Gout is the most common form of inflammatory arthritis. It can occur when there is too much uric acid in the blood. Uric acid is produced by the breakdown of purines, which are found in the food we eat.
The kidneys help filter the blood to remove uric acid from our bodies through urine. When the kidneys are not able to filter the blood or process the level of uric acid at the same rate as it is created, it can lead to high levels of uric acid in the blood.
Genetics play an important role in who is at risk of developing gout. In some people, the body breaks down purines into uric acid and is able to eliminate excess uric acid more easily than others. Even if two people have exactly the same diet and eating habits, one of them may have higher levels of uric acid in the blood and be at greater risk of developing gout.
After months or years of high blood uric acid levels (usually above 400 µmol/l), uric acid can move out of the bloodstream and form uric acid crystals in the joints and soft tissues.
Uric acid crystals in soft tissue are usually found under the skin and can lead to the formation of hard, white chalk-like bumps. When present, these crystal deposits, called tophus, are usually seen around the ears and the extensor tendons, which are found in the hands and feet. Uric acid crystals in the joints can be responsible for gout attacks.
What are the warning signs of gout?
Gout attacks, especially the first ones, seem to come on suddenly, but they are often the result of months or even years of uric acid build-up in the blood. After a long continuous period of high levels of uric acid, it can start to move out of the bloodstream and form crystals in the joints and soft tissues.
Gout attacks are often triggered by the body’s immune system attacking the uric acid crystals formed in the joints and soft tissues. When immune cells, called neutrophils, enter the joint in an attempt to remove the uric acid crystals, inflammation, redness, pain and swelling occur, resulting in what is known as a gout attack.
Uric acid crystals can accumulate in many joints, but gout attacks are most common in the joints of the lower limbs, such as the knees, ankles and especially the base of the big toe. Many people will have no warning signs of their condition until their first gout attack.
As we go about our daily lives, microtrauma can occur in our bodies and joints, which can cause neutrophils to rush into these areas to help with the healing process. If your joint already has a build-up of uric acid crystals, this rush of neutrophils sent as part of the normal healing process can also detect the uric acid crystals and begin to react to try and remove them. This process could trigger a gout attack. As these microtraumas are often more common in the lower limbs and joints, these areas are more prone to a gout attack.
Other risk factors for a gout attack are infections, a drastic increase in the level of uric acid in the blood – for example after a high-protein meal, an evening of alcohol consumption (especially beer) or a period of dehydration.
How is gout diagnosed?
Before diagnosing gout, your doctor will ask you questions about your diet and any medicines you have recently taken. He or she will want to know :
- when your symptoms started
- how long they lasted or how long the attacks were
- how intense they were
- which joints were affected by the symptoms?
A blood test can measure uric acid levels, but elevated uric acid levels are not necessarily indicative of a gout attack. During an attack, your doctor may ask you to have a blood test. He or she may ask you to have a repeat blood test after the attack is over, to compare your uric acid levels during and after the attack.
To get a confirmed diagnosis of gout, your doctor will need to take a sample of fluid from your joint during a gout attack. To do this, he or she will insert a needle into the affected joint and extract a sample of fluid.
The sample will then be examined under a microscope to determine whether neutrophils are actively trying to remove uric acid crystals. If this activity is seen in the fluid sample, your doctor will be able to confirm the diagnosis of gout. When neutrophils are trying to remove crystals, the crystals are said to be intracellular.
Although taking a fluid sample is the most effective way to diagnose gout, it is not always possible or necessary depending on your situation. Your doctor may also make a presumptive diagnosis based on a combination of signs, symptoms and test results, such as blood tests, X-rays and ultrasounds.
Why is treatment of gout so important?
If left untreated, the duration and frequency of gout attacks tend to increase, and the disease can even become chronic. The continued presence of uric acid crystals in and around the joint can lead to destruction of the joint and soft tissue.
Fortunately, when patients receive appropriate treatment and medical care, the disease does not usually progress to this advanced stage. Most people with chronic gout are able to control the disease with medication. Lifestyle modification is an important part of treatment and can help prevent and manage flare-ups. Early diagnosis and treatment can reduce the risk of permanent joint damage and can reduce the frequency and severity of attacks.
How is gout treated?
There are three main steps to treating gout.
Step 1: Treat the active gout attack.
Step 2: Lower the uric acid level in the blood (if necessary).
