. A number of new therapies have shown promise in recent studies including
biologic agents that block a chemical called tumor necrosis factor. This chemical is believed to play a role in
the inflammation of gout.

Discovering the role of foods. Gout is the one form of arthritis for which there is proof that specific foods
worsen the symptoms. Now, research is suggesting that certain foods may also prevent gout. In one study
scientists found that a high intake of low-fat dairy products reduces the risk of gout in men by half. The reason
for this protective effect is not yet known. Another study examining the effects of vitamin C on uric acid
suggests that it may be beneficial in the prevention and management of gout and other diseases that are
associated with uric acid production.

Searching for new treatment approaches. Scientists are also studying the contributions of different types
of cells that participate in both the acute and chronic joint manifestations of gout. The specific goals of this
research are to better understand how urate crystals activate white blood cells called neutrophils, leading to
acute gout attacks; how urate crystals affect the immune system, leading to chronic gout; and how urate
crystals interact with bone cells in a way that causes debilitating bone lesions among people with chronic gout.

The hope is that a better understanding of the various inflammatory reactions that occur in gout will provide
innovative clues for treatment.

Examining how genetics and environmental factors can affect hyperuricemia.Researchers are
studying different populations in which gout is prevalent to determine how certain genes and environmental
factors may affect blood levels of uric acid, which can leak out and crystallize in the joint, leading to gout.
Gout
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Gout is sometimes referred to as the disease of kings. This is because people long have incorrectly linked it
to the kind of overindulgence in food and wine only the rich and powerful could afford. In fact, gout can affect
anyone, and its risk factors vary.
Fortunately, it is possible to treat gout and reduce its very painful attacks by avoiding food and medication
triggers and by taking medicines that can help.

The base of the big toe and ankle are red, swollen, and extremely painful due to an acute attack of gout. As the
attack subsides, the superficial skin may peel.
FAST FACTS

Intensely painful joint swelling, most often in the big toe or other part of the foot, may indicate gout.

Treatments exist, but therapy should be tailored for each person.

By avoiding alcohol and certain fish and meats, you may help prevent further gout attacks.

Patients may need medications to lower their elevated blood uric acid levels that predispose to gout.
The goal is a uric acid level less than 6 milligrams per deciliter (mg/dL).
WHAT IS GOUT?
Gout is a painful and potentially disabling form of arthritis that has been around since ancient times. The first
symptoms usually are intense episodes of painful swelling in single joints, most often in the feet, especially the
big toe. The swollen site may be red and warm.
Treatments are available to control most cases of gout. However, diagnosing gout can be hard, and treatment
plans often must be tailored for each person.
WHAT CAUSES GOUT?

Gout occurs when excess uric acid (a normal waste product) collects in the body, and needlelike urate
crystals deposit in the joints. This may happen because either uric acid production increases or, more often,
the kidneys cannot remove uric acid from the body well enough. Certain foods and drugs may raise uric acid
levels and lead to gout attacks. These include the following:

Foods such as shellfish and red meats

Alcohol in excess
Sugary drinks and foods that are high in fructose
Some medications

low-dose aspirin (but because it can help protect against heart attacks and strokes, we do not
recommend that people with gout stop taking low-dose aspirin)

certain diuretics (water pills) such as hydrochlorothiazide (Esidrix, HydroD)

immunosuppressants used in organ transplants such as cyclosporine (Neoral, Sandimmune)

and tacrolimus (Prograf)

Over time, increased uric acid levels in the blood may lead to deposits of urate crystals in and around the
joints. These crystals can attract white blood cells, leading to severe, painful gout attacks and chronic arthritis.
Uric acid also can deposit in the urinary tract, causing kidney stones.
WHO GETS GOUT?
Gout affects more than 3 million Americans. This condition and its complications occur more often in men,
women after menopause, and people with kidney disease. Gout is strongly linked to obesity, hypertension
(high blood pressure), hyperlipidemia (high cholesterol and triglycerides) and diabetes. Because of genetic
factors, gout tends to run in some families. Gout rarely affects children.

In patients with chronic undertreated gout crystals can be found in deposits (called tophi) that can damage
joints & can appear under the skin.
HOW IS GOUT DIAGNOSED?
Some other kinds of arthritis can mimic gout, so proper diagnosis (detection) is key. Health care providers
suspect gout when a patient has joint swelling and intense pain in one or two joints at first, followed by pain
free times between attacks. Early gout attacks often start at night.
Diagnosis depends on finding the distinguishing crystals. The physician may use a needle to extract fluid from
an affected joint and will study that fluid under a microscope to find whether urate crystals are present. Crystals
also can be found in deposits (called tophi) that can appear under the skin. These tophi occur in advanced
gout. Uric acid levels in the blood are important to measure but can sometimes be misleading, especially if
measured at the time of an acute attack. Levels may be normal for a short time or even low during attacks.
Even people who do not have gout can have increased uric acid levels.
X-rays may show joint damage in gout of long duration. Ultrasound and dual energy computed tomography
(commonly called dual energy CT) can show early features of gouty joint involvement. These imaging
techniques also can help suggest the diagnosis.
HOW IS GOUT TREATED?
Treatment of acute attacks. One treatment for active flares of gout is colchicine. This medicine can be
effective if given early in the attack. However, colchicine can cause nausea, vomiting, diarrhea and other side
effects. Side effects may be less frequent with low doses. Patients with kidney or liver disease, or who take
drugs that interact (interfere) with colchicine, must take lower doses or use other medicines. Colchicine also
has an important role in preventing gout attacks (see below).
Nonsteroidal antiinflammatory drugscommonly called NSAIDsare aspirinlike medications that can
decrease inflammation and pain in joints and other tissues. NSAIDs, such as indomethacin (Indocin) and
naproxen (Naprosyn), have become the treatment choice for most acute attacks of gout. (The fact sheet
on NSAIDslists the types of patients who cannot take NSAIDs.) There is no proof that any one NSAID is better

