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GOUT

What is Gout ?

The normal joint contains two bone-ends, each covered with cartilage (which acts as a buffer). The joint is surrounded by a capsule (or sheath) and the capsule lining is called the synovium. It produces a little fluid to help oil and feed the cartilage surfaces. In crystal arthritis, crystals either of uric acid or calcium pyrophosphate form in the synovium and the joint fluid. This may result in a sudden reaction within the joint tissue. A condition called acute crystal arthritis is then said to be present. Attacks usually start at night, often in a big toe. The toe becomes red, hot, very swollen and tender. This can happen over a few hours. Any movement of the joint may be intensely painful. The attack lasts between 5 and 9 days on average. Attacks are likely to recur in the same joint and may later involve more than one joint if the underlying condition is not treated.

How does Gout occur ?

Uric acid is a naturally formed chemical in the blood. It comes from the breakdown of a natural chemical in food called purines. It is also formed by the breakdown of the body's own tissues, such as blood cells. The level of uric acid in the body is normally kept low because it is washed away in the urine by the kidneys. The level is mostly raised in people with kidney disease because they can't get rid of it. It is also raised in those with some rare blood disorders in which more uric acid is made. Some people's kidneys cannot get rid of uric acid, although the kidneys are otherwise completely healthy. This is a common factor leading to gout. The uric acid in the blood overspills in other body fluids such as joint fluid, where it forms crystals. It is these which may eventually lead to an acute attack of gout. It is not known why the other type of crystal (calcium pyrophosphate) occurs in joints. Such a condition is sometimes found in other medical conditions where the calcium level in the blood is raised (hyperparathyroidism). This type of joint problem is called pseudo-gout: the symptoms are very similar to ordinary gout.

Why does Gout occur ?

Gout runs in families but other factors also play a part. People who have a high uric acid level in the blood are more likely to get gout if they overindulge in eating rich food and drinking alcohol. The blood level of uric acid then goes up even further spilling into the joints and tissues. Dehydration may also bring on an acute attack in these people. It is therefore more common in hot climates. An upset such as injury, excessive fatigue, surgery or an illness may also bring on an attack. Gout is more common in men and is rare in children, and in women before the menopause.

Treatment Involved for Gout

A blood test will be done to measure the level of uric acid. If the level is high then gout is suspected. A high uric acid level can, however, occur in healthy people without gout, especially those who are overweight. In the early stages of gout, uric acid levels in the blood can occasionally be normal, especially if the blood sample is taken once the attack of gout has already settled. During an acute attack, the doctor may wish to take fluid out of the joint. It can then be examined for crystals. If uric acid is present, the diagnosis can be confirmed as gout. Other causes of crystal arthritis such as calcium pyrophosphate can also be identified in this way. This test also makes it possible to eliminate other causes of acute joint pain, such as an infected joint or rheumatoid arthritis. FOR THE ACUTE ATTACK, medicines called non-steroidal anti-inflammatory drugs, or NSAIDs are given. These are continued until the pain goes. They should be kept handy and started as soon as the joint starts to twinge. Early treatment shortens the attack. There are over 40 NSAIDs, and they should all be taken with food to avoid indigestion. Aspirin-containing tablets should be avoided: they can make gout worse. Colchicine is a good alternative which is used for those people in whom NSAIDs are for some reason unsuitable. PREVENTIVE TREATMENT is given to patients who have frequent attacks of gout and who have very high blood uric acid levels. Allopurinol tablets stop uric acid from being formed in the blood. Probenecid makes the kidneys get rid of more uric acid. Once started, both these types of tablets have to be taken every day for the rest of your life.

During Treatment for Gout

The acute attack of gout lasts 5 9 days. Starting anti-inflammatory drugs will shorten the attack. The tablets can be stopped once the pain and inflammation have settled. If the tablets appear to cause indigestion, rash, headache, dizziness or swollen ankles, the doctor must be consulted. Other side-effects are very rare. People with stomach ulcers cannot take NSAIDs and should have colchicine. If the attack does not respond to treatment, the doctor may prescribe steroids (cortisone-like drugs which reduce inflammation). The effects of allopurinol only last 24 hours after a dose and it therefore has to be taken daily. The dose needs to be gradually built up. It will be necessary to take an NSAID or colchicine at the same time as starting preventive treatment because an acute attack may be triggered by allopurinol or probenecid. If this happens, consult the doctor immediately.

After Treatment for Gout

If preventative treatment is started, it is likely that you will be free from acute attacks of gout within 2 years, and sometimes sooner.

If Gout Left Untreated

Uric acid crystals collect in the kidneys over a period of time to form stones. These can produce blood and pain on passing urine. They may also form deposits in the skin, visible as white chalky bumps called tophi . These are often seen on the hands and ears. If not treated, the attacks of gout may also become more frequent and affect more joints. They would gradually become damaged as the crystals collect and lead to osteoarthritis. Preventive drugs must be taken lifelong and daily. They are not just taken for an acute attack.