Gout is a form of arthritis that usually starts in the big toe.

Gout

Gout is a form of arthritis characterized by sudden, severe flares of pain, inflammation, swelling, redness and tenderness in the joints.

Although gout can affect any joint, it is most common in the big toe, often affecting the joint at the base of the toe. Other common locations include the knees, ankles, elbows, wrists and fingers.

An attack of gout can occur suddenly and often wakes patients in the middle of the night with a sensation of their joint being on fire. The affected joint is hot to the touch, swollen and so tender that any weight on it can feel unbearable, even the weight of the bed sheet.

What Causes Gout?

Purines are a group of chemicals found in body tissues and also in many foods. The body must continually process purines by breaking them down and recycling them or removing the byproducts, such as uric acid. Uric acid normally dissolves in the blood, passes through the kidneys, then exits the body in urine.

In some people, the body produces too much uric acid, or the kidneys do not excrete enough of the uric acid buildup. Sharp, needlelike urate crystals form from this excess uric acid, which then accumulates in a joint leading to inflammation and an attack of gout.How gout forms

High concentrations of uric acid levels in the blood (hyperuricemia) are necessary for the urate crystals to form; however, their presence does not necessarily indicate that gout will develop. For unknown reasons, some people with hyperuricemia do not develop gout, or they develop it after many years of retaining high uric acid levels.

Hyperuricemia affects approximately 23 to 24 million Americans, but only 8 million of these patients will actually develop gout. Hyperuricemia alone is not usually treated, though lifestyle changes may be suggested in attempt to prevent future gout.

What Are the Risk Factors for Gout?

Risk factors that increase the body’s uric acid level, and may lead to gout, include:

  • Age. Men usually develop gout between the ages of 30 and 50, and some research puts this age higher at 50 to 60. Women are more at risk of developing gout after menopause.
  • Gender. Women tend to have lower uric acid levels overall until after menopause. As such, men are more likely to develop gout earlier in life.
  • Ethnicity. Black men are more likely to experience gout than white men.
  • Heredity. If a family history of gout is present, the risk of developing the disease may be higher, though research is conflicting in this area.
  • Diet. Purines are found in certain foods and drinks, such as: certain meats and seafood; beverages sweetened with fruit sugar (fructose) or high fructose corn syrup, and; alcohol, especially beer. Low carb diets may also raise uric acid levels by the buildup of ketones, which are other acids in the body.
  • Obesity. The body produces more uric acid in overweight individuals and the kidneys also have a more difficult time eliminating the uric acid.
  • Certain diseases and medical conditions. Untreated high blood pressure and chronic conditions such as metabolic syndrome, diabetes, and heart and kidney diseases all are risk factors.
  • Certain medications. Thiazide diuretics (used to treat high blood pressure), low-dose aspirin, and cyclosporine (anti-rejection drug prescribed for people who have undergone an organ transplant) can all increase uric acid levels.
  • Recent surgery or trauma. These have both been associated with an increased risk of developing a gout attack.

Gout triggers

An attack of gout can also be triggered by either medical or lifestyle factors. Gout triggers include:

  • Chemotherapy
  • Crash dieting
  • Drinking too much alcohol
  • Dehydration
  • Diuretic medications
  • Eating large portions of certain foods high in purines (especially red meats or shellfish)
  • Fasting
  • Infection
  • Joint injury
  • Soda consumption
  • Sudden, severe illness
  • Starting a uric acid-lowering treatment
  • Taking cyclosporine
What Are the Stages of Gout?

There are three or four stages of gout, depending on how it is classified by a physician (stages 2 and 3 may be combined into one stage):

  1. Asymptomatic hyperuricemia – no symptoms, but high uric acid levels
  2. Acute gout – attacks of gout
  3. Interval gout – symptomless stage between attacks lasting from a few days to several months or even years
  4. Chronic gouty arthritis/chronic tophaceous gout – no pain-free periods; tophi develop in the joints and tissues around them

Tophi

During the third and fourth phase, tophi usually appear. These are collections of sodium urate monohydrate crystals (uric acid) deposited in and around the joints affected by gout. Tophi form when gout is not treated for an extended period of time – 10 years or more. They appear as swollen, bulbous growths on the joints just under the skin and may form anywhere in the body, even the ears.