than others. High doses of shortacting NSAIDs give the fastest relief of symptoms. These medicines may
cause stomach upset, ulcers or diarrhea but, if used for the short term, are well tolerated by most people.
Some people cannot take NSAIDs because of health conditions such as ulcer disease or impaired kidney
function or the use of blood thinners. Corticosteroids such as prednisone and triamcinolone are useful options
for patients who cannot take NSAIDs. Given orally (by mouth) or by injection (shot) into the muscle, these
medicines can be very effective in treating gout attacks. If only one or two joints are involved, your doctor can
inject a corticosteroid directly into your joint.
Health care providers may prescribe anakinra (Kineret), an interleukin 1 beta antagonist, for very severe
attacks of gout. Though this rheumatoid arthritis drug is not approved by the Food and Drug Administration
(commonly referred to as the FDA), for gout treatment, it can quickly relieve gout symptoms for some patients.
Some home remedies may help ease gout pain. Rest the affected joint and apply ice packs or cold
compresses (cloths soaked in ice water and wrung out) to that spot.
Treatment to remove excess uric acid. Patients who have repeated gout attacks, abnormally high levels of
blood uric acid, or tophi or kidney stones should strongly consider medicines to lower blood uric acid levels.
These medications do not help the painful flares of acute gout, so most patients should start taking them after
acute attacks subside. The drug most often used to return blood levels of uric acid to normal is allopurinol
(Lopurin, Zyloprim). It blocks production of uric acid. A recent option, febuxostat (Uloric), also acts by blocking
uric acid production.
Probenecid (Benemid) helps the kidneys remove uric acid. Only patients with good kidney function who do not
overproduce uric acid should take probenecid.
Pegloticase (Krystexxa) is given by injection and breaks down uric acid. This drug is for patients who do not
respond to other treatments or cannot tolerate them. New drugs to lower uric acid levels and to treat gouty
inflammation are under development.
If you are taking a uric acid-lowering drug, your doctor should slowly raise the dose and keep checking your
blood uric acid levels. Once your uric acid levels drop below 6 mg/dL (normal), crystals tend to dissolve and
new deposits of crystals can be prevented. You probably will have to stay on this medicine long term to prevent
gout attacks.
What works well for one person may not work as well for another. Therefore, decisions about when to start
treatment and what drugs to use should be tailored for each patient. Treatment choices depend on kidney
function, other health problems, personal preferences and other factors.
What you eat can increase uric acid levels. Limit the amount of high-fructose drinks, such as nondiet soda.
Also, do not drink alcohol, especially beer. Restrict eating foods that are rich in purines, compounds that break
down into uric acid. These compounds are high in meat and certain types of seafood. Purines in vegetables
appear to be safe, new research has found. Lowfat dairy products may help lower uric acid levels.
In almost all cases, it is possible to successfully treat gout and bring a gradual end to attacks. Treatment also
can decrease the number and size of tophi.

Lifestyle changes such as controlling weight, limiting alcohol consumption, and limiting meals with meats and
fish rich in purines, can be helpful in controlling gout.
BROADER HEALTH IMPACTS OF GOUT

Gout often is associated with high blood pressure, heart and kidney disease, or the use of medications that
increase uric acid levels. Therefore, health care providers should test for these related health problems.
Researchers are studying whether lowering blood uric acid levels can help heart disease and kidney disease.
LIVING WITH GOUT
Gout affects quality of life by both the intermittent attacks and the potential for chronic (lasting) arthritis.
Compliance with your treatment plan is critical.
Lifestyle changes may make it easier to manage this lifelong disease. Suggestions include gradual weight loss,
avoidance of alcohol and reduced consumption of fructosecontaining drinks and foods high in purines.
THE RHEUMATOLOGIST'S ROLE IN THE TREATMENT OF GOUT
Treatment of gout can be difficult because of coexisting illnesses and other medications. As experts in the
treatment of arthritis, rheumatologists examine patients to learn whether gout is the cause of their arthritis and
to educate them about the role and proper use of medications and other treatments for gout. They also act as
a resource to primary care doctors.
POINTS TO REMEMBER

Bouts of arthritis that come and go are a sign of gout.

