Gout is a type of arthritis characterized by sudden or long standing episodes of pain, swelling, redness and heat around one or more joints. The big toe is the most commonly affected joint. Deposition of urate crystals, due to raised level of uric acid in the blood, is the reason behind attacks of gout. Men and women after menopause are more at risk of suffering from gout. Treatment options include drug therapy along with lifestyle changes. Gout attacks can be prevented to a large degree but patients at risk need to be very disciplined with regards to the dietary and lifestyle changes.
Gout usually presents as :
- Sudden onset of excruciating pain which is so intense that even contact with a bed sheet makes it unbearable. The pain is usually at night along with swelling, redness commonly around the big toe. Other joints namely wrist, finger, knee even heel may also be affected.
- Repeated episodes of gout attack may occur several times a year leading to restricted movement of the affected joints due to joint damage.
- In untreated long standing cases of gout, hard deposits of urate crystals are found beneath the skin around fingers, hand, elbow, Achilles tendon. These deposits (“tophi”) are usually painless but may become painful during an acute attack of gout.
- Sometimes urate crystals may also deposit in the kidney (renal stones) hampering normal functioning of kidney.
Increased level of blood uric acid due to reduced excretion by the kidneys or increased production is the main reason behind gout. Symptoms of gout occur due to precipitation of urate (monosodium) crystals around the joints, beneath the skin and in the kidney. This crystallization of uric acid occurs under influence of certain precipitating factors, namely :
- Cool temperature which is the reason why joints of the feet are more commonly affected at night.
- Rapid fluctuation of blood uric acid level due to trauma, surgery and certain drugs (water pills).
- Acidosis which is increased acidity of the blood.
The urate crystal deposits trigger inflammatory changes around the affected area (symtoms) via improper activation of the immune system.
The various risk factors are :
- Diet: consumption of vegetables rich in purine (beans, peas, spinach, lentils, mushrooms), protein (meat), sea food.
- Alcoholism: more than 2 drinks/day in males and more than 1 drink/day in females.
- Lack of physical fitness.
- Genetic defects: certain genetic disorders may lead to inherited high level of uric acid (hyperuricemia).
- Certain medical condition may raise the level of blood uric acid secondarily like obesity, insulin resistance, high blood pressure, raised cholesterol, triglyceride levels, lead poisoning (compromising kidney function) and renal failure due to other medical causes like skin diseases such as psoriasis and organ transplant.
- Certain drug intake: diuretics (water pills), aspirin (pain killer), niacin, immunity lowering drugs (immunosuppressive) like ciclosporin and tacrolimus.
- Men are more commonly affected except postmenopausal women.
Choice of drug depends on the nature of gouty attack, acute or chronic.
- Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen etc to reduce pain and inflammation.
- Colchicine to relief gouty pain.
- Steroids to control inflammation
After relief of acute pain of gout, the following drugs are used to prevent relapse of acute attack.
- Allopurinol inhibits production of uric acid.
- Probenecid facilitates removal of uric acid via kidney.