Step 3: Add prophylaxis if medication is given to lower blood uric acid levels.
During an attack
When you have a gout attack, take these steps to control the pain and swelling:
- Apply ice to the joint, elevate it and rest it.
- Take colchicine, an anti-inflammatory drug, or prednisone as soon as possible, as recommended by your doctor.
- Drink plenty of water and fluids. Remember that alcohol, soft drinks or sugary drinks can trigger gout attacks, so avoid them.
- Take note of the joints affected, the intensity and course of the pain, and the duration of the attack.
- Make an appointment with your doctor for an assessment.
- Avoid stress as much as possible. Additional stress can make a gout attack worse. Consider using relaxation techniques, such as mindfulness meditation, to help regulate your body’s response to pain.
There are many home remedies for gout: Gout Home Remedies.
Cold and heat treatment
Cold
Using cold can help ease the pain during a gout attack. Cold reduces the flow of blood to the injury, which helps to reduce swelling and inflammation. However, cold should not be applied for more than 20 minutes at a time. In general, it is advisable to apply cold for 20 minutes, followed by a break of the same duration. Always put a protective layer (such as a towel) between the cold pack and the skin.
Using a commercial or homemade cold pack (such as a bag of crushed ice, ice cubes or frozen vegetables) can be helpful.
Cold is ideal for :
- reduce swelling
- reduce pain
- reduce blood flow to an inflamed joint
Heat
Heat should not be used during a gout attack as it can make symptoms worse. However, between attacks, a hot shower or the application of warm compresses (such as a hot water bottle or microwaveable compresses) are effective ways to reduce general pain and stiffness.
Heat is ideal for :
- relieving pain and stiffness
- relieving muscle spasms and stiffness
- improving range of motion
IMPORTANT: Do not apply heat to an inflamed joint – it may make symptoms worse.
Relaxation techniques and coping strategies
Someone, eye closed, meditating in natureEffective coping strategies can help you maintain balance in your life, keep your gout symptoms under control and cultivate optimism. Relaxing the muscles around a sore joint will reduce the pain you feel, although it is not always easy to relax when you are in pain. Gout attacks can be very painful, but there are techniques you can master to help you refocus your mind and relax your muscles during a painful attack.
Visualisation techniques, such as imagining burning sensations being put out by cold water or focusing on imagining what your pain might feel like, can also help to take your attention away from the pain itself and help you reframe your experiences of pain or discomfort.
Other techniques to consider include mindfulness meditation, deep breathing exercises or listening to a podcast, audiobook, narrated relaxation exercises or soothing music.
One of the keys to developing relaxation techniques is to practice the techniques you are most comfortable with, even when you are not feeling pain. This can be particularly useful for forms of meditation and visualisation.
Lowering the level of uric acid in the blood
After a first attack of gout, your doctor will discuss with you the possibility of taking medication to lower the level of uric acid in your blood. Your doctor will consider the following indications to help him or her make this decision:
- Two or more gout attacks within 12 months
- History of kidney stones
- Chronic kidney failure
- Bone erosion on x-ray
- Presence of tophus (uric acid crystals under the skin)
In order to lower the level of uric acid in your blood, your doctor will want to help you reach the following target uric acid level in your blood.
- If you do not have bone erosion or tophus present, a uric acid level below 360 µmol/l.
- If bone erosion or tophus is present, the uric acid level should be below 300 µmol/l.
Uric acid lowering drugs
Your doctor may prescribe medication to help lower your uric acid level in the blood. Uric acid lowering medication is intended to prevent future attacks of gout and to prevent the disease from becoming chronic.
Uric acid medication is often a long-term treatment option, as taking and discontinuing it can trigger a gout attack. Before prescribing this type of medication, your doctor may wait to determine how often you have gout attacks and whether they can be controlled by other treatment options. If you have two or three attacks a year, your doctor may want to consider this medication option with you.
Because starting a uric acid medication can also trigger a gout attack, your doctor will probably prescribe another medication, usually an NSAID or colchicine, to be taken daily for the first few months to help prevent further gout attacks while your body adjusts to taking a uric acid medication.
When you start taking a uric acid lowering drug, you may not see the benefits immediately. In some cases, it takes years to reach the target uric acid level and for the uric acid crystals in the joints and soft tissues to disappear.
The safest way is to start with natural medicine such as Curcuma or Boswellia which will will be your best ally.
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