What Is Gout?
Symptoms of Gout
What Causes Gout?
Gout and Kidney Disease
Managing Gout Symptoms
What is Gout?
Gout is a chronic, systemic (whole-body) condition that occurs in cycles. Typically, gout is a form of arthritis that affects joints, often causing pain, swelling, and discomfort in the big toe, ankle, knee, and fingers. However, the condition isn’t limited to these areas and can occur in any joint. For instance, some people may experience gout in the tissue surrounding the elbow, called the bursa, that contributes to bursitis.
To fully understand gout, you must first understand what causes the pain and inflammation.
Purines and Gout
Purines are a natural chemical compound made up of nitrogen and carbon. Purines are produced in the body and found in the foods we consume. Our bodies can metabolize purines during digestion, creating a byproduct called uric acid.
In people without gout, uric acid is reabsorbed, and any excess amounts exit the body through the urine. However, when uric acid levels become too elevated, the body is no longer able to keep up with elimination and uric acid levels rise in the bloodstream. This condition is known as hyperuricemia.
Individuals are considered to have hyperuricemia if their uric acid blood level is 7 mg/dL or above.
Uric Acid Buildup
When the levels of uric acid rise in the body, the small molecules of uric acid can stick together and start to form microscopic crystals. Uric acid crystals often form around the joints (especially the big toe), where the blood vessels are the smallest. Uric acid crystals also form easily in areas of lower body temperature, which tend to be places farthest from the organs and heart.
The collection of uric acid crystals in the body eventually leads to the intense inflammation symptoms that we attribute to gout: red, hot, swollen joints that are extremely painful. The process of so much inflammation from the immune system is what triggers very severe pain.
Symptoms of Gout
Gout symptoms are often experienced in episodes of flares or attacks. These “flares” can vary in duration but typically last anywhere from a few days to several weeks at a time. It’s common for gout flares to happen suddenly, hours after eating certain trigger foods, after an injury, or overnight.
It’s common for a single joint to be affected during a flare, but gout can be active in more than one joint at a time. Sometimes gout will start in one joint and move to another, making it seem like the attack is moving around.
- Heat and redness around affected joints
- Swelling around affected joints
- Peeling or flaking skin (caused by swelling)
- Extreme pain or discomfort
- Joint stiffness
- Development of tophi
- Erosions or damage to the affected joint
A common characteristic of uncontrolled gout is the formation of large bumps called tophi. Tophi form from the collection of gout crystals that the body is trying to wall off or ignore. White blood cells of the immune system try to dissolve uric acid crystals. But when the immune system cannot keep up with all the crystals, the white blood cells then try to “hide” the uric acid in clumps that develop into tophi.
Sometimes, tophi can be along areas of the skin or right next to a joint. Erosions in the joints or bones are collections of uric acid that have caused damage to the bone structure. This happens when there are repetitive gout flares in the joint and the immune system starts causing damage to the bone by trying to “eat away” at the uric acid.
Joint damage that occurs from gout is difficult to treat and considered irreversible. Tophi can sometimes burst open from the skin and a chalking white-yellow substance might be visible. This can lead to infection and is a sign that gout should be treated right away. When levels of uric acid remain high enough, some people can see a decrease in gout flares and an increase in tophi. This actually means that their gout is progressing and becoming more severe.
What Causes Gout?
A common misconception is that a person’s diet is the direct cause of gout. While certain foods and alcohol can contribute to gout and worsen symptoms, diet is not the main cause. People who eat a healthy diet low in gout-causing purines and sugars can still develop the condition. Unfortunately, many people still associate gout only with people who overindulge in red meat, seafood, fast foods, and alcohol.
The truth is that there is no one cause for gout. Gout can affect any kind of person and progresses at different rates for different people. This is why gout has traditionally been difficult to treat.
There is often a genetic component to gout. If a close family member has gout, an individual may be at a higher risk of developing the condition. The reason for this is how kidneys are made to filter uric acid. This is a unique genetic fingerprint that is not easy to identify. As we age, our kidneys naturally are less effective at filtering certain things, which is why gout can occur as our bodies age. Women are more prone to gout after menopause because their hormone levels change and can influence how the body processes uric acid.
