Understanding Gout, Diagnosis and Treatment

What is Gout?

Gout is a common form of inflammatory arthritis that can result in painful swollen joints involving usually one to two joints of the lower limb each time due to deposition of uric acid crystals into the affected joint.

It is a long term condition with recurrent episodes of sudden pain in the joint. Commonly affects the big toe and large joints in the lower limbs like the ankle or knee.

What is Purine?

Purines are molecules made up of carbon and nitrogen atoms and these molecules are found in cell’s DNA and RNA. 2/3 of purine in our body is due to the natural death and breakdown of our body cells while the other 1/3 are from our diet .

Food high in purine contents include:

• Red meat
• Animal innards like liver
• Seafood: anchovies, sardines, mussels, scallops, tuna
• Alcoholic beverages especially beer
• Food and drinks sweetened with fruit sugar ( fructose )

Purines have to be broken down in our body into uric acid to be removed through our kidneys and liver.

Gout occurs when uric acid crystals accumulate in your joint, causing inflammation and intense pain.

Uric acid crystals can form when you have high levels of uric acid in your blood due to high levels of cell breakdown or when there is excess ingestion of purine containing food.

Initially, gout attacks usually affect one joint with complete resolution of symptoms between attacks but at the later stages, gout attacks can affect multiple joints including those of the upper limbs with an increase in frequency of attacks.

Who are at higher risks? 

• Men are at a higher risk than female
• Age : gout tends to happen to adults in their 30s with risk increasing with age.
• Patients who are obese with metabolic syndrome
• Family history
• Diet high in purine
• Patients who are on certain type of medications such as : aspirin, hypertension medications like diuretics, ACE inhibitor and beta blockers

Diagnosing Gout

Through a combination of

• Typical symptoms

Patients often develop one or two joint pain and redness and swelling usually involving the lower limbs. The most common joint to be involved is the metatarsal-phalangeal joint of the big toe.

They often describe the pain to be of a rapid onset ( within a day or two ) and affects mobility. These joint pain comes and go.

• Lab tests including blood test and joint fluid analysis
• Visualising the uric acid crystals from joint fluid through polarised light microscopy. Not seeing any bacteria within the joint fluid to indicate an infective cause for the swelling. Having an elevated blood level of uric acid levels maybe used as a diagnosis.
• Typical X-ray findings. That include Subcortical cysts without erosions. Punched out or rat bitten erosion of bones

Treatment

In the acute stage when patient is suffering from pain,

• Rest
• Adequate hydration
• Anti inflammatory medications like NSAIDs and COX-II inhibitors, sometimes steroids
• Colchicine

Long term management of Gout

1) Dietary changes :

• Reduce intake of purine-rich animal protein like beef, lamb, pork and innards
• Reduce intake of shellfish , tuna, sardines, anchovies
• Reduce intake of alcohol especially beer
• Reduce intake of fructose sweetened food and beverages
• Take more plain water or unsweetened beverages.
• Take more fruits and vegetables
• Low fat or no fat fairy products are suitable too.

2) Get physically active and lose weight

These can help with obesity - which is a risk factor for gout. Exercise and losing weight can help reduce the inflammatory state of the body and helps in building strong joints as well

3) Medications

In patients with long term gout that has high uric acid levels in their blood with frequent gout attacks, medications like allopurinol and febuxostat can help in reducing the levels and therefore help in reducing the frequency of the attacks.