Finding the characteristic crystals in the fluid of joints allows health care providers to correctly diagnose
gout.

There are two types of medicine for gout. First, for control of acute attacks of joint pain, there are
NSAIDs, colchicine and corticosteroids. Second, after attacks have resolved, there are medications that
can lower the level of uric acid over time, to prevent or cause the attacks to occur less often.

People with chronic gout usually require lifetime treatment with drugs to lower uric acid levels.

Lifestyle changes such as controlling weight, limiting alcohol intake and limiting meals with meats and
fish rich in purines also can help control gout.
Gout Medications
These drugs relieve pain, inflammation and reduce uric acid in the blood.
By By Dorothy Foltz-Gray
The First Line of Defense
A gout attack is the result of a buildup of uric acid in the blood, which forms crystals in the
joints. At the onset of a gout attack characterized by an inflamed joints (usually the big toe),
thats reddened and warm to the touch, your doctor will give you one or more of the following
medications to address pain and inflammation.
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
Your doctor may prescribe indomethancine (Indocin), ibuprofen (Advil) or naproxen sodium
(Aleve), which can help relieve pain and inflammation within the first 24 hours after a gout
attack. However, these can have side effects such as stomach upset or ulcer, or heart disease
risk. People with gastrointestinal, kidney or heart problems should not take them.
Colchicine. This anti-inflammatory is most effective taken within 12 hours of an attack. It helps
prevent the buildup of uric acid crystals in the joints Colchicine is sometimes taken in addition to
NSAIDs for six to 13 months until uric acid levels are stabilized by other long-term medication.
(See below.)
Corticosteroids. Corticosteroids, such as prednisone work by suppressing the inflammation of
an acute attack, usually within 24 hours. When patients cant tolerate NSAIDs or colchicine,
corticosteroids may be injected into the painful joint. If a number of joints are involved, the
medication may be injected into the muscle or taken orally. They can make it more difficult for
people with diabetes to control their blood sugar, and they can cause temporarily blurry vision.

Long-Term Treatment
The goal of long-term treatment is to reduce and stabilize the level of uric acid in your blood.
Uric acid is a waste product made by the body as it breaks down purines compounds found in
foods, particularly those high in protein. If uric acid builds up in the bloodstream, crystals may
form in joint tissue, triggering the pain and inflammation associated with gout attacks.
Over time, accumulated uric acid crystal deposits (called tophi) can damage tissues and lead to
lumps under the skin, joint deformity, or can also accelerate degeneration in the joint that can
lead to osteoarthritis. When uric acid is very high, gout can affect the kidneys. About 20 percent
of people with gout develop kidney stones, which can damage the organs and ultimately lead to
kidney failure.
Before a doctor can prescribe long-term medication, he will need to determine whether your
body overproduces or underexcretes uric acid. Youll be given a blood test to measure your level
of uric acid. A high uric acid level means you have hyperuricemia; however, having
hyperuricemia does not necessarily mean you have or will develop gout.
Tips for Managing a Gout Attack
Gout attacks are unexpected and painful; heres how to get a handle on them.
By Dorothy Foltz-Gray
Few events are more painful than a gout attack. You wake in misery with a big toe thats tender,
swollen, red and radiating heat. Because most gout attacks occur in the wee hours, its wise to
know how you can best manage symptoms until you see a doctor. An attack can last from hours
to days, if treated, and weeks, if untreated. To best alleviate pain, gout must be treated within
36 hours.
Use medication already on hand. Nonsteroidal anti-inflammatory drugs (NSAIDs)such as
indomethacin (Indocin), ibuprofen (Advil), and naproxen sodium (Aleve); corticosteroids; and
colchicine are the three most common anti-inflammatory drug choices when it comes to easing
or stopping an attack.
Colchicine, an alternative for those who cant tolerate NSAIDs, works by relieving inflammation
and preventing the build-up of the uric acid crystals that form in joints. (See Treatments for
Acute Gout.) Do not take aspirin; it can affect your uric acid level, worsening the attack. If
youve never had an attack, youll likely only have over-the-counter anti-inflammatories such as
ibuprofen and naproxen on hand.
Call your doctor. Make an appointment for immediate gout treatment. Plan on discussing
medication and lifestyle changes such as a low-purine diet. Purines are substances in animal and
plant foods that the body converts to uric acid. They are the offending substance that has
crystallized and lodged in your joints, causing your pain. Ask your physician what measures you
can take if an acute attack occurs again.
Protect the joint. During an attack, get plenty of overall rest and protect the affected joints.
Drink plenty of fluids. Staying hydrated helps flush out uric acid and prevent kidney stones, a
possible complication of gout. Aim for eight to16 cups of fluids a day, at least half of them water.

