A gout is a form of arthritis that commonly affects the joints in the base of the big toe. It is caused by a buildup of excess uric acid in the bloodstream. The uric acid crystallizes into needle-like structures that lodges in the joint. It causes sudden severe attacks of intense pain, swelling, tenderness, and joint stiffness.

Gout attacks can strike suddenly and keep recurring over time, gradually degrading the tissues in the inflamed region. It usually affects a single joint and can be extremely painful. Severe gout that affects multiple joints is known as polyarticular gout.

One condition that is commonly confused with gout is pseudogout. The pseudogout flare-ups are usually less severe than that of gout. Pseudogout and gout should be treated differently.

 

Stages of Gout

Gout progresses through four different stages (sometimes referred to as different types of gout).

The four stages of gout:

    1. Asymptomatic hyperuricemia
  1. Acute gout
  2. Interval gout
  3. Chronic tophaceous gout

Asymptomatic hyperuricemia

Asymptomatic hyperuricemia is the period before a gout attack. There are no outward symptoms, but blood uric acid levels are high, and crystals are forming in the joint.

At this stage, treatment is not required. You may nevertheless take steps to address any underlying factors that contribute to uric acid buildup.

Acute gout (Gout attack)

Acute gout, otherwise known as a gout attack, happens when hyperuricemia causes uric acid crystals to develop suddenly in one of your joints. The resulting inflammation and intense pain usually strike at night and intensifies over the next 12 hours. Your joint may also feel warm. The sudden attack is referred to as a “flare.” Symptoms may ease after a few days and likely dissipate in a week to 10 days. Some people will experience a second gout attack within 1-3 years.

Interval or inter-critical gout

Interval gout, otherwise known as inter-critical gout, is the period between gout attacks. Although there are no symptoms at this stage, the gout isn’t gone. During this interval, some urate crystal may still accumulate, causing low-level inflammation that may cause minor damage to the joints.

Subsequent flares may not occur for months if preventive measures are taken to manage gout. However, if not treated, over time, they can persist longer and occur more frequently.

Chronic tophaceous gout

Chronic tophaceous gout is the most debilitating stage of gout. It develops in people with chronically high levels of uric acid. Permanent damage may occur in the joints; you may develop tophi – hard nodules – in joints of the fingers or toes. The gout attacks may become more recurrent, and the pain may not dissipate as it used to.

The condition can develop if you leave your gout untreated for ten years or longer. With proper treatment and management, you won’t progress to this stage.

 

Causes

Gout is caused by a buildup of uric acid in the blood – a condition called hyperuricemia. As a consequence, the urate crystals accumulate in the joint.

Uric acid is produced when your breaks down purines, which are found in red meat, organ meat, and shellfish, as well as alcohol and some sweetened drinks. Some conditions, such as blood and metabolism disorders, can also cause your body to produce excessive levels of uric acid.

You may also develop gout if your body is unable to eliminate the uric acid efficiently. Usually, uric acid passes through your kidneys and gets excreted via your urine. But if there’s too much uric acid for your kidneys to handle or the kidneys are unable to excrete the uric acid efficiently, and an excess of uric acid builds up.

 

Risk factors

Gout is a complex disease – there are a variety of factors that can contribute to the uric acid accumulation, and therefore gout.

 

Age and gender

Men produce a higher level of uric acid than women and are therefore more susceptible to gout. Nevertheless, women’s levels of uric acid approach those of men after menopause around age 60. Unlike women, men are more likely to develop gout earlier – usually between the ages of 30 and 50.

 

Genetics

If your family members have gout, you have 20% chances of developing it as well.

 

Diet and alcohol

A high-purine diet increases the accumulation of uric acid in the body. Foods such as red meat, organ meat, and shellfish contain a lot of purines. Furthermore, fructose in sweet sodas has also been shown to increase gout risk.

