Chronic Pain

Gout (Gouty Arthritis)

When I was a young girl, old movies always depicted royalty, usually the king, sitting on his throne, elevating his foot because his big toe was throbbing in terrible pain. In olden days, it was the rich, male, upper class who had gouty attacks because only they had access to the rich foods and alcohol that predisposed one to it.

Gout is due to persistently elevated levels of uric acid in the blood. This occurs due to a combination of diet and genetic factors. At high levels, uric acid crystallizes and the crystals deposit in joints, tendons, and surrounding tissues, resulting in a gouty attack. Diagnosis of gout may be confirmed by the presence of crystals in the joint fluid or in a deposit outside the joint. Sometimes the crystals can be seen on X-rays and present in blood uric acid levels even though they may be normal during an attack. There is also a relationship between gout and kidney disorders, enzyme deficiencies, and lead poisoning.

Nowadays, any of us can be royalty since we now know gout can be associated with multiple issues. According to The Arthritis Foundation, these include:

  • injury or surgical procedures
  • hospitalizations
  • periods of stress
  • reactions to diets high in meat and seafood
  • moderate to excessive alcohol use (especially beer)
  • being overweight
  • hypothyroidism
  • high blood pressure
  • diabetes
  • psoriasis
  • certain medications (such as antibiotics and water pills)
  • It can also occur with some tumors or cancers. Gout may also accompany psoriasis and is common in patients with transplanted organs due to medications that are often needed. Susceptibility to gout can also be inherited- if your parents have gout, you have a 20% risk of getting it as well.

The CDC estimates that more than 8 million Americans, or 4% of the population, suffer from gout and there are more than 3 million US cases annually. Gout is more prevalent in men then women, and usually men develop it between the ages of 30 and 50. Women are more prone to gout after menopause because estrogen appears to help flush uric acid into the urine. It is rare in children and young adults. Gout worsens with age and usually peaks at 75. It has become more common in recent decades due to increasing risk factors. Some factors include living longer, underlying medical issues, rising rates of obesity, changes in diet, and metabolic syndrome. (Read here to learn more about metabolic syndrome).

The Mayo Clinic reports that gout is a common and complex form of arthritis characterized by sudden, severe attacks of pain, swelling, redness, and tenderness in the joints. Often the joint at the base of the big toe if affected, but it can occur in the ankles, knees , elbows, wrists and digits. Gout is a general term for a variety of conditions caused by a buildup of uric acid in the blood which comes from two places- produced by the body and from the diet. Any extra uric acid usually filters through the kidneys and gets passed in the urine. If the body produces too much uric acid or fails to excrete it in the urine, crystals of monosodium urate form in the joints and tendons. These crystals cause intense inflammation leading to pain, swelling and redness. It is the body’s reaction to these irritating crystal deposits in the joints that causes intense pain. Mild cases may be controlled by diet alone. Recurring attacks of gout may require long-term medications to prevent damage to bone and cartilage and deterioration of the kidneys. Those who suffer from chronic gout may feel tiny, hard lumps accumulating over time in the soft fleshy areas in the hands, elbows, feet, or earlobes. These deposits, called tophi, are concentrations of uric acid crystals and can cause pain and stiffness over time. If similar deposits form in the kidneys, they can lead to painful and potentially dangerous renal stones.

An attack of gout can occur suddenly, often in the middle of the night, due to lower body temperatures, with the sensation that a joint is on fire. The affected joint is hot, swollen, red, and so tender that even the weight of a bed sheet can seem too much to bear.

• Intense joint pain: Gout usually affects the large joint of your big toe, but it can occur in any of the other joints listed above. The pain is likely to be most severe within the first four to twelve hours after it begins. Without treatment, it usually subsides in 3-10 days.

• Lingering discomfort: After the most severe pain subsides, some joint discomfort may last days to weeks. Later attacks are likely to last longer and affect more joints. Some people never experience a second attack, but an estimated 60% of people who have a gout attack will have a second one within a year. Overall, 84% may have another attack within three years. Controlling blood levels of uric acid is important.

• Limited range of motion: As gout progresses, the needle like crystal deposits can damage joints and limit range of motion.

Pseudogout is also a form of arthritis characterized by sudden, painful swelling in one or more joints. While it can affect the big toe, it is more commonly seen in larger joints such as the knee, wrist, or ankle. It can also be referred to as calcium pyrophosphate deposition disease or CPPD, the common term “pseudogout” was coined for the condition’s similarity to gout. Crystal deposits within a joint cause both conditions, although the type of crystal differs for each condition. It isn’t clear why crystals form in the joints and cause pseudogout, but the risk increases with age. These crystals become more numerous as people age, with symptoms usually occurring over the age of 60 in both sexes. They are also seen in nearly half the population older than age 85. But, most people who have these crystal deposits never develop pseudogout. It’s not clear why some people have symptoms and others don’t. Anti-inflammatory agents are the treatment of choice.

Gout symptoms may come and go, but there are excellent ways to manage symptoms and prevent flares. Nonsteroidal anti inflammatory agents (NSAIDs), steroids, or colchicine improve symptoms. Once the acute attack subsides, levels of uric acid can be lowered through lifestyle changes. Frequent attacks may require long-term medication use, such as allopurinol or probenecid. Eating a diet high in low-fat dairy products, reducing alcohol intake, weight and risk factors can be preventative. See your healthcare provider for a complete exam to delineate the source of your pain, rule out other possible concerns, and underlying conditions.

-Dr. Courtney

-Main image courtesy of Boulder Medical Center

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