Another cause of gout is high cell turnover, which occurs in people with psoriasis or individuals on chemotherapy drugs. These conditions cause rapid fluctuation of uric acid in the body over a short period of time.
Certain medications may also increase your risk of developing gout. Diuretics (water pills) are often taken as a treatment for high blood pressure. They work by increasing the frequency of urination to help the body shed excessive amounts of salt and water. These types of medications are linked to an increased risk of gout due to the increase in urination. This stimulates dehydration in the blood vessels and uric acid is more likely to clump together and crystalize. Diuretics also make it more difficult for the kidneys to filter out uric acid, so there is less uric acid leaving the body with urination.
Dialysis also shares a link to the development of gout. In a 2022 study conducted by Anthony J. Bleyer, MD, MS and colleagues, approximately 13% of dialysis patients studied experienced symptoms of gout. When the kidneys do not work appropriately, there is little uric acid that can leave the body and therefore, it can collect in the joints and tissues more readily.
Finally, immunosuppressants can increase your risk for gout. Cyclosporin is an immunosuppressant used after organ transplants to lower the chance of the body rejecting the new organ. In a study conducted by Mark D Brigham and colleagues, over 18% of patients in the study taking cyclosporine developed gout. This happens because these medications block the kidney’s ability to excrete uric acid effectively.
Gout and Kidney Disease
There is a strong link between gout and kidney disease. Individuals with gout could develop kidney disease, while individuals with kidney disease are more likely to develop gout. Chronic kidney disease develops when the filtration function of the kidneys decreases or slows down. This causes the body to build up toxins. As kidney disease progresses from Stage 1 to 5, the body filters less and less toxins, and this causes uric acid to build up.
According to the American Kidney Fund, 1 out of 10 individuals with chronic kidney disease (meaning kidney function that gradually worsens over time) has gout.
Uric acid can also crystallize inside the kidneys themselves, particularly in the tiny blood vessels where blood is filtered. This causes overall filtration to decrease over time. Gout in the kidneys can be reversed with treatment and kidney function can actually improve with the right medications.
The Risks of Kidney Disease
Kidney disease is a serious condition that can lead to multiple other health concerns. In addition to the increased risk of gout, kidney disease can also lead to:
- Itchy skin
- Fluid retention and swelling
- Decreased immune system function
- Anemia (low blood count)
- Bone disease
- Heart disease
- Kidney failure
If you are experiencing one or more of the common symptoms of gout, your doctor or rheumatologist may perform several tests to rule out other potential causes for your symptoms.
Uric Acid Blood Test
Uric acid can be measured from a simple blood test. You do not need to be fasting for an accurate result.
A normal test result is a value between 3.5-7.0 mg/dL. However, if a person has gout and is on medication, the lab reported “normal” value is not actually normal. The most recent American College of Rheumatology guidelines for the treatment of gout specifies that uric acid levels should be less than 6 mg/dL for those patients who have gout.
Synovial Fluid Test
A synovial fluid test involves removing fluid from a swollen joint and looking for uric acid crystals under a polarized microscope. This is often referred to as a joint aspiration and is performed by a healthcare professional. The fluid is then sent to the lab to be analyzed. A sample can also be taken from an area of swelling to confirm tophi.
Ultrasounds are a non-invasive imaging test that uses sound waves to examine tissues, organs, and other body structures. Your doctor may order an ultrasound test to examine a swollen joint. Ultrasounds are occasionally used to detect tophi and determine if there are characteristic features of gout within an area of swelling.
X-rays are another imaging technique that can be helpful in identifying common signs of gout within a joint. X-rays will only show bone and do not show soft tissue swelling or gout if it affects the tendons. For patients who complain of joint pain, an X-ray can identify if there are features of bone erosions or damage to the bone structure caused by gout. These areas are typically described as erosions with overhanging edges and appear as holes on the sides of the bone.
Dual Energy CT Scan (DECT)
Dual Energy CT scan is an imaging technique that can detect uric acid deposition anywhere in the body with the use of CT scan and specific technology. This imaging can only be performed with specialized CT scanners at select imagine centers and is an extremely helpful tool to diagnose gout and tophi, as well as monitor progress on treatment.