Alcohol consumption also interferes with the removal of uric acid. For most people, drinking more than two glasses of alcoholic beverages a day can increase the risk of gout.

 

Certain medications

Certain medications can impair your ability to eliminate uric acid efficiently. Examples include:

  • Diuretics (water pills; prescribed for high blood pressure)
  • Immune-suppressing drugs (prescribed for rheumatoid arthritis, psoriasis, fungal infection)
  • Specific cancer treatments
  • Anti-rejection drugs (prescribed after an organ transplant)

Surprisingly, acid-lowering uric medicines (e.g., allopurinol) can also initially trigger a gout flare. This is because anything that alters the uric acid level can cause uric acid crystals to deposit in the joint.

 

Obesity

Being overweight increase the risk of gout. This is because weight gain is associated with an increase in cell turnover, which in turns means that more uric acid is produced as a metabolic waste product (1). Obese individuals are also less able to eliminate uric acid efficiently due to higher levels of insulin in their body. Furthermore, body fat also increases the level of systemic inflammation as fat cells produce pro-inflammatory cytokines.

 

Recent trauma or surgery

You might have an increased risk of gout attack if you had surgery or injury recently. Gastric bypass surgery, in particular, increases gout risk.

 

Other health conditions

Kidney problems (e.g., renal insufficiency), thyroid problems, metabolic syndrome, and diabetes can impair your body’s ability to eliminate uric acid efficiently.

 

 

Symptoms

A gout attack can occur without warning in the middle of the night. It usually affects joints at the base of the big toe. The first symptom is a sudden onset of extreme burning pain, swelling, and tenderness.

More specifically, gout can cause symptoms such as:

  • Nodules under the skin (tophi)
  • Joint redness
  • Swollen joints
  • Sudden onset of intense joint pain
  • Heat or warmth in the affected area
  • Lingering discomfort
  • Limited range of motion

These symptoms usually affect only one joint. The affected joint is hypersensitive to touch – you may experience pain even when pulling bedsheets over the inflamed joint.

Without treatment, the first gout attacks may resolve typically within one to two weeks. However, gout usually strikes again. The frequency of gout attacks can occur more frequently and last longer over time, affecting multiple joints.

If you have a fever in addition to an inflamed joint, you may have an infection. Urgent medical care is necessary.

 

Complications

Eventually, untreated gout can develop into more severe conditions.

 

Recurrent gout

Some people may have regular gout flare-ups, causing gradual damage to the joints and surrounding tissue. Subsequent gout attacks may occur in other joints, primarily those of the ankle and knee. Gout in the knee can affect everyday movements, such as walking or standing.

To prevent recurrent gout attacks, you should take medication as directed by your doctor. If left untreated, gout can lead to irreversible joint destruction and physical deformity.

 

Tophi

Another complication of gout is the presence of tophi (TOE-fie) – indicating tophaceous gout. It is typically painless but can be disfiguring and unsightly.

A tophus is a large nodule of uric acid that crystallizes around the joints. It can develop in various locations in the body, commonly on the elbows, upper ear cartilage, fingers, hands, elbows, Achilles tendon, and on the surface of other joints. Tophus is an indication that the body is substantially overloaded with uric acid.

Medication is necessary to treat tophi.

 

Kidney stones

If urate crystals lodges in the kidney or the urinary tract, they become kidney stones. The risk of kidney stone formation can be reduced by taking medication.

 

Diagnosis

Either a primary care physician or a rheumatologist can assist you. Rheumatologists, in particular, have expertise in diagnosing and treating gout, especially complicated situations.

Your doctor may base your diagnosis based on your description of symptoms, how often you experience the flares, and how red or swollen the area is. The doctor may also review your medical history and conduct a physical exam.

Gout can be challenging to diagnose because its symptoms are similar to other conditions. Related conditions that need to be considered and ruled out include infection, injury, or other types of arthritis.

