Features July 2018 Issue

Understanding Gout

Gout is a chronic condition that usually requires lifelong treatment.

If you’ve ever had an attack of gout, you remember it. A joint suddenly becomes swollen, red, tender and painful. “A common scenario is waking up with pain in the toe or ankle,” says Cleveland Clinic rheumatologist Brian Mandell, MD, PhD.

To really understand gout you have to realize that this dramatic event is a symptom of the disease and not the disease itself. “The disease of gout occurs when deposits of uric acid accumulate in and around joints,” says Dr. Mandell. These deposits can occasionally break down and form crystals, which cause the symptom, which is the gout attack.

What Is Uric Acid?


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A gout attack is the symptom of a chronic condition that occurs when uric acid collects in joints.

The next logical questions are, what is uric acid and why would it collect in joints? Uric acid occurs naturally in the body. As cells break down, uric acid is released, and it is eliminated by the gastrointestinal (GI) tract and the kidneys.

“People get rid of uric acid with different degrees of efficiency, which is genetically determined,” says Dr. Mandell. In people whose kidneys and GI tract aren’t very efficient at removing uric acid, it can build up in the bloodstream.

When the level goes above 6.8 milligrams per deciliter (mg/dL), uric acid can leave the bloodstream and deposit in other parts of the body, primarily joints in the lower extremities (feet, ankles and knees). Some, but not all, people will react to these deposits with gout attacks.

“The basic concept is simple,” says Dr. Mandell. “High levels of uric acid predispose you to have uric acid deposits in joints, and these predispose you to have attacks.” The tendency to have high uric acid levels is inherited.

What about Food?

There’s a common misconception that gout is caused by overindulging in foods that are high in substances called purines, which break down into uric acid in the body. These foods include organ meats, some seafood and alcohol.

Food does not cause gout. Foods high in purines may raise uric acid levels, but only slightly and not enough to cause the disease. “That’s not the major problem for most people,” says Dr. Mandell.

Similarly, just eliminating foods that contain purines from your diet won’t lower uric acid levels enough to treat the disease. Most people also need to take medication. Nonetheless, following a healthy diet and losing weight (if overweight) are recommended.

What Triggers Attacks?

It’s not known exactly what prompts individual gout attacks. But there are some factors that make them more likely. People who are obese make more uric acid than normal, and they are more susceptible to gout attacks.

Food and drink don’t cause gout, but they may play a role in making attacks more likely. For example, if your uric acid level is already high, eating a lot of purine-rich foods may push it up just enough to cause problems. “Sudden changes in uric acid levels – which can occur if you binge drink alcohol or eat a big steak covered with crabmeat – can destabilize uric acid deposits, causing an attack,” says Dr. Mandell.

In addition, certain foods and types of alcoholic drinks may influence the body’s inflammatory reaction to uric acid crystals in joints, increasing the chance for attacks. Beer, for example, appears to affect both uric acid levels and the body’s response to crystals. Some foods cause the bacteria in the intestines to release fatty acids, which can influence the inflammatory response. This is not yet well understood, and is currently under investigation.

Some medications, such as diuretics (used to treat high blood pressure and heart failure), can raise uric acid levels, which may increase risk for attacks in a person who already has a high level.

Detecting Gout

For most people, the first indication that they have gout is an attack. Because joint swelling, pain and tenderness can have other causes, the first step is to be sure of the diagnosis.

A blood sample may be taken to measure uric acid levels. But just having a high level is not sufficient to make the diagnosis. Uric acid levels tend to fluctuate. In addition, some people can have high uric acid levels, but it hasn’t settled in joints. “Not everyone who has high uric acid levels develops gout,” says Dr. Mandell.

The definitive diagnostic test involves removing some fluid from a red, hot, swollen joint and examining it for the presence of uric acid crystals.

Treating the Symptom

Gout is treated with a two-pronged approach. Drugs that reduce inflammation are used for the acute attack. These may be over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen (Aleve®) or ibuprofen (Advil®, Motrin®), a stronger prescription-strength NSAID, colchicine or a corticosteroid.

An episode of gout usually lasts several days to a week, with or without treatment. If you do nothing else, the attacks are likely to come back within a year. Over time, they can become more frequent, last longer and involve new joints. But you can prevent this by treating the disease, not just the symptoms.

Treating the Disease

“To treat the disease, you need to lower uric acid levels and keep them significantly below the saturation point of 6.8 mg/dL,” says Dr. Mandell. The uric-acid-lowering drugs most commonly used are allopurinol (Aloprim®, Zyloprim®) and febuxostat (Uloric®).

The goal is to maintain the uric acid level below 6 mg/dL. Once this is achieved, uric acid will no longer leave the bloodstream and settle in joints. The uric acid that is already in joints will eventually dissolve and get excreted from the body. “Once you take away the deposits, you’ve treated the disease and the attacks will stop,” says Dr. Mandell.

Be warned that when the medication is first started, gout attacks may actually increase until the crystals are dissolved, which can take several months to over a year. “This doesn’t mean the urate-lowering drug is not working, and it should not be stopped,” says Dr. Mandell. He also emphasizes that this is a chronic condition and medication must be taken for life.

People with gout should also adhere to a healthy diet and limit alcohol consumption, especially beer. A study published in the journal BMJ (May 2017) found that following the DASH (Dietary Approaches to Stop Hypertension) diet may help lower uric acid levels. This diet focuses on vegetables, fruits, nuts, legumes, low-fat dairy products and whole grains.

Multidisciplinary Disease

A growing body of evidence suggests that high levels of uric acid are associated with other conditions in addition to gout, including diabetes, high blood pressure, kidney disease and heart failure.

These conditions, including gout, are increasingly being managed with a multidisciplinary approach. “Many medical centers are establishing gout care clinics,” says Dr. Mandell.

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