Ice down. Applying an ice pack to the painful joint may help ease pain and inflammation. Wrap
a pack (a bag of crushed ice or frozen peas will also do), in a dish cloth and apply to the area for
20 to 30 minutes at a stretch several times a day.
What Is Gout?
Gout is a form of inflammatory arthritis that is sometimes called gouty arthritis. It develops in
some people who have high levels of uric acid in the blood. That acid can form needle-like
crystals in a joint and cause sudden, severe episodes of pain, tenderness, redness, warmth and
swelling.
For many people, the first symptom of gout is excruciating pain and swelling in the big toe
often following a trauma, such as an illness or injury. Gout may also appear in another low-body
joint such as the ankle or knee. Subsequent attacks may occur off and on in other joints,
primarily those of the foot and knee, before becoming chronic.
Eventually, untreated gout can cause other problems. Tophi painless but disfiguring lumps of
crystals formed from uric acid may develop under the skin around joints. The crystals can also
form kidney stones. Gout is associated with other serious health risks such as high blood
pressure, diabetes, chronic kidney disease and cardiovascular disease, so an overall healthy
lifestyle including eating a healthy diet, maintaining a healthy weight and engaging in physical
activity is important.
What Are The Stages of Gout?
There are several stages of gout:
Asymptomatic hyperuricemia is the period prior to the first gout attack. There are no symptoms,
but blood uric acid levels are high and crystals are forming in the joint.
Acute gout, or a gout attack, happens when something (such as a night of drinking) causes uric
acid levels to spike or jostles the crystals that have formed in a joint, triggering the attack. The
resulting inflammation and pain usually strikes at night and intensifies over the next 8 to 12
hours. The symptoms will begin to ease after a few days and will probably be completely gone in
a week or 10 days. Some people never experience a second attack, but an estimated 60 percent
of people who have a gout attack will have a second one within a year. Overall, 84 percent may
have another attack within three years.
Interval gout is the time between attacks. Although theres no pain, the gout isnt gone. Lowlevel inflammation may be damaging joints. This is the time to begin managing gout via
lifestyle changes and medication to prevent future attacks or chronic gout.
Chronic gout develops in people with gout whose uric acid levels remain high over a number of
years Attacks become more frequent and the pain may not go away as it used to. Joint damage
occurs, which can lead to a loss of mobility. However, with proper management and treatment,
this stage is preventable.

Gout
What is it?
Arthritis is a complex family of musculoskeletal disorders consisting of more than 100 different
diseases or conditions that destroy joints, bones, muscles, cartilage and other connective
tissues, hampering or halting physical movement. Gout is a form of inflammatory arthritis that

causes sudden, severe pain, swelling and tenderness most often in the large joint of the big
toe. However, gout isnt limited to the big toe; it can affect other joints including the feet, ankles,
knees, hands, wrists, elbows and sometimes soft tissue and tendons. It usually affects only one
joint at a time, but it can become chronic and, over time, affect several joints.
A gout attack can last anywhere from a few days to two weeks, if untreated. An estimated 6.1
million Americans have experienced at least one gout attack. The disease most commonly
affects men and can manifest anywhere from age 30 onward. Women get gout too, although
they are at a slightly lower risk, and it usually appears after menopause.
What are the effects?
For many people, the first symptom of gout is excruciating pain and swelling in the big toe
often following a trauma, such as an illness or injury. Subsequent attacks may occur off and on in
other joints, primarily those of the foot and knee, before becoming chronic. In its chronic stage,
gout can affect many joints, including those of the hands. Other problems related to gout can
include the formation of tophi, or lumps of crystals under the skin, in the joints and in bone;
kidney stones; and impaired kidney function.
How is it diagnosed?
A doctor who has experience with gout attacks may be able to recognize this type of
inflammatory arthritis simply by evaluating signs and symptoms, such as:
how quickly the attack came on
the severity of the inflammation and pain
which joints are involved
the number of joints affected
your medical history, including medications youre taking
your eating and drinking habits
the level of uric acid in your blood, as determined by a lab test
The only way for your doctor to make a definite diagnosis of gout is to examine synovial fluid a
lubricating liquid found inside your joints under a microscope. The presence of uric acid crystals
signifies gout. Blood tests can determine if your uric acid levels are elevated, but not everyone
with a high level of uric acid develops gout.

What are the treatment options?

Although gout is chronic, it can be controlled and you can get on with living your life. Once your
doctor has confirmed a gout diagnosis, youll work together to come up with a treatment plan
likely involving both medication and lifestyle changes.
The first objective will be to relieve the pain and inflammation of the current gout attack. Once
the gout attack is under control, which can take a few hours or a couple of days, you and your
doctor will focus on managing the disease long-term. Your efforts will center on preventing future
attacks, avoiding the long-term damage to your joints and chronic pain associated with
uncontrolled gout and preventing the formation of tophi, lumps of crystallized uric acid that can
form in the affected joints or surrounding tissues.
What resources are available?
The Arthritis Foundation leads the way in helping people with arthritis live better today and
create better tomorrows through new treatments, better access and, ultimately, cures. We do
this by:
Funding life-changing research that has restored mobility in patients for more than six decades
Fighting for health care policies that improve the lives of the millions of Americans with arthritis
Partnering with families to provide empowering programs and information

If you are diagnosed with gout, some Arthritis Foundation resources that may help you better
manage and live with your disease are:

What Causes Gout?