Managing Gout Symptoms
Severe gout pain is very common for those who have the condition, and gout flares can stop even the most physical person in their tracks. There are ways to help manage symptoms of gout. Like all medical conditions, it takes a little bit of work and adjustments in medication.
At Summit Rheumatology, we strive to be advocates to help our patients manage flares and recover as quickly as possible. If you are consistently struggling with gout flares and your management plan is not moving you forward toward remission, we want to know. Often, we can help manage flares with a timely in-office appointment or telemedicine visit if needed. We want you to leave each appointment feeling like you understand your gout action plan and have enough medication refills to help you if flares occur.
Changing one’s diet won’t cure gout, but it could lower the risk of recurring gout attacks and even slow any progression of joint and kidney damage.15 A gout diet is designed to reduce the amount of purines in your bloodstream, which ultimately get converted to uric acid. Certain foods may be triggers for a flare.
Foods to avoid if you have uncontrolled gout include:
- Red meat, especially beef, lamb, and pork
- Organ meats, including sweetbreads, liver, and kidney
- Shellfish and certain kinds of seafood, including shrimp, crab, and some types of fish (specifically tuna, anchovies, and sardines). However, there are health benefits to consuming moderate amounts of fish, especially salmon, as a part of a gout diet.
- Beer and distilled liquor
- Sugary foods and drinks, like cereals, baked goods, and candy
- Read More About Foods to Avoid and Gout Friendly Alternatives
Once your gout is controlled, it is possible to eat some of these foods again in moderation. It’s important to understand what triggers gout for each individual and how medications work for you. At Summit Rheumatology, we strive to help our patients live with as few symptoms as possible.
If you are prone to gout attacks, increasing vitamin C, coffee (decaf or caffeinated), and tart cherry juice or extract can help decrease the intensity of flares. These natural remedies do not lower uric acid in the body the way medications can. Therefore, they are not substitutes for prescriptions that treat gout but can help manage symptoms and are potent anti-inflammatory foods.
Lifestyle modifications are also helpful ways to manage gout symptoms and decrease flares. Being overweight can increase the risk of developing gout16, which means losing weight can reduce the number of gout attacks—even without reducing purine consumption.
Physical activity has also been shown to reduce inflammation associated with gout flares. You do not have to participate in an expensive exercise plan or invest in a gym membership! Moderate exercise, like walking, can make a difference when trying to prevent severe gout pain. Exercise gets your blood flowing through your muscles and joints, which helps move uric acid through your body as well.
Physical activity that puts stress on the joints—jumping of any sort, for example—may increase the risk of a gout flare. High-intensity workouts can increase uric acid levels in the body if you become dehydrated, or promote the formation of uric acid crystals in a joint that is injured.
Medication for Gout
There are medications that treat the symptoms of gout, and those that treat the reason gout happens in the first place. Medications for symptoms include: NSAIDs like ibuprofen, Celebrex, or Toradol; corticosteroids like prednisone or Medrol, and colchicine (colcrys, Mitigare). These medications are effective at reducing pain, swelling, and inflammation from gout.
Medications like allopurinol, febuxostat (Uloric), or pegloticase (KRYSTEXXA®) are used to lower the uric acid levels in the body. These are the mainstay medications for the treatment of gout. Often, these medications require dose adjustments and the same dose does not necessarily work for everyone. KRYSTEXXA® IV therapy given every 2 weeks is the most effective medication used to treat severe gout.
If you have more than 2 flares in 6 months, visible collections of uric acid on your body (tophi), or uric acid kidney stones, you would qualify for treatment with one of these medications.
Gout relief is possible when treated with the proper gout medications, diet, and lifestyle changes. It is certainly possible to decrease gout flares for good when you are on the right combination of medications. Our gout specialists will work closely with you to help you wherever you are in your journey.
If you are ready to kick gout flares to the curb, we are ready to help you! For an appointment with one of our gout specialists, give us a call at (480) 618-1192. Our Arizona Gout Center of Excellence is designed specifically for the care and treatment of gout patients.