While tophi are painless, their presence causes pain to the affected area by placing pressure on a joint, causing limited range of motion and pain to the inflamed area. Tophi may also cause skin pain and discomfort by stretching the skin and causing it to split. In these cases, it may expel a white substance formed from the uric acid buildup. Tophi on the big toe can interfere with walking and cause pain while wearing shoes.

What Are the Symptoms of Gout?

Gout symptoms almost always occur suddenly and many times at night. Gout pain is usually most severe within the first 4 to 12 hours after onset of the attack. Signs and symptoms in the affected joint experiencing an attack of gout include:

  • Inflammation
  • Redness
  • Swelling
  • Tenderness
  • Warm or hot to the touch; burning feeling
  • Intense pain
  • Lingering discomfort for a few days to a few weeks
  • Limited range of motion

In advanced gout, later attacks of pain are likely to last longer and affect more joints. As gout progresses, the joints may start to have limited range of motion.

How Is Gout Diagnosed?

Uric acid tests can help diagnose goutThe only way to officially diagnose gout is by doing a joint fluid test. A syringe is used to draw fluid from the affected joint. The fluid is examined under a microscope to look for the urate crystals associated with gout. Other tests that may be used to help diagnose gout include:

  • Blood test to measure the levels of uric acid and creatinine in the blood (though not a true diagnostic test due to patients with high uric acid levels, but no gout)
  • X-ray imaging to rule out other causes of joint inflammation
  • Musculoskeletal ultrasound to detect urate crystals in a joint or in a tophus
What Are the Treatment Options for Gout?

Treatment for gout most often involves medications. Gout medications can be used to treat acute attacks, prevent future attacks and reduce the risk of complications from gout, such as the development of tophi. Medications to treat acute gout attacks and prevent future attacks include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs include over-the-counter medications as well as more powerful prescription NSAIDs, such as indomethacin (Indocin) or celecoxib (Celebrex). A higher dose may be prescribed to stop an acute attack, and then lowered to a regular daily dose to prevent future attacks.
  • Colchicine: Colchicine (Colcrys, Mitigare) is a type of pain reliever for gout pain, but may cause side effects, especially in large doses. A lower daily dose may be prescribed after an acute attack in order to prevent future attacks.
  • Corticosteroids: Corticosteroids are often used only in people with gout who cannot take or tolerate either NSAIDs or colchicine. These drugs, such as prednisone, may control gout inflammation and pain

How to prevent gout

Lifestyle changes and controlling gout through medications are the best ways to prevent gout. Diet changes can be implemented to avoid foods and drinks high in purines and include heart-healthy choices that are low in uric acid levels. Losing weight and maintaining a healthy weight are key factors in preventing gout, as well as regular physical exercise.

Where to Go for Gout

Essex Union Podiatry is a complete foot and ankle practice serving the podiatric needs of Essex and Union counties. Our specialty trained physicians utilize the latest techniques and tools to diagnose, treat and provide preventative care for all foot and ankle conditions. With an emphasis on patient education, our practice offers quality care by creating an informative and personalized treatment plan tailored to meet individual needs.

For more information or to schedule an appointment with one of our doctors specialized in treatment of gout, give us a call at (973) 671-1977 or contact Essex Union Podiatry today.

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Jason P. Galante, DPM,
DABPM, AASPS

Jason Galante, DPM, AASPS

Nancy A. Kaplan, DPM, MBA, AACHE, FACFAS

NANCY A. KAPLAN, DPM, FASPS

Sarah E. Haller, DPM, AACFAS

SARAH E. HALLER