Gout appears to come out of nowhere, but its the result of a long process.
Gout appears to come on suddenly, often in the form of a painfully swollen big toe or lower body
joint. In reality, its the end result of a process thats been taking place in the body for a while.
The underlying cause of gout is different from those things that trigger a gout attack. Gout is the
result of excess uric acid in the body, a condition called hyperuricemia.
Uric acid is a substance that normally forms when the body breaks down purines, which are
found in human cells and in many foods. Uric acid is transported by the blood to the kidneys
and eliminated in the urine. However, some people either overproduce uric acid or they produce
a normal amount, but their kidneys cant process it efficiently and so an excess of uric acid
builds up. Some, but not all of those people may develop gout.
Lifestyle factors, such as a diet high in certain high-purine foods, obesity and excessive alcohol
use, especially heavy beer consumption, also can contribute to development of hyperuricemia
and gout.
Gout Triggers
Gout, the underlying condition, is caused by excess uric acid in the body. But what brings on a
gout attack?
Medical or health triggers:
Joint injury
Surgery or sudden, severe illness
Infection
Taking certain diuretic medications for high blood pressure, leg swelling (edema) or heart
failure
Taking the drug cyclosporine
Starting a uric acid-lowering treatment
Chemotherapy
Lifestyle triggers:
Crash diets and fasting
Drinking too much alcohol
Eating large portions of certain foods high in purines (red meats or shellfish)
Dehydration
Drinking sweet sodas
How is Gout Diagnosed?

Work with your doctor to determine if you have gout.

To diagnose gout, your doctor will ask about your medical history, examine your joint and do a
blood test.
He will also ask about:

Your symptoms
What medications youre taking
Your diet
How quickly and intensely the gout attack came on
Details of the attack: severity of pain, length, joints affected

Your doctor will need to rule out other potential causes of joint pain and inflammation such as
infection, injury or another type of arthritis. He will take a blood test to measure the level of uric
acid in your blood. A high level of uric acid in your blood doesnt necessarily mean you have
gout, just as a normal level doesnt mean you dont have it. He may take an X-ray, ultrasound,
CT or MRI to examine soft tissue and bone.
Your doctor might also remove fluid from the affected joint and examine it under a microscope
for uric acid crystals. Finding uric acid crystals in the joint fluid is the surest way to make a gout
diagnosis.
The Latest Gout Research
Heres a roundup of research on this painful disease that affects millions.
By Jennifer Davis
Gout was a hot topic in late 2010 at the American College of Rheumatology Annual Scientific
Meeting in Atlanta. Researchers from around the world shared their latest findings on this type
of arthritis that occurs when uric acid builds up in the body and crystallizes in the joints, causing
intense pain, inflammation, stiffness and swelling.
One finding, written about in the March-April 2011 issue of Arthritis Today, is that sugary
beverages including orange juice can greatly increase a womans risk of getting gout.
Heres what else researchers at the conference had to say about the disease.
Gouts On the Rise
The number of people with gout more than doubled between the 1960s and 1990s, but Yanyan
Zhu, PhD, a research assistant professor at the Boston University School of Medicine, wanted to
find out whats happened since then. So Zhu compared a survey of more than 18,000 people
taken between 198 to 1994 with a survey of about 5,700 people gathered between 2007 to
2008.
By the latter time period, 8.3 million Americans or 4 percent of U.S. adults had gout. This
was up from 2.7 percent between 1988 to 1994. These findings indicate that the prevalence of
gout continues to be substantial in the new millennium, Zhu says.
Hyperuricemia is a condition thats often the precursor to gout because its marked by higher
than normal levels of uric acid in the blood. Between the two time periods, instances of

hyperuricemia increased by 3.2 percent. Researchers think risk factors like obesity and high
blood pressure helped drive the increase.
Better management of these factors could help prevent further rise in the disease burden of
gout and hyperuricemia and other associated complications in the U.S. Zhu says.
Uric Acid Linked With Hypertension
While Zhu suggested that high blood pressure may be a cause of hyperuricemia and gout,
another study presented at the conference suggested that high uric acid may put you at risk of
developing high blood pressure.

Who Gets Gout?

Gout is on the rise among Americans.
Gout may be historically known as the disease of kings or certainly those wealthy enough to
afford rich food and drink. But new research has shown that the number of people with gout is
growing. It occurs in about 4 percent of American adults. This translates to about 8 million
individuals 6 million men and 2 million women.
Men in their 40s and 50s are most likely to develop gout. But by age 60, gout affects men and
women roughly equally. After age 80 more women than men have gout.
High uric acid levels (hyperuricemia), which can lead to gout, occur for one of two reasons: the
body produces too much uric acid or the body is not efficient at excreting uric acid in the urine.
For more than 90 percent of people with gout, the cause is the latter. There are certain inborn
errors of metabolism that can cause hyperuricemia, but these genetic disorders account for a
very small fraction of people with gout.
Risk factors for gout include:
Genes: If family members have gout, youre more likely to develop it.
Other health conditions: High cholesterol, high blood pressure, diabetes and heart disease
may raise your risk.
Medications: Diuretic medications, or water pills taken for high blood pressure can raise uric
acid levels; so can some drugs that suppress the immune system taken by rheumatoid arthritis
and psoriasis patients, as well as transplant recipients.
Gender and age: Gout is more common in men than women until around age 60. Experts
believe natural estrogen protects women up to that point.
Diet: Eating red meat and shellfish increases your risk.
Alcohol: For most people, more than two liquor drinks or two beers a day can increase the risk
of gout.
Sodas: The fructose in sweet sodas has recently been shown to increase gout risk.
Obesity: Obese people are at a higher risk for gout, and they tend to develop it at a younger
age than people of normal weight.

