Gout
Treatment and prevention of painful attacks caused by uric acid crystal deposits
What is gout?
Gout is caused by crystals of uric acid forming inside a joint. The immune response to those crystals produces an attack that comes on over a few hours, most often at night, and is severe enough that the weight of a bedsheet is unbearable.
The base of the big toe is the classic site. Uric acid rises because the kidneys clear too little of it, and diet, alcohol, obesity, diuretics and kidney disease all contribute.
What you might notice
- A sudden hot, swollen big toe
- Several joints swollen and painful at once
How it is diagnosed
The history is characteristic: a single joint, rapid onset, exquisite pain, redness and swelling. Your doctor examines it and considers infection, which can look identical and is the important alternative.
Withdrawing fluid from the joint and finding the crystals under a microscope is the definitive test. A uric acid level taken during an attack is often misleading, since it commonly falls at that moment, so it is measured once the attack has settled.
Recovery
An attack treated within the first day settles over three to five days. Treated later it takes longer, so people prone to gout are given medicine to keep at home.
Uric-acid-lowering treatment is started after the attack has settled and is lifelong. The dose is raised until the level is under target, with cover for the first few months because starting it can itself provoke an attack.
If it is left untreated
Attacks become more frequent and involve more joints. Crystals accumulate as visible lumps in and around joints and under the skin, and those deposits erode bone and permanently damage the joint.
The kidneys are affected at the same time, through stones and through direct damage from urate. High uric acid also travels with high blood pressure, diabetes and heart disease, and those are looked for alongside.
Questions about gout
Is it caused by what I eat?
Diet contributes, and it is not the whole story. Red meat, shellfish, beer and sugary drinks all raise uric acid, and so do genetics, kidney function and diuretics. Diet alone rarely lowers the level enough in someone with repeated attacks.
Why did an attack start after I began the preventive tablet?
Lowering uric acid mobilises the crystals already in the joint, which can provoke an attack in the first months. That is expected, it is not a reason to stop, and cover is prescribed alongside for exactly this.
Do I need the preventive tablet for life?
Where attacks are recurrent, where there are visible deposits, or where there has been a urate stone, yes. The level has to stay under target continuously, and it rises again within weeks of stopping.
Other rheumatology treatments
Long-term treatment to control autoimmune inflammation affecting the joints and other organs
Day CareManagement of joint pain and stiffness caused by cartilage wear and degenerative joint changes
Day CareTalk to a care coordinator about gout
Leave a number and a care coordinator calls you back with what the treatment involves and which hospital it would be at. They book a consult only if you want one