Dr Stuart Myers

Gout

Gout is a form of  inflammatory arthritis caused by deposition of uric acid crystals in joints. The big toe is commonly effected but any joint can be involved. It  is due to  excessive accumulation of uric acid in the blood. Uric acid is produced by the body when it breaks down foods high in purines.  Eg Prawns, Oysters, steak.  Other foods can cause increases in the  levels of uric acid in the blood. Eg Alcohol especially beer, and drinks sweetened with fruit sugar (fructose). Sometimes dehydration or Surgery  can precipitate an attack. The body either produces too much uric acid or your kidneys excrete too little uric acid. When this happens, uric acid can build up, forming sharp, needle-like urate crystals in a joint or surrounding tissue that causes severe pain, inflammation and swelling.


There are 2 forms of gout:


1.    Acute Gout - sudden and severe pain, stiffness, and swelling in a joint.eg in a big toe. The pain is often so severe that the sheets can’t even rest on the toe at night.

   In this case the wrist is red , hot and swollen and presents like an infection. Early on the Xrays are normal.


2.    Chronic Gout – This is a more insidious form of the disease. The problem is that the Uric acid  crystals can lodge in any or all joints in the body causing an accelerated form of Osteoarthritis. The damage can occur “silently” and when one becomes aware of  the damage  it is too late. It is important therefore to reduce the blood levels of Uric Acid. Uric acid can also cause Kidney stones and kidney damage. Gouty tophi can develop in the soft tissues. Below the tophi are almost "replacing" the finger.

 

 

In Australia the typical story for an acute attack of gout  is:
1.    A Hot Saturday afternoon
2.    A BBQ with prawns and oysters
3.    Multiple beers
4.    Then wake at 2:00 AM on Sunday morning with the sudden onset of  severe pain.- the pain may be  so severe that one cannot even tolerate the sheets resting on the toe.


Over time if gout is left untreated it  may cause damage to joints and  tendons. Below the wrist joint is destroyed with multiple cysts and collapse.

 
Diagnosis:
- Typical  history – see above .

There may be a +ve Family History of the condition.  

Medical conditions associated with gout include:
-  the Metabolic syndrome-  a combination of abdominal obesity, hypertension, insulin resistance, and abnormal cholesterol
- Kidney disease

- Leukaemias


Gout occurs especially in men age 40 – 60 and slightly later in women  ( Post Menopausal).

Gout may develop  in joints already affected by arthritis, eg Heberden's nodes in the DIP joints of fingers.

 

Gout is very rare in men before adolescence or women before menopause.


-  Examination – Red hot swollen stiff joint, Tophi – white lumps under the skin
- Blood tests – elevated Uric acid  ( > 0.42)
- Joint Fluid – A needle is is inserted  into the joint and tested for the presence of uric acid crystals -  -ve Birefringent Crystals seen under the microscope. 

       

 Treatment:


- Reduce alcohol intake
- "Every second glass is a glass of water"
- Avoid high purine foods – Seafood, Red meat, Organ foods eg Pate.
- Regular exercise
- Reduce weight

- Coffee & Vit C may reduce number of attacks of gout


 - Medications  - 1. Treat acute attack   Colchicine,  NSAIDS eg Indomethacin
                       2. Preventative – reduce blood levels of uric acid  Allopurinol   (Zyloprim )
                                - Indications for Zyloprim  – 2 or more acute attacks / year in an ongoing way.
                                                                    - Persistent elevated Blood Uric acid levels

                                 - Start with low dose  eg 50mg Zyloprim second daily but do not start during an acute attack of gout.

                                 - Increase dose over time and then have repeat blood tests to assess the response.
                                 - Start Zyloprim with NSAID cover for 2 – 3 weeks