Bypass surgery: Those who have undergone gastric bypass surgery also have an increased
risk.
Women Get Gout, Too
The risk of gout increases after menopause. Learn why and how to lower it
Once called the disease of kings, gout has long been associated with portly men especially
those who could afford to overindulge in rich foods and alcohol. But gout in women is not
uncommon, especially after menopause. Vicky King, 46, of Alpharetta, Georgia a thin, petite,
active woman was dumbfounded when she was diagnosed with gout. Women of her age were
not typical candidates, she thought.
For the past three years, I lived under a diagnosis of OA; I never imagined gout was the true
cause of my pain, says King. But one night I had such burning, stabbing pain, and my foot
swelled to the point where I could not walk. On that night I was ready to accept any diagnosis as
long as they could fix the problem.
During menopause, which occurs at age 51 on average, a womans body drastically cuts its
production of the hormone estrogen. Estrogen may help the kidneys excrete uric acid, so after
menopause, a womans uric acid level begins to increase. It usually takes several years for the
uric acid level to reach the point where crystals can form. By about age 60, the number of cases
of gout in women and men are about equal; after age 80, more women than men have gout.
Your doctor can determine whether your body makes too much uric acid (an overproducer) or
doesnt excrete uric acid fast enough (an underexcreter) in diagnosing gout. Women who are
overproducers can take allopurinol (Zyloprim) to decrease their bodies uric acid production.
Underexcreters can take probenecid (Benemid, Probalan) to help their bodies eliminate uric
acid.
In addition to medication, you can control how much uric acid your body produces by avoiding
foods high in purines, which increase the uric acid level when digested and metabolized. Such
off-limit foods include alcohol, bacon, haddock, liver, scallops, turkey, veal and venison. Go light
on moderate-purine foods, such as asparagus, beef, chicken, ham, mushrooms and shellfish.
Obesity and Gout
Studies show a connection between obesity and the onset of gout.
By Dorothy Foltz-Gray
Controlling your weight is crucial if you have gout. Results from a 52-year follow-up study
published in 2010 at Boston University School of Medicine found that obesity is a leading risk
factor for gout.
Approximately 71 percent of people with gout are overweight and 14 percent are obese
defined as a body mass index (BMI a measurement of weight in relationship to height) of more
than 30. Calculate your BMI. The researchers led by Hyon Choi, MD, DPh, analyzed data from
the Framingham Heart Study for 2,476 women and 1951 men.
This isnt the first study to make that connection. A 2005 study, also led by Dr. Choi, found that
men who gained more than 30 pounds since age 21 had more than twice the risk of gout
compared to men who hadnt. And those who had lost more than 10 pounds reduced their risk

by 30 percent. Dr. Choi used data from the Health Professionals Follow-Up Study, a large
ongoing study of 51,529 Caucasian male health professionals. The 2005 Nurses Health Study
had similar results for women.
The rise of gout over the last two decades (from 45 to 62.3 per 100,000) parallels the increase
in obesity from 22.9 percent during 1988-94 to 30.5 percent in 1999-2000. According to the
Boston University study, people are eating more meat, seafood and fat, drinking more beer, and
exercising less habits that worsen both obesity and gout.
Obesity also heightens other risk factors people with gout face, such as cardiovascular disease,
high blood pressure, insulin resistance and high cholesterol. And obesity increases stress on
joints, exacerbating the pain and inflammation that accompanies gout.
Obviously, losing weight is one way to control both the risks that come with obesity and the risk
of gout. But speak to your doctor about the safest way to go about it. Although losing weight is
a good thing, losing weight too quickly or by fasting can temporarily raise uric acid levels,
possibly bringing on a gout attack. Aim to lose slowly, about one to two pounds a week.
Healthy Foods for Gout
What to eat and what to avoid when it comes to managing gout.
If you have gout, you know that lists of high and low purine foods abound. The best plan is to
use them as a guide for a strict low-purine diet. Your goal is to develop a lifelong eating strategy,
so focus on following a heart-healthy diet that includes all the food groups, especially
vegetables, whole grains, plant proteins such as nuts and legumes and low-fait dairy. Keep
refined carbohydrates and processed foods to a minimum.
Eat More of These Foods
These foods either lower uric acid levels or are good for the heart:
Skim milk
Low fat dairy products
Whole grain foods
Plant oils (olive, canola, sunflower)
All vegetables
Some fruits (those that are less sweet)
Vitamin C supplements (500 to 1,000 milligrams daily)
Coffee if you already drink it
Water
Limit or Avoid These Foods
These foods are high in purines, or are known to trigger gout attacks:
Red meat and organ means (liver, tongue and sweetbreads)
Shellfish such as shrimp and lobster
Sugary beverages
Excessive alcohol (more than one alcoholic drink for women and two for men within 24 hours)
Talk to Your Doctor About These Foods
Some foods associated with high uric acid levels are heart healthy. Your doctor can help you
decide if theyre right for you.
Moderate alcohol (one drink daily for women and two for men)
Seafood (oily types such as salmon and mackerel)
Fruits

