Find out about gout

Gout is an increasingly common cause of arthritis, which typically results in sudden and very severe flares of joint pain and inflammation. Information about gout and how to get it under control is summarised here, along with videos created by Lothian’s rheumatology service and information leaflets from Versus Arthritis.

Understanding Gout

Gout is more common in men than in women, and for both sexes becomes more common with increasing age; gout currently affects about 1 in 40 people in the United Kingdom. Gout is caused by an inflammatory reaction to urate crystals that have built up within the joints. Urate (or uric acid) is a normal break down product of our cells, which circulates in the blood and usually passes harmlessly in urine. However when levels of urate become raised, then crystals can form within the joints, or under the skin. High urate levels can be caused by kidney problems, drug treatments (particularly water tablets for high blood pressure or heart failure), as well increasing body weight, and sugary drink, alcohol and meat consumption. As the crystals build up in the body the risk of gout attacks increase, though it is still not well understood what triggers the acute reaction to these crystals.

What Causes gout?

Watch this video to find out more about gout, flares and how these relate to your urate level.

What is it like to live with gout?

Many thanks to former patient Tim for talking through his experience of gout.

Download an information leaflet about gout from the Versus Arthritis charity here.

What are the symptoms and signs of Gout?

Gout typically causes an intense swelling, redness, and heat in the affected joint. A typical flare comes on suddenly with pain building in intensity over a number of hours, though sometimes there is a preceding itch or tingling in the joint that can act as a warning. Flares usually settle over 7 to 10 days, though prompt use of gout medicines can resolve the flare more quickly. After the flare the skin can sometimes peel away, as the swelling subsides. The most commonly affected joints are the toes, feet and ankles, however knees, hands and elbows are relatively frequently involved and any joint in the body can be affected.

In patients with severe gout lumps of urate crystal can build up under the skin. A single lump is called a tophus, multiple lumps are called tophi. If these form close to the skin then they have a chalky, white appearance. Tophi typically form in cooler, more peripheral parts of the body such as the fingers and toes, overlying the elbows and knees, or even in the ear. Tophi are a marker of severe disease, but with sustained lowering of urate they should eventually disappear.

How is Gout diagnosed?

A diagnosis of gout can is often straightforward when there are recurrent flares of sudden onset, pain, redness and swelling of the big toe. The diagnosis can be confirmed by taking fluid from an affected joint and identifying urate crystals. This is not usually necessary, but in cases where the diagnosis is not obvious this is the most reliable test.

A simpler test in establishing a gout diagnosis is measuring serum urate levels. Urate must be raised for urate crystals to form and so all patients with gout will have had high levels of urate. This test result is often a cause of confusion however because urate levels often fall during a flare of gout. This means that if the blood test is taken from a patient suffering an acute flare of gout the result is often low and so misleading. The best time to measure urate is at least 4 to 6 weeks after the flare has resolved. Conversely most people with high levels of urate never go on to have attacks of gout, so by itself this blood test does not establish a diagnosis of gout.

How is Gout treated?

There are two key parts to the treatment of gout. Immediate treatment targets the pain and inflammation of an attack itself. For most people flares are treated with prompt use of non-steroidal anti-inflammatory pain killers such as naproxen, or ibuprofen. There is no evidence that one NSAID is more effective than any other, the key is taking an adequate dose, at the earliest sign of an attack coming on. For patients that are unable to take NSAIDs then alternative treatments include colchicine or prednisolone.

Long term treatment of gout aims to clear the crystals of urate from the body, and so prevent flares from happening again. This can only be achieved by lowering urate levels and keeping them low. This allows the crystals of urate to dissolve and be removed from the body, though it can take over a year for this process to be completed. Keeping levels of urate low ensures that no new crystals form and hence ensure flares of gout are permanently avoided.

Urate lowering is usually be achieved with allopurinol, though an effective alternative is febuxostat. Both treatments stop the body from making urate, and both are safe to take lifelong. The key for both treatments is to make sure that an adequate dose is taken to achieve target serum urate levels in the blood. In newly diagnosed individuals, or patients with severe tophaceous disease the target level is 0.3mmol/l or lower. In patients whose disease has been well controlled for a few years it is probably good enough to keep levels at 0.36mmol/l or lower.

A discussion of the treatments for gout is included in the video below summarising all you need to know about the treatments for gout flares and for flare prevention.

Links to information leaflets about gout treatments from the Versus Arthritis charity are included here

Ongoing management of gout

The key to keeping gout under control is ensuring that levels of urate are kept so low that no more crystals are ever formed. For most patients this can be achieved with a level of urate kept at or below 0.36mmol/l. Specialist guidelines suggest that urate levels should be checked once a year to ensure this goal is being maintained. Being careful in your diet and lifestyle is also important to help get gout under control

This video discusses a number of issues important in the ongoing care of gout.

We know that living with gout is hard, and can result in patients feeling anxious or low in mood. Some of the challenges in living with gout are discussed in this video

What about the future?

Research in Edinburgh has shown that supporting self-monitoring of urate levels using a finger prick test results in much better outcomes for patients with gout than usual gout care, with the frequency of flares reduced within 12 months and most patients free of flares completely after 2 years. One of the participants in a clinical trial of this approach speaks about his experience here.

If you would be interested in finding out more then follow the link HERE to the GoutSMART website where you can find out if any trials are currently recruiting in Edinburgh.

Other Sources of Information

More information is available on the Versus Arthritis website which is a great resource for all sufferers of arthritis, including gout.