Living with Gout - Arthritis Ireland

Living with
Gout
Arthritis Ireland helps people with arthritis take their lives
back. We provide real solutions by empowering people
with arthritis and those caring for them to take positive
action to manage the effects of their disease on their lives.
Our innovative and life changing education and
support programmes including Living Well With Arthritis,
Fit for Work and Breaking the Pain Cycle give people with
arthritis the knowledge and practical skills they need to
live their best possible quality of life. Our helpline provides
vital emotional and practical support and, because we
know that knowledge is power and central to living well
with arthritis, we provide an extensive range of free
educational information, such as this booklet.
Through our work we campaign for increased levels
of funding in rheumatology services to provide a world
class service that will positively change the outlook and
outcome of patients lives.
We also actively support and fund research into arthritis to
ensure that Ireland is at the forefront of new breakthroughs
leading to possible cures and also fund the training of
health professionals through medical students in university
to create a direct and positive improvement in patient care.
Many people have probably heard the
word gout but few people know much
about it. Gout has been known for more
than 2000 years. It can affect men of any
age. It is less common in women and then
usually only occurs after the menopause.
Luckily, gout is probably the rheumatic
disease for which there is the most
satisfactory treatment.
This booklet will help you understand
more about gout, what it is, what causes
it and how it can be treated so you can live
your best possible life with this condition.
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Contents
What is gout?
4
What causes gout?
4
What are the symptoms?
5
What to look out for before an acute attack
6
What are the long-term risks?
6
How is gout diagnosed?
7
Treatment of acute attacks
8
What you can do to avoid developing gout?
11
FAQs
13
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What is gout?
Gout is a medical condition that causes sudden and
severe episodes of joint pain, tenderness, warmth and
swelling. It usually affects the joint at the base of the big
toe but can affect other joints such as the knee, ankles,
hands or wrists.
What causes gout?
Gout is caused by the high levels of uric acid (also
known as urate) that occur as a result of eating foods
such as organ meats, anchovies and herring which are
high in chemicals called purines. When the human body
breaks down purines it produces uric acid.
In a healthy individual the body rids itself of any excess
uric acid through the kidneys into the urine. However,
those who are prone to gout will find that their body
may be producing too much uric acid or their kidneys
may not be excreting enough uric acid and causing a
build up in the body. As the uric acid levels increase, it
begins to collect in the joints and crystallises into sharp
needle-like, urate crystals. They accumulate in the joints
or surrounding tissue and cause pain, inflammation and
swelling.
A tendency to develop gout is influenced by genetics
and family history. In saying this, just because it is in
your family, does not mean that it will be passed onto
you. If you maintain a healthy diet and lifestyle it can
be potentially avoided. [You can read Arthritis Ireland’s
booklet ‘Healthy Eating and Arthritis’ for further
information or visit www.arthritisireland.ie]
Gout is more common amongst men as it has been
found that they have higher uric acid levels in their blood
than women. However, it can cause problems in women,
especially after the menopause.
What are the
symptoms?
Signs and symptoms of gout are generally acute –
they come on suddenly without warning. A significant
proportion of people with gout experience them at night.
1 Attacks usually occur in the big toe and any
physical contact is painful. The symptoms develop
over a few hours and the swelling can very often
look like an infection and the skin may peel.
2 Gout may also occur in the ankles, hands,
wrists, knees or feet. Many people describe the
affected areas as warm/hot. If several joints are
inflamed at once this is called polyarticular gout.
3 Urate crystals cause inflammation. This is where
the joint becomes intensely painful, red, hot, shiny
and swollen. Urate crystals can also collect under
the skin and elsewhere, forming small, firm, white
pimples called tophi, which are not usually painful.
4 Similar attacks can be caused by calcium crystal
deposits in joints. This type of crystal arthritis
(termed pseudogout or pyrophosphate arthritis)
affects the knee and other joints more than the
big toe and is linked with osteoarthritis.
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What to look
out for before
an acute attack
1 Look out for the early signs of an acute attack in
order to start taking treatment as soon as possible.
2 Suspect an acute attack of gout if a joint is unusually
painful.
3 Excessive eating of rich foods or drinking alcohol
can cause an attack to occur.
“It really helps to know
what triggers to look out for”
What are the
long-term risks?
