All About Gout

What is Gout?

Gout has been around for thousands of years. It is believed that the Egyptians were the first to identify gout in 2,640 BC, and evidence of the condition has been discovered in mummies. Much later, in the 5th century BC, the great Hippocrates, referred to it as the ‘un-walkable disease.’

The term ‘gout’ comes from the Latin word ‘gutta’ meaning ‘drop.’ Hundreds of years ago it was believed that viscous humors circulated in the body, affecting its health, and that gout was caused by drops of these humors entering the joints.

Often referred to in the past as ‘the disease of kings’ or ‘the rich man’s disease,’ because of their propensity to overindulge in food and drink, that certainly isn’t the case today…

Incidences of gout are on the increase, particularly in the West. One study in the UK showed an increase of nearly 30% between 1997 and 2012, with an estimated 1 in 40 (2%) people afflicted in 2014. A similar study in the USA, in 2011, put the number of American sufferers at 1 in 20 (4%).

It is thought that the dramatic rise in gout over the past 20 years is due to several factors, including rising obesity levels, increasing alcohol consumption, and dietary and lifestyle changes.

Gout is recognized as one of the most painful types of arthritis, caused by a severe inflammatory reaction to monosodium urate crystals deposited in the joints. This inflammatory reaction triggers the classic symptoms of gout which are:-

  • hot to touch
  • tenderness
  • redness
  • shiny looking skin
  • swelling
  • inflammation
  • stiffness
  • severe pain

The most common place for gout is in the big toe, but it also affects the instep, heel, side of the foot, ankle, knee, fingers, wrist, and elbow.

It’s very common that the very first attack one gets is in the big toe, during the night in bed.  It is thought that 60% - 70% of all gout attacks occur in the joint at the base of the big toe. It even has its own name: when in the big toe it is sometimes referred to as ‘podagra,’ from the Greek meaning ‘foot pain.’

Many folks having their first gout attack, unaware that it could be gout, don’t bother seeking medical attention and treat it at home with painkillers or anti-inflammatories. For a mild case, this usually does the trick, with the attack subsiding after two or three days.

A more severe attack usually warrants attending your doctor for a diagnosis. This level of gout can last for two or three weeks, with some discomfort continuing for several weeks more.

The affected area usually returns to normal after an attack. However, once having had an initial attack, irrespective of its severity, the patient is at a very high risk of having further flare ups, which usually increase in frequency and severity.

In some cases, particularly where the sufferer does not address the problem and does not take the condition seriously enough, these flare ups can merge to form almost constant gout. Chronic gout such as this can result in deformities and several serious health issues, including a higher risk of death.

What Causes Gout?

Gout is caused by too-high levels of uric acid in the body. This is a condition called ‘hyperuricemia’ which, if not addressed, can lead to the formation of microscopic needle-shaped crystals (monosodium urate) in the joints and surrounding tissue.

Crystals of Urate in Polarized Light | Image: Wikipedia

The body’s innate immune system recognizes these crystals as potentially harmful and triggers an inflammatory response that floods the joint with inflammatory mediators to resist and eventually expel the intruders. It’s this inflammatory response at the site that actually causes the painful symptoms we associate with gout, not the crystals per se.

There are 2 situations which can lead to excess uric acid in the blood and therefore hyperuricemia. These are:-

  • the kidneys, for one reason or another, are not processing and excreting enough uric acid.
  • the body is producing too much uric acid for the kidneys to process.

 Where Does Uric Acid Come From?


Uric Acid and Purines

Uric acid is a byproduct of the metabolic breakdown of organic compounds called ‘purines’ which exist naturally in our bodies’ cells and in most of our food, with high concentrations in high protein food.

Normally, the uric acid produced is dissolved in the blood which is then processed by the kidneys and expelled out of the body through urine, with a small amount through stools.

This process is sufficient to maintain the uric acid at healthy levels. And this is important, because we need uric acid in our system as it’s one of the body’s most potent antioxidants.

Fructose and Uric Acid

Another cause of increased uric acid, often overlooked even by some general practitioners, is too much fructose consumption.

Fructose can be found in table sugar and a whole array of processed foods and drinks, often in the form of High Fructose Corn Syrup (HFCS).

Fructose can also be found naturally in some fruits and vegetables but in lower concentrations.