 

Joint fluid test

Doctors can use a needle to extract fluid from the inflamed joint. The liquid is then examined under the microscope to see if any urate crystals are present. Observing uric acid crystals in the joint fluid is the surest way to make a gout diagnosis. This is important because other medical conditions, such as pseudogout and bacterial infection, can have symptoms similar to gout. Sometimes, other types of crystals can be found in the joint fluid, such as calcium pyrophosphate, which is caused by a different condition called pseudogout.

 

Blood test

Doctors can also perform a blood test to measure the levels of uric acid in the blood.

The uric acid level is typically lowered during a gout flare. Therefore, the optimal time to measure uric acid level is after a flare has resolved when acute inflammation is absent.

Unfortunately, blood test results can be misleading, as people with high uric acid levels do not always experience gout. Likewise, some people develop gout symptoms without having high uric acid levels.

 

Imaging test

Finally, a musculoskeletal ultrasound scan can be used to detect urate crystals around the joints or tophus.

Your doctor may also take an X-ray to assess underlying joint damage, particularly in those with recurrent episodes of gout.

 

 

Treatment

Seek treatment to manage gout symptoms and prevent flares. Treatment is especially necessary if:

  • Frequent disabling gouty attacks occur
  • Presence of kidney stones due to uric acid
  • Evidence of joint damage
  • Presence of tophi

Gout medications can mitigate acute attacks and prevent future flares. It also reduces the risk of complications, such as the development of tophi and kidney stones. Your doctor’s prescribed treatment plan depends on the stage and severity of your gout. You can expect to recover within 1 to 2 weeks without treatment, but there may be significant pain during this period.

Gout medication generally falls into one of three categories:

  • uric-acid lowering medications
  • prophylactic medications (medicines used in conjunction with uric-acid-lowering medication to prevent a gout flare)

 

Medications to control uric acid levels

Urate-lowering medications are the mainstay treatment for gout. These medications decrease the amount of uric acid in the body to prevent gout attacks and keep the condition from worsening. The goal of uric-acid lowering medicine is to achieve a serum uric acid level of below 6 mg/dl.

Allopurinol (Lopurin, Zyloprim) is an oral xanthine oxidase inhibitor that limits uric acid production. It is initially prescribed at a low dose. The dose is increased every two to four weeks to establish stable uric acid levels. It is not recommended for people with severe kidney disease, liver disease, or congestive heart failure. If you take this drug during an attack, you may also be at an increased risk of a symptom flare-up.

Febuxostat (Uloric) is also an oral xanthine oxidase inhibitor. It may be an alternative option if allopurinol doesn’t suit you. Like allopurinol, febuxostat lowers the production of uric acid. It’s also given at a lower dose initially, which may be increased if necessary. Common side effects may include nausea, joint pain, and muscle pain. You may experience a gout flare when you first take the drug. Febuxostat presents a higher risk of blood clots as compared to allopurinol.

Probenecid (Benemid, Probalan) is an oral drug that helps the kidneys eliminate uric acid to reduce gout attacks and its severity. However, it may increase attack frequency within the first 6 to 12 months of taking it. Common side effects include kidney stones, skin rash, stomach upset, headaches, and nausea.

Pegloticase (Krystexxa) reduces uric acid more promptly and efficiently than other drugs. It is reserved for severe cases of gout when other medications fail to work. The drug is administered via intravenous (IV) infusion every two weeks. Side effects may include infusion reactions, bruising, gout flares, sore throat, nausea, vomiting, constipation, and chest pain.

Medications to prevent gout attacks

Prophylactic medications are used during the first six months of therapy in conjunction with uric acid-lowering drugs. It is meant to either avoid gout flares or decrease the uric acid level.

By taking one of these preventive medications during the first six months of treatments with uric acid-lowering drugs, the risk of having a gout attack during this period is decreased. Prophylactic medicines should not be used in combination with pegloticase.