Gout attacks may only occur once and never again,
or infrequently. However, some may experience regular
attacks after the first episode. The first few attacks of
gout may not cause any permanent damage to the joints
and you can expect a complete recovery, leaving you with
a normal joint. It is only when a joint is repeatedly attacked
by gout that the urate crystals can damage the joint and
start long-term (chronic) arthritis.
One of the most noticeable effects of regular gout attacks
is joint damage that is caused by the crystals that are
formed. Other consequences of gout are: problems with
the kidneys such as kidney stones and deformity and
decrease in mobility in the affected joints over time.
How is gout
diagnosed?
Gout can be difficult for doctors to diagnose because
the symptoms may be non-specific and they often mimic
other conditions such as joint infections. A doctor who
suspects a joint infection will have to rule out infectious
arthritis and establish a diagnosis of gout.
As a result of this, it is important for doctors to carry
out certain tests in order to be sure of the right course
of treatment and correct diagnosis.
n
Blood test – this test measures your levels of uric
acid. It is not definitive as some people with high uric
acid levels do not show gout symptoms while others
who have gout symptoms do not have high levels of
uric acid in their blood at the time of the attack.
n
Joint fluid test – in some cases a needle may be
used to collect synovial fluid from the affected joint.
The liquid is then examined under a microscope to
see whether urate crystals are present. This test is
usually only carried out in hospital or special clinics.
n
X-rays of joints – X-rays of the affected joints
maybe be examined to identify deposits of urate
crystals. X-rays show soft-tissue swelling and places
where the bone has been eroded as thinning of the
bone can occur.
Without treatment, an initial acute attack of gout will run
its course within several days or a week, by which time
all outward evidence of the disease disappears.
However, approximately 50% or more of people with
gout will have a second attack – which may not occur for
months or years. Subsequent attacks, however, are likely
to be more frequent, more severe, and more destructive
to joints and other tissue unless the problem is treated.
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“I tried so many things at different
times – just to get rid of the pain”
Treatment of
acute attacks
There are a number of possible treatments for
acute attacks:
1 NSAIDs – Non-Steroidal
Anti-Inflammatory Drugs
Acute attacks can be treated with non-steroidal antiinflammatory drugs (NSAIDs). NSAIDs are the most
commonly used medication for gout. NSAIDs help to
relieve the pain of gout and reduce inflammation. It is
advisable to take an NSAID prescribed by your doctor
at the very first sign of an attack as any delay in treating
an acute attack of gout delays relief.
NSAIDs can cause side effects including indigestion,
diarrhoea, a rash, headache, dizziness or aggravate
asthma. If NSAIDs are used for a long period of time,
they may produce other side effects, such as stomach
ulcers, heartburn, bleeding of the stomach lining or kidney
damage. Those with a history of peptic ulcers should be
especially careful and if possible, avoid taking NSAIDs.
Most NSAID should be taken with a stomach protector
such as a proton pump inhibitor. More recently, NSAID’s
have been associated with heart attacks and strokes in
some individuals.
2 Colchicine
Colchicine is commonly prescribed for the treatment of
gout. Colchicine works to reduce the inflammation and
swelling in the affected joints and these greatly reduce
the pain caused by gout. Side effects, such as nausea,
vomiting, and diarrhoea may occur with colchicine.
3 Steroids
If an acute attack of gout doesn’t improve with NSAIDs
or colchicine, or if you are not suitable for treatment with
these drugs, your doctor may prescribe a steroid injection
into the joint or a short course of steroid tablets by mouth
(usually no more than a few days).
4 Urate-Lowering
Therapy (ULT)
The goal of urate-lowering therapy is to encourage
urate crystals to dissolve and to prevent further crystal
formation. Urate-lowering therapy may prevent disease
progression, reduce the frequency of acute attacks or
eliminate gout attacks altogether.
Allopurinol
Allopurinol is a xanthine oxidase inhibitor. It reduces the
production of uric acid in your body. The safest option is
to start on a low dose (100mg/day) and increase the dose
gradually to lower the risk of gout flares and side effects.
Achieving full therapeutic benefit may involve an increased
dose of 300mg/day or greater. If a rash develops while
taking allopurinol, the drug should be discontinued, as this
can be a precursor to severe systemic hypersensitivity.