When too much fructose is ingested it can raise uric acid levels in several ways…

  • When fructose breaks down, lactic acid is produced. Studies have found a link between increased lactic acid and a decrease in uric acid excretion.
  • Too much fructose can lead to insulin resistance which has also been linked to decreased excretion of uric acid.
  • It has been found that when the liver has to deal with too much fructose, it results in elevated uric acid.  
  • Fructose is known to increase the breakdown of ATP (adenosine triphosphate), a molecule in the body which is the primary source of energy for the cells. It also happens to be a purine so, as it breaks down, uric acid is produced. 

Does High Uric Acid Always Mean Gout?

No, not everyone with high uric acid will get gout. But on the other hand, not everyone with low levels of uric acid will escape gout either.

The reasons for this anomaly are not known but, generally speaking, it is agreed that a person with high uric acid is at a higher risk of gout than someone with low levels of uric acid.

What Are The Safe Levels of Uric Acid?

According to the American College of Rheumatology, the target is to have a serum uric acid level less than 6 milligrams per deciliter (6 mg/dL).

The University of Rochester Medical Center have a slightly different measure: they allow a maximum of 7 mg/dL for males and 6 mg/dL for females.

The fact is that different laboratories and health authorities around the world use different reference points. Your doctor will advise you on what your results mean to you whilst taking into account your health position at the time.

Who is Most at Risk of Gout?

There are quite a number of high risk factors for developing gout. People at a higher risk of gout are those that…

  • are male, typically between the ages of 30 and 50, for the onset of gout.
  • females, usually over 50, (but males are 10 x more likely to get gout than females).
  • have a family history of gout or arthritis.
  • are overweight.
  • have a high-purine diet.
  • consume too much fructose.
  • drink too much alcohol.
  • have certain medical conditions such as, diabetes, arteriosclerosis, hypertension, thyroid problems, and hyperlipidemia.
  • have had surgery or extended bed rest.
  • have had an organ transplant.
  • are on certain medicines such as, diuretics, niacin (vitamin), salicylic acid (e.g. aspirin),  levodopa, and cyclosporine.

Note that, after the first gout attack, a sufferer will be at a very high risk of recurring gout. The second flare up can occur at any time, even months after the first, but subsequent attacks will usually occur with increasing frequently and severity.

How is Gout Diagnosed?

Your doctor will usually ask about your symptoms, when they appeared, and inspect the physical signs. Even although the symptoms could indicate gout, they will want to first rule out any other possible causes by asking pertinent questions and may even arrange for an x-ray.

They may also want to quiz you on any sudden change of diet (which can elevate uric acid levels), and any medications you may be taking.

They should also ask about any family history of arthritis and / or gout, if they don’t already have that information on record.

The symptoms are so classic that many doctors, in my experience, are able to diagnose the condition just with the steps above. Some may seek confirmation through a blood test to measure uric acid serum concentration. However, uric acid levels can go down during a gout attack (nobody really knows why) so a blood test is unreliable at this time.

They may even arrange for synovial fluid to be drawn off (needle aspiration) and examined under the microscope for evidence of crystals in the joint. This test can also help to rule out bacterial infection as a potential cause of the symptoms.

A recent study (2014) by the Mayo Clinic has shown that the most accurate test for some patients is a CT scan. The study author, Dr. Tim Bongartz, said that it should only be used where the patient has had several attacks of what looks like gout, but needle aspirations had shown up negative.

He took this view because, whilst the CT scan was more accurate in multiple attacks, the study showed that the synovial fluid test is effective in most cases and was actually more accurate in identifying first time gout flare ups.

How is Gout Treated Today?

Gout is generally treated with medications: one type to help relieve the pain and inflammation and another to help lower and maintain uric acid levels. Your doctor should also advise on dietary and lifestyle changes to be made alongside the medication.

Pain and Inflammation

For pain and inflammation, non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, indomethacin, and diclofenac can be effective.

Where a patient cannot take NSAIDs, or where they have been found to be ineffective, then colchicine may be prescribed instead. Colchicine is not a painkiller as such, but rather, helps to relieve pain by reducing the white blood cell count in the inflamed area.

And in the situation where a patient cannot take NSAIDs or colchicines, then corticosteroids, such as prednisone, can be prescribed. These can be administered orally or by injection into the affected area.