Fight Gout with Your Gut

Research shows some foods may help reduce the risk of gout attacks.
Coffee or tea? Wine or beer? Mushrooms or anchovies? Regular or diet?
If youre one of the estimated 8 million Americans who have gout, you share a common
confusion about how your diet can bring on or stave off a gout attack. The latest research may
provide some answers.
Most people with gout believe they should avoid all purines, the nitrogen-containing compounds
that are metabolized into uric acid in the body. But the reality is, the over-consumption of
purine-rich foods and the under consumption of water are often what lead to gout attacks, and
research has shown that not all purines are bad and they arent the only part of your diet to
watch.
A gout attack can occur when uric acid builds up in the bloodstream. High levels of uric acid in
the blood lead to the formation of crystals that often accumulate in the joints at the base of the
big toe, but also can form in the elbows, ankles, wrists and other joints. Painful gout flares are
characterized by severe pain and inflammation.
The good news is there are many ways to alter your diet to help keep a gout flare at bay. Based
on recent research, here are some of the best preventative measures you can take.
Go with good dairy. Investigators also found that low-fat dairy products may improve
excretion of uric acid in the urine. Those who consumed a serving or more of low-fat milk or
yogurt a day had less uric acid in their blood than those who abstained. High protein and low
purine content of milk may explain dairys protective effect.
Get your java perks. Once thought to contribute to gout attacks because of its caffeine
content, coffee may now be in the clear. Two separate studies reveal thatdrinking coffee reduces
the risk of gout for men and women. Results of the larger study, which included 45,869 men
older than age 40 with no history of gout, showed the risk of gout was 40 percent lower for men
who drank four to five cups a day and 59 percent lower for men who drank six or more cups a
day when compared to men who never drank coffee. In the other study researchers reviewed
food questionnaires from 14,000 men and women age 20 or older, and found that the more
coffee (regular or decaf) the participants drank, the lower their uric acid levels were. Tea
seemed to have no effect.
Switch to diet soda. Fructose (a component of sugar) has come under fire for bringing on
bouts of gout inflammation. Over 12 years, data was collected on soft drink intake from 46,000
men without gout. The more regular soda (a concentrated source of fructose) the men drank,
the higher their risk of gout. Diet soda however, had no effect.
Fill up on water. Research shows drinking more water means fewer gout flares.One study done
at Boston University School of Medicine revealed that with each glass of water consumed in 24
hours before an attack, the risk for recurrent gout attacks decreased. For example, those who
drank five to eight glasses of water had a 40 percent reduced risk of a gout attack compared
with those who drank only one glass of water or less in the prior 24 hours. The studys authors
could not make specific recommendations about the amount of water people should drink
because it depends on their underlying medical conditions and physical activity levels. Talk to
your doctor about how much water you should drink each day.

Treatments for an Acute Gout Attack: What You Should Know

Follow this step-by-step plan for treating gout attacks.
When you experience your first gout attack, youre bound to be full of questions. Most
immediately, youll want to know how to relieve the excruciating joint pain and swelling that has
erupted overnight probably in your big toe, the site of 50 percent of initial gout attacks. Youll
also want to know what your doctor is likely to do for you in both the short and long term.
Heres a brief overview of what you can expect.
What Caused Your Gout Attack?
Gout attacks occur when excess uric acid crystallizes in the joints. The acid is a byproduct of the
breakdown of purines, substances in plants and animals, during the digestive process. Some
peoples systems cant process uric acid efficiently; others produce too much. The buildup results
in the pain and inflammation that characterize a gout attack.
How to Handle a Midnight Gout Attack
You may be in so much pain that dashing off to the emergency room is unthinkable. Thats OK
the immediate goal is to relieve pain and to lessen swelling and inflammation. You can begin
that process by taking nonsteroidal anti-inflammatory drugs (NSAIDs).
Commonly used over-the-counter NSAIDs such as ibuprofen (Advil), and naproxen sodium
(Aleve) help relieve both pain and inflammation often within 24 hours and are usually the first
line of defense. Unfortunately, when taken orally, they can have side effects such as stomach
upset or ulcers, headaches, skin rashes, fluid retention, kidney problems or heart disease risk.
That means people with gastrointestinal, kidney, or heart problems shouldnt take them.
Most doctors suggest taking the highest recommended
Treatments for Chronic Gout: What You Should Know
Learn about these options for managing your gout long-term.
If you have chronic gout persistently high levels of uric acid and gout attacks the most
important part of your care is keeping uric acid levels low (below 6.0 mg of uric acid to l dl of
blood) in order to stave off future attacks.
Uric acid is formed from purines, substances in animal and plants that the body converts to uric
acid during digestion. Some peoples systems produce too much acid; others cant excrete what
it produced. When excess acid remains in the system, it can form crystals that lodge in the
joints, causing the pain and inflammation that characterize a gout attack. If gout is left
untreated, tophi deposits of uric acid crystals can form under the skin around joints and
other soft tissues.
Your doctor will likely prescribe long-term medications to keep uric acid levels steady. Because
these drugs cause acid level to shift, you wont start taking them until your acute attack is under
control. (To learn how to manage an acute gout attack, click here).
Some patients only experience one gout attack, so physicians may not start long-term drugs
until after a second episode occurs.