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Do not use this medication if you have ever had a serious
allergic reaction to allopurinol. Stop taking allopurinol and
call your doctor at once if you have any signs of skin rash,
no matter how mild. Take each dose with a full glass of
water. To reduce the risk of kidney stones forming, drink
eight to ten full glasses of fluids every day.
Febuxostat
Febuxostat is a newer treatment for gout and works in the
same way as allopurinol by lowering uric acid production.
It is usually recommended to start febuxostat therapy after
the gout flare has subsided. The recommended starting
dose of febuxostat is 80mg once daily. Some patients
may need a dose increase to 120mg depending on the
changes in serum uric acid levels.
Treatment with febuxostat is not recommended in patients
with ischaemic heart disease or congestive heart failure;
in patients in whom the rate of urate formation is greatly
increased; in patients taking azathioprine/mercaptopurine;
and in patients intolerant to lactose.
10
What you can
do to avoid
developing gout?
Weight management
If you are overweight, losing weight will help to prevent
gout attacks and improve overall health.
1 Diet
When too many purine-rich foods are consumed, uric
acid levels rise which leads to the formation of uric acid
crystals around the joints. It’s these sharp, needle-like
crystals that cause the pain of gout. Overproduction of or
excess uric acid may be the result of particular beverages
and food.
Try to reduce or eliminate foods high in purines from your
diet. Examples of foods high in purines are:
n
Red meat, organ meats like kidneys, liver and
sweetbreads
n
Shellfish
n
Gravy, meat extracts e.g. Oxo®, Bovril®
n
Fructose sweetened soft drinks
Sudden dramatic changes in diet and weight gain/loss
can be associated with gout attacks.
“It really helps to know what foods
trigger my gout attacks so I can
take positive action”
11
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2 Alcohol
Excessive consumption of alcohol has been linked to
gout. Large consumptions of alcohol such as beer, wine
and spirits can lead to a build-up of uric acid in the blood
which can cause gout.
If you are having a gout attack, alcohol should be avoided.
3 Fluids
A simple but effective way to reduce the risk of urate
crystallising in the joints is to drink lots of fluids, in
particular water. Sugary soft drinks should be avoided,
especially if you are trying to lose weight.
“When I feel the slightest tinge
of a possible gout attack,
I triple my water intake”
4 Cold
Applying cold to the area affected can provide temporary
pain relief
5 Exercise
Moderate stretching exercises can help keep the muscles
and tendons around the affected joint more flexible and
strong. Always consult a doctor or physiotherapist before
beginning an exercise programme. For more ideas on
exercising when you have gout, check out Arthritis
Ireland’s ‘Be Active with Arthritis’ exercise DVD and
booklet specifically designed for people with arthritis
available to purchase on www.arthritisireland.ie.
12
FAQs
Can women get gout?
Gout is more common among men; however it can
occur in women especially after the menopause.
Is gout curable?
It cannot be completely cured. But it can be prevented by
administering medication which can prevent further attacks.
Will I need to take gout
medication forever?
It depends on the type and severity of your gout. Gout
is different for each individual and some patients can
just have one or two gout attacks. They may be treated
only when attacks occur and/or some may require more
long-term, regular treatment.
Should I continue to
take my urate-lowering
therapy should
I experience a flare?
Urate-lowering therapy is not usually started during a flare,
however if you are already taking urate-lowering therapy
and you experience a flare it should NOT be stopped.
13
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Can gout cause serious
joint disease?
If the condition is left untreated, the results can
sometimes be serious. The attacks can be acute at
first and the joint returns to its normal state but eventually
the deposits of urate can lead to deformity and disability.
However preventative treatment can be taken as
mentioned in this leaflet.
Is urate deposited in
places other than the
joints?
Yes, urate can be deposited under the skin, for example
on the ears, fingers and toes. It can also be deposited in
internal organs particularly the kidneys.
Can it be harmful to take
the drugs that lower urate
over a long period of time?
It is unlikely the drugs in question will cause side effects
but occasionally may have to be discontinued depending
on the individual. Adverse effects such as a rash or
indigestion may arise occasionally, but otherwise they can
be taken indefinitely without side effects.
“I am vegetarian and don’t drink.
I thought it was only drinkers and
meat and fish eaters who got gout
– it just goes to show you”
14
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