Uric Acid Reduction

For the reduction and maintenance of uric acid, allopurinol and the much newer febuxostat have proved effective. They come from the class of drugs called ‘xanthine oxidase inhibitors’ which prevent the release of xanthine oxidase, which is an enzyme that aids in the breakdown of purines and the formation of uric acid.

Another common uric-acid-lowering medication is probenecid from the class of drugs called ‘uricosurics.’ This works by increasing uric acid excretion in the urine with the result that uric acid levels in the blood are reduced.

Uric-acid-lowering medications have to be taken continuously as they can only work whilst being taken. In other words, if they are stopped, uric acid levels can rise again. Anyone who has been prescribed these drugs is usually advised to take them for life.

Many people find this tough to do. But if they go along the drug route they just have to, because it has been found that ‘stop-starting’ these types of medications can actually trigger gout attacks.

Side Effects

As with any drug, medications for gout have varying degrees of side effects. Depending on the drug, these can include things like:-

  • heartburn
  • nausea
  • vomiting
  • upset stomach
  • bloating / gas
  • stomach cramps
  • diarrhea
  • constipation
  • fluid retention
  • headache
  • dizziness
  • drowsiness
  • insomnia
  • blurred vision
  • loss of appetite
  • tinnitus (ringing in the ears)
  • mood swings
  • muscle weakness
  • slurred speech
  • numbness
  • tingling
  • rashes
  • balance problems
  • fever
  • chest pain
  • shortness of breath
  • poor wound healing
  • high blood pressure

This list is not complete but does give a good idea of the range of negative side effects that gout drugs can have. The actual side effects for a particular gout drug will be listed in the fact sheet inside the packaging.

Your doctor will be able to advise you on the most appropriate drug for your particular case, taking into consideration your medical history and any other medications you may be taking.

Diet and Gout

As well as prescribing medication, your doctor will normally advise you to change to a low purine diet…

Foods don’t all contain the same levels of purines; some have relatively low, some medium and some high concentrations.

The highest concentrations of purines are generally found in high protein food such as red meat, fish and shellfish, with particularly high levels in organ meat such as liver, kidneys, heart, and brains.

So your doctor will probably tell you to concentrate on avoiding or reducing your intake of foods such as:-

  • organ meat
  • game
  • fatty red meat
  • mincemeat
  • meat extracts
  • broth / gravy / consomm√©
  • sweetbreads
  • poultry
  • fish
  • shellfish
  • roe

But purines also exist in vegetables at varying concentrations. So your doctor may also advise you to reduce or avoid those with the highest levels of purines. These are typically:-

  • mushrooms
  • cauliflower
  • asparagus
  • lentils
  • spinach

Finally, they will definitely advise you to avoid alcohol, especially beer, which has been proved to be a major trigger for gout.

And don’t forget fructose and HFCS.

A sensible low purine diet should contain…

  • vegetables, especially dark green leafy vegetables (but not those above).
  • fruit, especially cherries, strawberries, blueberries, and pineapple.
  • low-fat dairy produce.
  • foods high in vitamin C, e.g., oranges, red cabbage, red bell peppers, potatoes.
  • essential fatty acids like, flaxseed, sunflower seeds, pumpkin seeds, walnuts, etc.
  • complex carbohydrates such as cereals, pasta, rice, vegetables, fruit, etc.

Are There Other Health Risks Associated with Gout?

It has been known for some time that frequently recurring gout can cause permanent joint damage and kidney stones. But more recently it has been discovered that high uric acid can lead to many more serious health problems, even death…

A recent University of Maryland study suggested that kidney disease, kidney failure, diabetes, stroke, heart disease and increased risk of death, was linked to hyperuricemia.

In 1997, researchers at the University of Kuopio, Finland, linked high levels of uric acid to increased risk of non-fatal and fatal stroke.

In the same year, researchers at John Hopkins found that high uric acid was linked to mini strokes that, although hardly noticeable, could lead to mental decline in aging adults.

So, not only is it important to get rid of the excruciating pain of a gout attack, it’s absolutely vital to do everything in your power to prevent recurring gout.

Click here for how to get gout relief in as little as 2 hours AND prevent the future gout attacks that can seriously damage your health.

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