1. Remember: Gout is common
- When joints suddenly become swollen and painful, your first thought should be gout.
- About 2.5% of people in the UK have gout and their number is increasing.
- Gout is 5 times more common in men than in women and your chances of having it increase with age: at age 65-70, 10% of men and 2% of women have gout.
2. It’s all about Uric Acid -what’s that?
- The white chalky substance in bird droppings is uric acid (or “UA”). You know what it does to your paintwork, imagine what it does to your joints.
- UA is produced when we breakdown chemicals called purines, which are the building blocks of DNA and found in almost all foods.
- High levels of UA can lead to the accumulation of crystals in the tissues. These crystals trigger sudden and often disabling attacks of joint pain. Over time this damages joints.
- UA can form stones in the kidneys and build up deposits under the skin called tophi.
- What causes high UA levels? In the majority of cases it’s because the kidneys are not removing UA efficiently. This is often hereditary but a high total intake of purines in the diet worsens the problem. Some people “over produce” purines because of other medical conditions and, very rarely, high levels can be due to genetic abnormalities.
3. Take ALL gout seriously
- It’s not just joints that are at risk. The first attack of gout is a warning of health problems in the future.
- People with high UA levels have increased risk of heart attack and stroke. This effect is magnified since people with gout tend to be heavier, with higher blood pressure and greater diabetes rates; the (Metabolic Syndrome).
- So, if you have these problems and now find you suffer from gout too, your health risks are even higher.
4. You can’t diagnose gout with a blood test, but it does help!
- When gout starts in the usual way – with sudden pain, swelling and redness in the big toe – it’s fairly easy to diagnose.
- Some people, however, have attacks in other joints, especially as the gout advances.
- UA levels go down while you are unwell, so it’s best to check the levels once the acute attack has settled. It’s useful to have blood tests for Rheumatoid Arthritis (Rheumatoid Factor and Anti-Citrullinated Protein Antibody) at the same time.
- If the cause of attacks isn’t obvious, look for hard yellow collections of UA crystals under the skin (tophi) which will clinch the diagnosis.
- If there is fluid in a joint your doctor can draw some out look for crystals in the laboratory.
5. Concentrate on changing lifestyle, not just eliminating ‘Trigger Foods’
- Most people are aware that certain foods may trigger gout attacks. Seafood, red meat, offal and beer often bring on attacks, but just avoiding “trigger foods” won’t cure the problem.
- Dieting reduces the UA level by about 10% but weight loss must be gradual as crash dieting can bring on attacks.
- If you are overweight, work hard on weight reduction. We should all focus on “Healthy Eating” but this alone isn’t enough for most. Cut calorie intake and combine with steady weight loss . This can reduce the number of attacks and significantly decrease the health risks that go with it.
- Don’t forget! Alcohol contains a lot of calories, as do sugary drinks.
6. Control the ‘flares’
- Acute attacks can be really painful and disruptive so you need to know how to control them.
- Anti inflammatories are widely available and are often used as “first line” treatment. Colchicine can help shorten attacks but many people get nausea and diarrhoea at higher doses or in combination with some other treatments.
- Occasionally short courses of steroids for a few days are helpful. Injection of steroid directly into the joint seems drastic but can be very helpful.
- Believe it or not eating cherries or taking cherry extract can cut the number of attacks while the crystals are dissolving, but many patients still have attacks.
7. Don’t wait too long to start long term medication to sort out gout
- As more and more crystals accumulate in the joints, skin and kidneys it gets harder to control gout. The more crystals you have built up the slower the recovery.
- The usual first treatment chosen to lower UA levels is Allopurinol.
- Febuxostat can be used if there are problems with Allopurinol.
- Some Rheumatologists use Febuxostat first especially if there are problems with the kidney function. There are other treatments to try if these are not successful.
8. Know your UA levels. Aim for a target of 360μmol/L (6mg/dL)
- If you have gout it is vital to check the UA level to see if is going down with the changes you make. It turns out that the magic number is 360.
- Below a blood level of 360μmol/L the crystals slowly dissolve. Sometimes a lower “target” of 300μmol/L (5mg/dL) is chosen to speed up the clearance of crystals especially if there are large tophi.
- In the “Treat to target” approach the UA levels are checked every month and the Allopurinol dose is slowly stepped up until the UA is at target. It can take a few months after that for the attacks to settle.
9. If you start on treatment – stick to it or the gout will return
- Long term it is a good idea to check the UA levels once per year keep gout under control and avoid complications.
- In the UK 40% of patients given long term treatment such as Allopurinol do not stick to their treatment plan.
10. You’ve made ‘lifestyle changes’ – now stick with them long term
- Now your gout is under control that doesn’t mean you can forget the lifestyle changes. You still need to stick with these changes to keep it at bay, and to control risks of other problems like heart attack and stroke.