Gout

Overview

Gout is a type of arthritis characterized by the accumulation of urate crystals in the joints due to elevated uric acid levels in the blood. It presents with severe pain attacks and joint inflammation.

It is seen in 2-3% of men in our country, and more often in postmenopausal women. Although it is also known as "the disease of the rich," it can actually develop in any condition that increases uric acid production or decreases its excretion.

Symptoms

Acute gout attack:

• Usually starts at night or early morning
• Most commonly in the big toe joint (podagra) - 50%
• Severe, unbearable pain
• Redness, warmth, swelling in the joint
• Joint tenderness (even contact with bedsheet unbearable)
• Attack lasts 3-10 days
• Other commonly affected joints: foot, ankle, knee, wrist, fingers

Triggers:

• Excessive alcohol consumption (especially beer)
• High-purine foods
• Dehydration
• Trauma
• Surgery
• Intense physical activity
• Diuretics
• Fasting
• Stress

If untreated:

• More frequent attacks
• Involvement of multiple joints
• Joint damage, deformity
• Balls of urate crystals under the skin (tophi)
• Persistent pain, limited mobility

Types / Stages

1. Asymptomatic hyperuricemia: High uric acid, no symptoms
2. Acute gout attack
3. Intercritical period: Between attacks
4. Chronic tophaceous gout: Late stage

Causes

Uric acid is the end product of purine metabolism. When it accumulates in the blood, it forms sharp crystals in the joints.

Causes of excess uric acid:

• Excessive purine intake (diet)
• Overproduction by the body
• Inadequate excretion by the kidneys (most common)

Risk Factors

Nutrition:

• High-purine foods: red meat, organ meats (liver, kidney), shellfish, sardines, anchovies
• High-fructose corn syrup drinks
• Alcohol (especially beer)
• Sugar consumption

Medical conditions:

• Obesity
• High blood pressure
• Diabetes
• Metabolic syndrome
• Cardiovascular diseases
• Kidney disease
• Hypothyroidism
• Some cancers, chemotherapy (tumor lysis syndrome)
• Psoriasis

Medications:

• Thiazide diuretics (hypertension)
• Aspirin (low dose)
• Cyclosporine
• Some tuberculosis medications

Other:

• Being male (4 times more common than women)
• Family history
• Age (30-50, after menopause in women)
• Recent surgery or trauma

Complications

• Recurrent acute attacks
• Chronic gout arthritis
• Tophi (outside joints, cartilage)
• Kidney stones (uric acid stones)
• Kidney disease
• Joint deformity
• Increased risk of cardiovascular disease
• Metabolic syndrome

When to See a Doctor

• Suspected first gout attack
• Recurring joint pain, swelling
• If attacks continue despite treatment
• Fever + joint inflammation (may be confused with septic arthritis)
• Lumps under the skin (tophi)
• Kidney stones
• Medication side effects

Diagnosis and Treatment

Diagnosis:

• Clinical findings
• Joint fluid analysis (gold standard - urate crystals)
• Blood test: Uric acid level (>6.8 mg/dL)
• Joint ultrasound (double-contour sign)
• Dual-energy CT
• Direct X-ray (in advanced cases)
• 24-hour urine uric acid (to distinguish overproduction/underexcretion)

Treatment:

Acute attack treatment (3-7 days):

• NSAIDs: Indomethacin, naproxen, ibuprofen
• Colchicine (effective at attack onset)
• Corticosteroids: Oral or intra-articular
• IL-1 inhibitors: Anakinra (resistant cases)
• Joint rest, ice application

Long-term preventive treatment:

Indications:

• More than 2 attacks per year
• Tophi
• Joint damage
• Kidney stones
• Chronic kidney disease

Medications (uric acid lowering):

• Allopurinol: Most common, xanthine oxidase inhibitor
• Febuxostat: Allopurinol alternative
• Probenecid: Increases uric acid excretion
• Pegloticase: Severe, resistant cases
• Target uric acid: <6 mg/dL (<5 in those with tophi)
• Can trigger attacks at start of treatment; prophylaxis (colchicine) recommended

Prevention and Nutrition

Nutrition:

To avoid:

• Red meat, organ meats (especially liver, kidney)
• Shellfish (shrimp, mussels, oysters)
• Sardines, anchovies, herring
• Sweet drinks, juices (fructose)
• Excessive alcohol (especially beer)
• Processed foods

To limit:

• Meat consumption (moderate)
• Peas, dried legumes (moderate)
• Mushrooms, spinach (moderate)

To consume:

• Dairy products (especially low-fat)
• Whole grains
• Vegetables, fruits (cherries are protective)
• Sweet potatoes, potatoes
• Eggs
• Plenty of water
• Vitamin C
• Coffee (moderate)

Lifestyle:

• Drink plenty of water (2-3 L per day)
• Maintain a healthy weight
• Regular exercise (rest during acute attack)
• Limit alcohol, especially beer
• Quit smoking
• Manage stress
• Keep blood pressure and sugar under control
• Regular check-ups
• Do not skip medications