Gout

Gout symptoms often come on overnight and typically cause severe attacks of pain, heat, swelling and redness in the joints. Gout often affects joints in the ankles and feet, especially the big toes, but other joints including knees, wrists, elbows and fingers can also be affected. Attacks can last anything from a few hours to days or weeks depending on what action is taken. An acute attack of gout affecting a big toe is usually very easy to diagnose but some people with gout have a more chronic form of the condition where the joints can become more persistently swollen and painful, and this can sometimes be confused with osteoarthritis or rheumatoid arthritis, and the diagnosis of gout can be missed. If there is any doubt about the cause of your arthritis you should ask to be referred to a rheumatologist for an expert assessment.

The only certain way to diagnose gout, is if crystals of uric acid from a sample of joint fluid taken during an attack can be seen under a microscope. It is easy for a trained person to take a sample of joint fluid from a large swollen joint such as a knee, but this is often tricky or impossible if a small joint is affected, so doctors often have to assume that a diagnosis of gout is likely if there has been a typical attack of pain, swelling and redness in a joint, especially a big toe. The diagnosis is easiest if a doctor can see and examine a red and swollen joint but it can help if you take a photograph of any swollen joint if there is likely to be a delay in being seen by a doctor.

During an attack of gout, uric acid levels in the blood can often be low or normal, so checking the uric acid levels in the blood during an attack is not helpful. Uric acid levels should be checked between attacks of gout to get a correct reading and if you have had a typical attack plus have high uric acid levels, the diagnosis of gout is very likely.

Gout treatment consists of first aid treatment for acute attacks and then long-term treatment to prevent more attacks from happening in the future.

If you have persistently high uric acid levels, it is important that these are treated as long-term high uric acid levels can cause kidney problems and are associated with high blood pressure and other cardiovascular diseases such as stroke and heart attacks. High uric acid levels in the long term can also lead to collections of uric acid in the soft tissues including the fingers, around tendons and in the cartilage of the ear called tophi, or tophaceous gout. These can ulcerate and become infected and as well as being very painful, can be very difficult to manage.

We have some information on pain management in our Resources pages (opens pdf).

An acute attack of gout can be excruciatingly painful, but simple first aid measures can help. As soon as you feel an attack starting, rest and elevate the affected joint, apply ice packs which can help reduce pain, and if necessary take a high dose of Non-Steroidal Anti-Inflammatory drugs (NSAIDs) such as ibuprofen or naproxen.

There are many different brands of NSAIDS – all types are equally effective in gout but NSAIDs are not suitable for some people as they can trigger asthma, cause indigestion, irritate the stomach and lead to bleeding and ulcers. Long term use can also raise blood pressure, reduce kidney function and increase the risk of cardiovascular diseases such as stroke and heart attack.

During an acute attack, prescribed drugs such as colchicine can help shorten the length of an attack, as can a short course of oral steroids such as prednisolone, or an injection of steroid plus anaesthetic into the affected joint.

You can read more information on medication and arthritis in our Resources pages (opens pdf).

Gout is caused by too much uric acid (serum uric acid) in the blood. If you have recurrent gout attacks, it is important to reduce the level of uric acid in the blood to prevent more attacks.

Some people with gout have an inherited tendency to have high uric acid levels, but in most people lifestyle factors such as alcohol or diets rich in seafood or red meat, or drinks sweetened with sugar or fructose are important risk factors. Self-management and lifestyle changes are vital.

In some people, certain medicines including aspirin and some medicines for blood pressure can make gout attacks more likely, so speak to your doctor if you think this may be relevant to you.

Lowering uric acid levels will reduce the frequency of attacks. European guidelines for gout prevention recommend a target serum uric acid level of less than 360 (micromoles per litre), however British Society for Rheumatology (BSR) guidelines suggest even lower levels of 300.

The lower your level of uric acid, the fewer gout attacks you will have. Keeping to a healthy weight can also significantly reduce uric acid levels and the risk of gout, and current BSR guidelines suggest slow weight reduction by healthy eating rather than fasting, as sudden fasting can trigger an acute attack.

BSR guidelines also include several specific dietary measures that may help reduce uric acid and the risk of gout attacks. These include:

• Reducing alcohol intake, especially beer or avoiding alcohol completely
• Avoiding sugar-sweetened and fructose-containing drinks
• Increasing your intake of fruit and vegetables, especially those containing Vitamin C
• Including additional skimmed milk or low fat yoghurt
• Avoiding high purine foods such as yeast extract, offal, pate or too much red meat
• Following a diet generally high in fibre and low in fat and added sugars
• Drinking cherry extract

New evidence shows that diets low in salt such as the “DASH” diet designed to treat high blood pressure can also reduce serum uric acid levels and help with gout management.

Acute gout attacks can also follow a period of dehydration, for example after travelling, so you should make sure that you stay hydrated and drink plenty of water.

Many people will only ever have one attack of gout, but if you are having recurrent attacks, have tried lifestyle advice and your uric acid levels are still high, or have tophaceous gout, you may need medicines to help reduce your uric acid.

The most common medicine for this is allopurinol which is a so-called xanthine oxidase inhibitor that reduces uric acid production in the body. A newer form of medicine which works in the same way is called febuxostat. Both these drugs will reduce serum uric acid levels and both need to be taken regularly and usually for life to prevent gout attacks. These drugs can be both extremely effective and over time will gradually lead to uric acid crystals in the joints dissolving back into the blood.

When allopurinol or febuxostat are started, they can sometimes trigger an attack of gout, and so they are usually prescribed for up to 6 months with a gout preventer such as a NSAID or colchicine, which can then be stopped. Allopurinol and febuxostat usually need to be taken for life, which is why lifestyle measures are very important.

If you have an attack of gout on allopurinol or febuxostat, you should NOT stop the allopurinol as this can make long term control much more difficult. If this is the case, you should treat the acute attack and may need to increase the dose of allopurinol in the long term to prevent more attacks.

If you have had a bad reaction to allopurinol or febuxostat, there are other medicines which can help reduce uric acid but these need to be prescribed by a specialist, so ask your GP for a referral to a rheumatologist.

Gout is caused by too much uric acid in the blood leading to crystals of uric acid in the joints which can then trigger very painful attacks of hot, swollen joints. If you have gout, the uric acid levels in your blood can be reduced by weight loss, avoiding purines from animal sources and yeast extract, and by keeping alcohol intake to 1-2 units per day or less. You can also help reduce the number of gout attacks you have by drinking plenty of fluids, especially water, but you should avoid drinks sweetened by sugar or too much fruit juice as these can trigger an attack. Diet drinks are fine. Increasing your intake of cherries either as fruit or juice, and drinking skimmed milk may also help prevent gout attacks.

For more on the role of nutrition in arthritis you can visit our Self-Management page and read our factsheet under our Resources (opens pdf).