When we think about arthritis, we usually imagine of diseases in which the joints gradually become swollen and painful over many years, eventually becoming deformed.
However, there are certain types of arthritis in which joint pain and swelling can “develop suddenly within a matter of hours”, become almost unbearable, and then improve over a few days with or sometimes even without treatment. Gout is one such form of arthritis.
How do they present?
You may have experienced, or heard about someone experiencing, a sudden episode where the big toe becomes extremely painful, swollen, and red, often during the night. The pain may then settle relatively quickly after taking painkillers. The same thing can happen in the ankle, knee, wrist, elbow, or the joints of the fingers. Pain can be so severe that some may end up in acute and emergency seeking urgent pain relief.
What happens in gout?
Gout occurs when the level of uric acid in the body becomes elevated. However, “not everyone with a high uric acid level develops gout”. That is one of the interesting things about this disease.
When uric acid levels become high, urate can deposit as crystals in and around the joints. The immune system then reacts against these crystals, causing the sudden inflammation and severe symptoms, characteristic of a gout attack, within a few hours. When this process happens repeatedly, it can gradually damage the joints and surrounding tissues.
Why even doctors can get confused sometimes?
Someone who is not familiar with gout may assume that bacteria have entered the skin around the joint, causing cellulitis, or that bacteria have entered the joint itself, causing septic arthritis. That is because the skin around the area will look horrifyingly inflamed, especially in people with fair skin, misleading the clinician to think this is an infection. The inflammation can be so severe to a level where patient may even develop fever which would make the clinician suspicious of an infection furthermore.
These patients may be given antibiotics while they also receive painkillers for the pain. Since a gout attack can improve within a few days, they may “mistakenly believe that the antibiotics cured the condition”. In reality, the improvement may have occurred naturally or as a result of the medication used to control the inflammation and pain (painkillers/NSAIDs) as antibiotics do not help in gout.
Does this happen only once?
The next attack may sometimes occur years later. However, if gout is not properly treated, or if the uric acid level is significantly elevated, attacks can occur more frequently.
Dr Aruna Caldera Consultant Rheumatologist MBBS, MD, MRCP (UK), MRCP (Rheumatology)
One of the serious complications of untreated gout is “kidney damage”. Persistently elevated uric acid and urate crystal deposition in kidney tissues can contribute to kidney injury. This condition is known as urate nephropathy. Urate can also contribute to the formation of kidney stones, a condition known as urate nephrolithiasis.
In many people, who have a genetic predisposition to gout, the underlying problem is that the kidneys have a limited ability to remove uric acid from the blood. Uric acid is produced naturally in the body when amino acids, called purines, are broken down in the body.
Another important point is that if a person’s kidneys become impaired for any reason (even due to gout), their ability to excrete uric acid in the urine decreases. Therefore, kidney disease itself can contribute to the development of gout. In simple terms, gout can damage the kidneys as well as the damaged kidneys can also cause gout!
Disease at its most symptomatic with normal blood test!
Another unusual feature of gout is that the blood uric acid level can be normal during an acute attack. If the person assessing you is not sufficiently familiar with gout, they may see a normal uric acid result during a severe attack and incorrectly conclude that you do not have gout, specially if the clinical picture suits at infection, like I stated before.
That is why, if gout is suspected, the uric acid level may need to be checked again, after the acute attack has settled, often around 2–4 weeks later. You should also know that the reference range for uric acid also differs between men and women.
Treatment of Gout
There are two main aspects of treating gout. The first is short-term treatment to control the symptoms of an acute attack, particularly pain and inflammation. The second, and extremely important, approach is long-term treatment aimed at lowering and maintaining the body’s uric acid level at a target range. Without appropriate long-term urate-lowering treatment, when it is indicated, it can be difficult to prevent recurrent attacks and complications.
In patients who require urate-lowering therapy, the goal is “not” simply to bring the uric acid level somewhere within the laboratory’s general “normal range.” Treatment aims for a sufficiently low target urate level (lower limit of normal) so that existing urate crystals can dissolve and new crystal formation is prevented.
For many patients, gout requires long-term treatment. In selected patients, however, long-term medication may not always be necessary, depending on their individual circumstances.
Can this disease present differently?
Gout can also occur in different stages, and forms, including intercritical gout I’ve mentioned chronic gout, and tophaceous gout. In some stages, patients may experience persistent joint symptoms.
In tophaceous gout, deposits of urate crystals, known as tophi, can accumulate under the skin, producing visible lumps and swelling, sometimes causing significant deformity (refer the pictures).
With appropriate treatment, it is possible to protect both the joints and the kidneys and live a normal life. Reducing the pain of an acute gout attack by applying an ointment or taking pain medication, if and when you need it, does not mean that the underlying disease has been cured.
If you are receiving treatment for gout, excessive alcohol consumption should be avoided. Beer, in particular, can increase the risk of gout attacks. Red meat and certain other foods may also need to be consumed in moderation.
However, do not develop the misconception that you can cure gout simply by avoiding alcohol and controlling your diet. Lifestyle and dietary changes are important, but for many patients they are not a substitute for appropriate medical treatment.
Are there any other related risks like for many other forms of arthritis?
People with gout also have an increased risk of cardiovascular problems, including heart attacks and strokes, apart from the kidneys.
With proper treatment, you can protect your joints and kidneys and continue to live a normal life. Do not assume that simply reducing the pain of a gout attack means the disease itself has gone away. There is no magic oil to cure gout as quacks may claim, but as always, we have magic pills!