NSAIDs. NSAIDs are frequently used to relieve pain quickly during a gout attack and shorten the attack, especially if taken within the first two hours. NSAIDs can include over-the-counter options such as ibuprofen (Advil, Motrin) and naproxen (Aleve), as well as prescription-strength NSAIDs such as indomethacin (Indocin) or celecoxib (Celebrex). These reduce pain and inflammation in the affected areas. Common side effects include headache, diarrhea, dizziness, rash, nausea, and vomiting.

Colchicine (Colcrys) is an anti-inflammatory drug that is prescribed upon the first signs of a gout attack to relieve pain and inflammation. It can also be used to prevent a recurrent attack. Common side effects include abdominal cramps, diarrhea, and nausea. Do not take colchicine if you have liver or kidney disease.

Corticosteroids such as prednisolone (Orapred), methylprednisolone (Medrol), and prednisone, are powerful anti-inflammatory drugs that can control an acute gout flare. However, the corticosteroid is prescribed only at a small dose due to potential side effects such as cataract formation and bone loss.

 

Home remedies

When gout is mild, uncomplicated, and infrequent, it can be remedied with diet and lifestyle modification. Adopting healthy lifestyle habits can also decrease uric acid levels, and should be seen as a supportive treatment – but not a replacement – to medication. Home remedies could be beneficial for the management of chronic gout as well.

 

Balanced diet

Eating a balanced diet can lower your risk of recurrent gout attacks. Adopt a low-cholesterol, low-fat diet – this diet would reduce your risk for gout and also heart disease. Also, you should eliminate purine from your diet. If you are overweight, you should follow a weight-reduction diet such as the Mediterranean diet.

Restrict your intake of alcohol, especially beer. Drinking more than two alcoholic drinks per day increases your risk for gout.

Here are the top five foods that are ideal for controlling and preventing gout:

  • Cherry juice for gout. Cherries have a high amount of anthocyanins, which are antioxidants that reduce inflammation. Cherries may also help to reduce uric acid levels. Black cherry juice or dried cherries may also have the same effect. You can drink them, eat them, or take a cherry extract supplement.
  • Apple cider vinegar for gout. There is no direct scientific evidence that apple cider vinegar may remedy gout. However, apple cider vinegar may help you lose weight and reduce inflammation, which will indirectly reduce uric acid. Preliminary studies also showed that acetic acid, a key component of apple cider vinegar might help or manage gout risk (2).
  • Drink plenty of water. Drinking water may reduce gout flares because water enables the kidneys to excrete uric acid efficiently. However, if you have congestive heart failure or kidney disease, talk to your doctor before increasing your water intake.
  • Dairy products. Low-fat dairy products may improve the elimination of uric acid, possibly due to its high protein and low purine content. Furthermore, research shows that orotic acid, casein, and lactalbumin found in milk may help reduce gout flares by increasing the capacity of the kidneys to excrete uric acid (2).
  • Drinking coffee reduces the risk of a gout attack. Risk of gout is lower for men who drank more than four cups a day.

What to put in your shopping cart – and what to pass up when shopping for an anti-gout diet:

Eat/DrinkAvoid
VegetablesAnchovies
CherriesAsparagus, dried beans, peas, mushrooms
WaterBeef kidneys, brains, game meat, red meat, organ meats
Low-fat dairy productsGravy
CoffeeSeafood
Plant oils (olive, canola, sunflower, etc.)Alcohol
Apple cider vinegarSugary beverages
Whole-grain productsProcessed foods
Vitamin C supplements

 

Physical Activity and weight management

Attaining and maintaining an ideal weight is an integral part of managing gout. Not only does losing weight help reduce your uric acid levels, but it can also lessen the risk of stroke or heart disease, both common in people with gout.

Lose weight gradually. Do not lose weight too rapidly because it may precipitate gout attacks. Being physically active is also an essential part of weight management.

Essential oils for gout

Essential oils are an effective all-natural gout remedy. It can break down uric acid crystals that lodge in and around the affected joint. Furthermore, essential oils have anti-inflammatory properties that are perfect for reducing pain and inflammation.

