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Know More About GOUT

Gout causes attacks of pain and swelling in one or more joints. An anti-inflammatory painkiller usually eases an attack quickly. Lifestyle factors may reduce the risk of having gout attacks. These include losing weight (if overweight), eating a healthy diet, and not drinking much alcohol or sugar-sweetened soft drinks. If gout attacks recur, then taking vitamin C supplements and/or allopurinol each day can prevent them.

Gout causes attacks of painful inflammation in one or more joints. It is a type of arthritis (although it is very different to the more common rheumatoid arthritis and osteoarthritis). The pain of a gout attack can be severe.

Gout is caused by a chemical in the blood called uric acid (urate). Uric acid is usually harmless and is made in the body. Most is passed out with the urine and some from the gut with the stools (faeces). In people with gout the amount of uric acid in the blood builds up. From time to time the level may become too high and tiny grit-like crystals of uric acid may form. The crystals typically collect in a joint. The crystals irritate the tissues in the joint to cause inflammation, swelling and pain – a gout attack.

Note: some people have a high level of uric acid but do not form crystals or have gout. Also, rarely, some people with a normal level of uric acid have gout attacks. However, as a rule, the higher the level of uric acid, the greater the chance of developing gout.

Why does uric acid build up?

Normally, there is a fine balance between the amount of uric acid (urate) that you make and the amount that you pass out in the urine and faeces. This keeps the level of uric acid in the blood in check. However, in most people with gout, their kidneys do not pass out enough uric acid and the blood level may rise. They are said to be under-excreters of uric acid. Their kidneys usually work otherwise normally.

In some people, the build-up of uric acid may due to other factors. For example:

  • Drinking too much alcohol can cause uric acid to build up.
  • If you do not have enough vitamin C in your diet.
  • If you drink sugar-sweetened soft drinks high in fructose it can cause uric acid to build up. A recent research study found that having two drinks a day of a sugar-sweetened soft drink increased the risk of developing gout by 85%. (Drinks labelled as ‘diet’ or drinks containing artificial sweeteners were not found to increase the risk.) Fructose-rich fruits and fruit juices may also increase the risk.
  • Certain foods may ‘tip the balance’ to raise your uric acid higher than normal. In particular, eating a lot of heart, herring, sardines, yeast extracts, or mussels may increase the level of uric acid. However, eating a normal balanced diet should not have much effect on the uric acid level.
  • Some medicines may raise the level of uric acid. For example, ‘water’ tablets (diuretics) such as bendroflumethiazide, aspirin (at full painkiller dose – not low-dose aspirin used to prevent blood clots), and some chemotherapy medicines.
  • More uric acid is made than usual in illnesses where the cells of the body have a rapid turnover. For example, severe psoriasis and some blood disorders.
  • People with certain other conditions have an increased risk of developing gout. These include:
  • Obesity.
  • High blood pressure.
  • Kidney damage.
  • Diabetes mellitus.
  • Bone marrow disorders.
  • Lipid disorders (especially hypertriglyceridaemia).
  • Vascular disease.
  • Enzyme defects such as hypoxanthine guanine phosphoribosyltransferase (HGPRT) deficiency and glucose-6-phosphate dehydrogenase (G6PD) deficiency.

Gout affects about 1 in 200 adults. Men are more commonly affected than women. A first attack of gout typically develops in middle age but it sometimes occurs in younger people. It tends to run in some families, as there is a family history of gout in about 1 in 5 cases. It may be that the genetic make-up that you inherit from your family may be a factor in becoming an under-excreter of uric acid (urate).

Gout usually occurs in attacks. An attack typically develops quickly over a few hours. It usually causes severe pain in one joint. The base of the big toe is the most commonly affected joint. Walking can be very painful and even the weight of bedclothes can hurt.

However, any joint can be affected. Sometimes two or more joints are affected. Affected joints usually swell and the nearby skin may look red and inflamed. If left untreated, a gout attack may last several days but usually goes completely within 7-10 days. Less severe attacks can occur which may be mistaken at first for other forms of arthritis. Weeks, months or even years may go by between attacks. Some people only ever have one attack.

A gout attack can be very painful. However, other effects from gout are uncommon. Joint damage may occur if you have recurring attacks. In a few people, uric acid crystals form kidney stones or may cause some kidney damage. Sometimes the crystals form bumps (tophi) under the skin. These are usually harmless and painless but sometimes form in awkward places such as at the end of fingers. Tophi occasionally become infected.

