Gout

What is gout?

Gout is a type of inflammatory arthritis that causes sudden, severe pain, swelling and redness in a joint. It happens when high levels of a substance called urate build up in your blood and form sharp crystals in and around your joints.

What are the symptoms of gout?

Gout usually causes attacks, also called flares, rather than constant symptoms. Between attacks, you may have no symptoms at all, even though urate crystals can still be present in your joints:

• Sudden, severe pain in a joint, most often at the base of your big toe, though it can affect your feet, ankles, knees, hands, wrists or elbows
• Hot, swollen, red skin over the joint, though redness can be harder to see on brown or black skin
• Tenderness so severe that even a bedsheet resting on the joint can be painful
• Shiny skin over the joint, which may peel as the attack settles.

Attacks often start suddenly, commonly overnight, and are usually at their worst within the first 12 to 24 hours. Left untreated, an attack usually lasts 1 to 2 weeks, and future attacks may last even longer if gout isn't treated.

What are the causes of gout and who is at risk?

Gout is caused by having too much urate (also called uric acid) in your blood. Urate is made when your body breaks down substances called purines, found in your own tissues and in certain foods. Your kidneys normally remove extra urate in your urine, but if your body makes too much, or your kidneys can't remove enough, urate levels build up and can form crystals in your joints.

Gout is more common in men, especially as they get older, affecting men roughly four times as often as women. Women rarely develop gout before the menopause, as the hormone oestrogen helps your kidneys remove urate, but this protection reduces once oestrogen levels fall.

Your risk is also higher if you're overweight, drink alcohol, have a family history of gout, or take certain medicines such as diuretics (water tablets) or some blood pressure medicines. Health conditions such as high blood pressure, high cholesterol, type 2 diabetes and chronic kidney disease are also linked to a higher risk.

Even if you're at risk, certain things can trigger an attack, such as an illness with a high temperature, drinking too much alcohol, a large or fatty meal, dehydration, or an injury to the joint.

Are there different types of gout?

Doctors sometimes describe gout as primary or secondary:

• Primary gout has no single identifiable cause and is often linked to your genes, especially if close family members also have it.
• Secondary gout is caused by something else, such as long-term kidney disease or long-term use of certain medicines that affect how well your kidneys remove urate.

Gout can also move through different stages. You can have high urate levels for years without any symptoms (called hyperuricaemia) before having a gout flare, and between flares, you may have long symptom-free periods.

If gout isn't treated, urate crystals can eventually build up under your skin as firm lumps called tophi, most often found on the ears, elbows or fingers.

How is gout diagnosed?

Gout can often be diagnosed from your symptoms alone, particularly if you have a typical attack affecting your big toe.

Your doctor will ask about your symptoms and may do a blood test to measure your urate levels, though high levels alone don't confirm gout, as some people have high urate without ever developing symptoms.

If the diagnosis isn't clear, you may be referred to a specialist (a rheumatologist) for further tests. These can include taking a small sample of fluid from the affected joint with a needle, which is examined under a microscope for urate crystals, or a scan such as an ultrasound or CT scan.

X-rays aren't usually helpful for spotting gout itself, since the condition doesn't often show up this way, but they're sometimes used to check for joint damage from repeated attacks, or to rule out similar conditions.

How is gout treated?

Treating gout has two parts: easing the pain of an attack, and longer-term treatment to lower your urate levels and prevent future attacks.

Treating a gout attack

You have a few different options for easing a flare up:

• Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, taken as soon as you notice an attack starting
• Colchicine, a medicine that reduces inflammation, though it can cause diarrhoea or stomach ache
• Steroids, taken as tablets for a few days, or sometimes as an injection into the joint or a nearby muscle.

Treating an attack doesn't lower your urate levels or stop future attacks, it only manages your symptoms while the attack lasts. Starting treatment as early as possible, ideally at the first sign of an attack, helps it work better.

Preventing future attacks

If you have frequent attacks or high urate levels, you may be offered a urate-lowering medicine, most often allopurinol, to take regularly, even when you're not having symptoms.

These medicines gradually dissolve urate crystals. It can take months or years to clear them completely, but once they're gone, your attacks should stop.

You may have more attacks in the first 6 months of starting a urate-lowering medicine, as shrinking crystals become more likely to shift, so your doctor may also prescribe a low dose of colchicine or an NSAID during this time. This doesn't mean the treatment isn't working, and you shouldn't stop taking it.

Self-care during a flare

Here are some things you can do alongside taking medication:

• take any prescribed medicine as soon as possible, ideally within 2 days of an attack starting
• rest and raise the joint
• keep the joint cool with an ice pack, or a bag of frozen peas wrapped in a towel, for up to 20 minutes at a time
• drink plenty of water, unless a doctor has told you not to
• keep bedsheets and clothing off the affected joint
• avoid putting pressure on the joint, as this can make the pain feel worse.

Between attacks, losing weight if you're overweight, cutting down on alcohol, eating a balanced diet, and staying active can all help reduce how often attacks happen. Avoid crash diets, though, as rapid weight loss can raise your urate levels and trigger an attack.