Lemongrass oil. A potent dose of lemongrass essential oil could reduce uric acid levels. It also has antimicrobial and antibacterial properties.

Celery seed oil enhances the anti-inflammatory effects of gout medications, including NSAIDs and corticosteroids. Dilute celery seed oil with a carrier oil, such as jojoba oil, coconut oil, or almond oil. Apply it directly to the painful areas.

Yarrow oil. Topical application of diluted yarrow oil can reduce inflammation. You may also brew and drink yarrow tea.

Ginger extract contains flavonoids that may reduce uric acid levels and prevent recurrent gout flares. Dilute the ginger essential oil in a carrier oil and then apply it to the affected area. Alternatively, you can use fresh ginger root in cooking or as a tea. Liquid ginger extract can also be added to beverages, and the powdered form can be taken as a supplement.

Chinese cinnamon (also known as cassia oil) may be used to treat inflammation and reduce uric acid levels. Dilute and apply it topically.

 

CBD oil

CBD oil may be used to relieve gout pain. While scientific studies on the relationship between CBD and gout are limited, there are substantial reports that CBD has anti-inflammatory properties and is useful for arthritis management (3).

Start with a conservative dose of CBD oil (20-25 mg per day) and increase it gradually until you begin to see positive results. Alternatively, you may find relief with topical CBD creams.

 

Prevention tips

During symptom-free periods, you should adopt these dietary guidelines to prevent future gout attacks:

  • Drink plenty of water. Stay well-hydrated. However, avoid sweetened beverages.
  • Limit or avoid alcohol. Don’t consume more than what your doctor recommends.
  • Get protein from low-fat dairy products because it may have a protective effect against gout.
  • Limit your intake of meat, poultry, and meat – a small amount is fine, but pay attention to what types and how much you take.
  • Maintain a healthy body weight to keep your uric acid level low. But avoid rapid weight loss or fasting, since doing so may temporarily raise uric acid levels.

 

Conditions associated with gout

Gout is associated with several health conditions, including kidney disease, diabetes, sleep apnea, cardiovascular disease, and other types of arthritis.

Kidney stones and kidney disease

Kidney stones are a common problem associated with uric acid, affecting approximately 20% of people with gout. Kidney stones develop when uric acid crystals deposit in the kidneys and block the urinary tract. If untreated, kidney stones can cause kidney damage and infection.

Kidney disease, ranging from impaired function to total failure, can also occur with gout.

Diabetes

Diabetes occurs when insulin production is low, or there is a lack of response to insulin. As a result, high levels of sugar buildup in the blood.

The risk for diabetes – particularly for women – is greater for those who are susceptible to gout. It might be due to gout inflammation as well as common risk factors such as high cholesterol and high blood pressure.

Sleep apnea

Sleep apnea is characterized by frequent pauses in breathing, which can last from a few seconds to minutes during sleep. People with sleep apnea are more susceptible to a gout attack. It might be because the pauses in breathing cause oxygen deprivation, which trigger the overproduction of uric acid.

Cardiovascular disease

Uric acid and its potential effects on the blood levels have been linked to an increased risk of cardiovascular disorders. People with gout have two to three times higher incidence of clinical heart failure and echocardiographic measures of systolic dysfunction – the impaired ability of the heart’s ventricles to contract – compared to those without. Women with gout have a higher chance of having a heart attack than women without gout – the increased risk is more significant than that for men.

Other types of arthritis

Gout can coexist with osteoarthritis, rheumatoid arthritis, and psoriatic arthritis. Differentiating between gout and other types of arthritis is essential because the treatment is different.

 

The Bottom Line

Gout is a chronic condition. The flare-ups can be painful and debilitating. Left untreated, you may suffer from recurrent acute attacks of gout and other complications. Nevertheless, excellent treatments for gout are available.