Gout is usually diagnosed if you have the typical gout symptoms and a raised blood level of uric acid. If there is doubt as to the cause of the pain and swelling, your doctor may take some fluid out of a swollen joint. This is done with a needle and syringe. The fluid is looked at under the microscope. Crystals of uric acid (urate) can be seen in the fluid to confirm the diagnosis of gout.

General measures

If you are able to, raise the affected limb (usually a leg) to help reduce the swelling. The easiest way to raise your leg is to recline on a sofa with your leg up on a cushion. An ice pack (or pack of frozen peas) held against the inflamed joint may ease the pain until the gout treatment medicines (below) start to work:

  • Wrap the ice pack (or peas) in a towel to avoid direct skin contact and ice burn.
  • Apply for about 20 minutes, and then stop. (It should not be applied for long periods.)
  • Repeat as often as required BUT make sure the temperature of the affected part has returned to normal before applying again.

Anti-inflammatory painkillers

A short course of an anti-inflammatory painkiller will quickly ease most gout attacks (within 12-24 hours). There are several types and brands, such as diclofenac,indometacin and naproxen. Your doctor will prescribe one. Many people with gout like to have a supply of tablets on standby in the home just in case an attack occurs. They are usually needed only for a few days until the inflammation and pain go.

Most people can take short courses of anti-inflammatory painkillers without any problem, although side-effects occur in some people:

  • Bleeding from the stomach is the most serious possible side-effect. This is more of a risk if you are aged over 65, or have had a duodenal or stomach ulcer. Stop the tablets and see a doctor if you develop indigestion, have upper tummy (abdominal) pain, pass black stools (black faeces), or if you are sick (vomit) or pass blood. Read the leaflet that comes with the tablets for a list of other possible side-effects.
  • Some people with asthma, high blood pressure, certain kidney problems and heart failure may not be able to take anti-inflammatory painkillers.
  • Some people taking certain other medicines should not take anti-inflammatory painkillers. This is because of a possible risk of the two medicines interacting. Therefore, check with your doctor or pharmacist if you are taking other medication, before taking anti-inflammatory painkillers.

Also, don’t take more than one anti-inflammatory painkiller at a time unless specified by a doctor. For example, some people take low-dose aspirin every day (which is classed as an anti-inflammatory medicine) to prevent blood clots. Aspirin plus another anti-inflammatory medicine increases the risk of bleeding from the stomach.

Therefore, if you are already taking aspirin and develop gout, you need to discuss the options with your doctor. For example, your doctor may advise that you take another medicine to ‘protect the stomach’ if you need to take aspirin and another anti-inflammatory medicine. Remember – some painkillers that you can buy from pharmacies contain aspirin.

Other treatments

Colchicine is an alternative medicine that eases gout attacks. It is usually only used if you have problems or side-effects with anti-inflammatory painkillers. Steroid tablets or injections can also reduce the pain and inflammation. They are another alternative if there are problems or side-effects with anti-inflammatory painkillers and colchicine.

Canakinumab is another option that has recently been introduced.

Lifestyle measures and medicines can help to prevent gout attacks.

Lifestyle suggestions

  • If you are overweight, try to lose some weight. This can help to lower the uric acid (urate) level. However, do not use diets that increase uric acid levels, such as high-protein diets or starvation diets.
  • Eat sensibly. A high uric acid level may be lowered a bit by avoiding a high protein intake and foods rich in purines, such as liver, kidneys and seafood. Also avoid eating foods high in yeast extracts, such as Marmite®. See separate Gout Diet Sheet for more details.
  • If you drink a lot of alcohol then it may help if you reduced the amount that you drink. You do not need to stop drinking alcohol altogether but cutting down may help if you drink a lot. In particular, avoid binge drinking. Keep to within the recommended levels of alcohol – these are 21 units per week for men and 14 units per week for women.
  • If you drink a lot of sugar-sweetened soft drinks, especially those containing fructose, it may help to reduce the number or cut them out all together.
  • If you are taking any medicines, check whether they are a cause of gout (see above). An alternative medicine may be available. Your doctor will advise.
  • Avoid lack of fluid in the body (dehydration) by drinking plenty of water (up to two litres per day unless there is a medical reason why not to).
  • Have your blood pressure checked at least once a year. High blood pressure is more common in people with gout.