It can take time for long-term gout medications. You may even have a flare after you start the
medication. So, in the meantime, keep taking the medications your doctor prescribes to treat
the acute attack as well.
Below are the medication options for chronic gout.
Allopurinol (Lopurin, Zyloprim), the most traditional and widely used medication for lowering
uric acid levels, slows the production of uric acid and may dissolve the uric acid crystals in tophi.
However, the drug can take three to six months to dissolve the crystals, and during that time, a
gout attack may occur. Doctors typically start patients on a low oral dose, increasing it every two
to four weeks, as needed to establish safe uric acid levels. Its a good choice for patients who
overproduce uric acid as opposed to those who under-excrete it (the difference is determined by
blood or urine tests). Side effects may include skin rash, sleepiness and stomach upset; the
latter usually diminishes as your body adapts to the drug.
Rarely, the drug causes a severe allergic reaction, particularly if you already have congestive
heart disease, high blood pressure, diabetes, kidney disease, stomach ulcers or other digestive
difficulties, or cancer being treated by radiation or chemotherapy. If you experience itching, a
skin rash with hives, fever, nausea or muscle pain, call your doctor immediately. Up to 5 percent
of patients cant tolerate the drug.
Febuxostat (Uloric) was approved by the U.S. Food and Drug Administration (FDA) in 2009. It
helps prevent uric acid production by blocking an enzyme that breaks down purines into uric
acid. Taken orally once daily, febuxostat is safe for people with mild to moderate kidney or liver
disease. Side effects can include liver irritation, nausea, joint pain, and rash. Febuxostat has a
higher risk of blood clots than allopurinol.
Probenecid (Benemid, Probalan), taken orally, lowers uric acid in the body by increasing the
amount excreted in urine. Its most likely to be used by people who have trouble excreting uric
acid, as opposed to those who overproduce it. Some rheumatologists prefer probenecid to
allopurinol because it has less dangerous side effects. However, it isnt recommended for people
with kidney disease. Possible side effects include kidney stones, nausea, skin rash, stomach
upset and headaches. Patients taking probenecid need to drink at least eight cups of water or
other fluid a day to reduce their risk of kidney stones.
Pegloticase (Krystexxa) is used in severe cases of gout when standard medications are
unable to lower the uric acid level, a condition known as chronic refactory gout. Pegloticase
lowers uric acid quickly and to lower levels than other medications, but it can lose potency over
time. The drug is administered every two weeks by intravenous (IV) infusion. The infusion will
take about two hours, but youll probably be at your doctors office for four hours. Youll receive
medications prior to the treatment and be observed afterward to make sure you dont have
reactions to the infusion or an allergic reaction, which may happen within two hours of
treatment. Other side effects can include gout flares, nausea, bruising, sore throat, constipation,
chest pain and vomiting. Tell your doctor if you have high blood pressure or are planning on
becoming pregnant.
What Doctors Choose:
Allopurinol: For patients who overproduce uric acid; have kidney failure, kidney stones or
tophi; use aspirin; or who dont respond to probenecid.

Febuxostat: For patients with mild to moderate kidney or liver disease. Has an effectiveness
and side effects similar to allopurinol.
Probenecid: For patients who cannot tolerate allopurinol. NOT for elderly patients; those with
kidney failure or kidney stones; those who take aspirin (it blocks the effect of probenecid); those
who overproduce uric acid.
Pegloticase: For patients form whom standard medications have failed to lower uric acid levels.
Gout Triggers
Uric acid levels arent the only causes of gout attacks.
Gout, the underlying condition, is caused by excess uric acid in the body. Here's a list of things
that can trigger a rise in uric acid, thus setting off a painful gout attack.
Medical or health triggers:
Joint injury
Surgery or sudden, severe illness
Infection
Taking certain diuretic medications for high blood pressure, leg swelling (edema) or heart
failure
Taking the drug cyclosporine
Starting a uric acid-lowering treatment
Chemotherapy
Lifestyle triggers:
Crash diets and fasting
Drinking too much alcohol
Eating large portions of certain foods high in purines (red meats or shellfish)
Dehydration
Drinking sweet sodas