With the help of lifestyle changes, many people only have an attack of gout every now and then. All you may need is to have some anti-inflammatory painkillers on standby to treat each attack.

For some people, attacks occur more often. In this situation, you can take a medicine to prevent attacks.

Allopurinol is used to prevent gout attacks

Allopurinol is a commonly used medicine to prevent gout attacks. Allopurinol does not have any effect during a gout attack and it is not a painkiller. It works by lowering the level of uric acid in the blood. It takes 2-3 months to become fully effective. You need to take it every day to keep the uric acid level normal to prevent gout attacks.

As a general rule, regular allopurinol may be advised by your doctor if you:

  • Have had two or more attacks of gout within a year.
  • Have one or more tophi (described above).
  • Have any joint or kidney damage due to gout.
  • Have one or more kidney stones made from uric acid.
  • Have had a gout attack and are taking long-term medication that can cause gout.

When you first take allopurinol, it can sometimes cause a gout attack. This is because it may cause the level of uric acid to rise slightly before it falls. For this reason it is not normally started during a gout attack. It is best to start it about 3-4 weeks after an attack has settled. Also, an anti-inflammatory painkiller is often prescribed for the first 2-3 months after you start allopurinol, just in case the allopurinol causes a gout attack. Once the level of uric acid has been brought down, taking allopurinol each day usually works well to prevent gout attacks.

The dose of allopurinol needed varies from person to person. Treatment is usually started with a low dose. A blood test is often done after a month or so to check that the level of uric acid has come down. If not, the dose may need to be increased. Most people end up taking about 100-300 mg each day to stop gout attacks.

If a gout attack occurs while you are taking allopurinol, you can still take an anti-inflammatory painkiller to relieve the pain. However, this may indicate that you need an increased dose of allopurinol. Side-effects are uncommon with allopurinol. Read the information that comes with the packet of tablets for details about possible side-effects. If side-effects do occur, other medicines with a similar action are sometimes prescribed. For example, a medicine called febuxostat may be an option if you cannot take allopurinol for medical reasons or due to side-effects.

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Patient Guide to GOUT

Gout, a painful form of arthritis, has long been associated with diet, particularly overindulgence in meat, seafood and alcohol. As a result, gout treatment used to include severe dietary restrictions, which made the gout diet hard to stick to. Fortunately, newer medications to treat gout have reduced the need for a strict gout diet.

In many ways, the gout diet resembles the healthy eating plan recommended for most people. Besides helping you maintain a healthy weight and avoid several chronic diseases, this diet may contribute to better overall management of  your gout.

Gout occurs when high levels of uric acid in your blood cause crystals to form and accumulate around a joint. Your body produces uric acid when it breaks down purines. Purines occur naturally in your body, but you also get them from eating certain foods, such as organ meats, anchovies, herring, asparagus and mushrooms.

Purpose

A gout diet helps to control the production and elimination of uric acid, which may help prevent gout attacks or reduce their severity. The diet isn’t a treatment for gout, but may help you control your attacks. Obesity also is a risk factor for gout, so losing weight can help you lower your risk of attacks.

Diet details

A gout diet reduces your intake of foods that are high in purines, which helps control your body’s production of uric acid. If you’re overweight or obese, lose weight. However, avoid fasting and rapid weight loss because these can promote a gout attack. Drink plenty of fluids to help flush uric acid from your body. Also avoid high-protein diets, which can cause you to produce too much uric acid (hyperuricemia).

To follow the diet:

  • Limit meat, poultry and fish. Animal proteins are high in purine. Avoid or severely limit high-purine foods, such as organ meats, herring, anchovies and mackerel. Red meat (beef, pork and lamb), fatty fish and seafood (tuna, shrimp, lobster and scallops) are associated with increased risk of gout. Because all meat, poultry and fish contain purines, limit your intake to 4 to 6 ounces (113 to 170 grams) daily.
  • Eat more plant-based proteins. You can increase your protein by including more plant-based sources, such as beans and legumes. This switch will also help you cut down on saturated fats, which may indirectly contribute to obesity and gout.
  • Limit or avoid alcohol. Alcohol interferes with the elimination of uric acid from your body. Drinking beer, in particular, has been linked to gout attacks. If you’re having an attack, avoid alcohol. However, when you’re not having an attack, drinking one or two 5-ounce (148 milliliter) servings a day of wine is not likely to increase your risk.
  • Drink plenty of fluids, particularly water. Fluids can help remove uric acid from your body. Aim for eight to 16 8-ounce (237 milliliter) glasses a day.
  • Choose low-fat or fat-free dairy products. Some studies have shown that drinking skim or low-fat milk and eating foods made with them, such as yogurt, help reduce the risk of gout. Aim for adequate dairy intake of 16 to 24 fluid ounces (473 to 710 milliliters) daily.
  • Choose complex carbohydrates. Eat more whole grains and fruits and vegetables and fewer refined carbohydrates, such as white bread, cakes and candy.
  • Limit or avoid sugar. Too many sweets can leave you with no room for plant-based proteins and low-fat or fat-free dairy products — the foods you need to avoid gout. Sugary foods also tend to be high in calories, so they make it easier to eat more than you’re likely to burn off. Although there’s debate about whether sugar has a direct effect on uric acid levels, sweets are definitely linked to overweight and obesity.

There’s also some evidence that drinking four to six cups of coffee a day lowers gout risk in men.

Results

Following a gout diet can help you limit your body’s uric acid production and increase its elimination. It’s not likely to lower the uric acid concentration in your blood enough to treat your gout without medication, but it may help decrease the number of attacks and limit their severity. Following the gout diet and limiting your calories particularly if you also add in moderate daily exercise, such as brisk walking also can improve your overall health by helping you achieve and maintain a healthy weight.

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Patient Education for Gout

Gout is an arthritic condition that occurs primarily on the feet, although it certainly can manifest itself in other parts of the body. It affects about 3% of the population and is predominantly a male disorder with only 5% of the cases affecting females, generally post menopause.

This condition is associated with hyperuricemia which is an increased amount of uric acid crystals circulating through the blood, however, not all people with hyperuricemia experience gout attacks.

Unlike osteoarthritis or the “wear and tear” arthritis we all suffer, the symptoms of gouty arthritis are different in that it is manifested by an acute onset of severe pain, redness and swelling, many times for no apparent reason. Many patients will complain of a sudden onset of pain occurring early in the morning while asleep. The theory behind this is that when sleeping, the feet are elevated and there is a slight diminishment of blood to the feet which in turn decreases the temperature of the feet just enough for the uric acid to crystallize in the joint of the foot and create pain.

Other factors that may precipitate this attack include local trauma, including foot surgery, with an acute medical illness, or following a high purine (protein) diet or alcohol binge.

These attacks most commonly occur in the foot, primarily in the big toe joint. The next most common locations are the middle of the foot followed by the ankle joint. They can also occur at the attachment of tendons such as the Achilles tendon into the heel. It is possible to have these attacks in more than one area at the same time.

Diagnosis is generally on clinical appearance and the presenting history because it is not uncommon for a patient’s uric acid level to be normal during an attack. Colchicine is the drug of choice in acute attacks and is almost diagnostic for gout if the pain is alleviated by the drug. There are other drugs available, primarily the anti-inflammatory class of drugs, but it is important to note that they all do not work in gout. In fact, low doses of aspirin will actually worsen an attack. Consultation with your foot specialist is essential.

The pain generally lasts a few days, and then begins to diminish. The problem is when a person experiences multiple gout attacks over short periods of time. Aside from the pain of the attack, each attack does damage to the affected joint and a person can reach the point where there is so much damage from the repeated attacks, which the joint now becomes constantly painful and surgical intervention is usually necessary.

In those individuals experiencing repeated attacks of gout it is necessary to find out why. Generally speaking, it is usually from either the body overproducing too much uric acid or the kidneys excreting too little uric acid. In either event there is too much uric acid circulating throughout the body. Consultation with specialist is necessary to determine the cause. There is medication available to treat both causes.

Patients who are prone to gout attacks should modify their diets in regards to a low purine diet and should abstain from organ meats such as sweetbread, liver, kidney; anchovies, sardines; rich gravies and alcohol.

A simple gout treatment that has been mentioned in various sources is that of eating cherries or drinking cherry juice on a regular basis. This may diminish gout attacks. It is postulated that the anthrocyanins in cherries reduces the amount of uric acid circulating in the blood.

Read more about Gouty Arthritis

Ready more about Patient Education to Gout

Read more about Gout