Gout - AJPHI

Issue

Vol. 1 No. 2 (2024)

Date Log

Submitted
August 15, 2024
Accepted
November 27, 2024
Published
December 1, 2024

Understanding Gout – Pathogenesis, Diagnosis and Management

https://doi.org/10.69512/ajphi.v1i2.63
Aakriti Karki
Jalalabad Ragib Rabeya Medical College and Hospital, Bangladesh
Lumanti Manandhar
Rajiv Gandhi University of Health Sciences, Bangalore, India

Corresponding Author(s) : Aakriti Karki

iamaakritikarki@gmail.com

The American Journal of Patient Health Info, Vol. 1 No. 2 (2024)

Abstract


  1. Gout is one of the most common types of inflammatory arthritis caused by accumulation of uric acid crystals within joints.

  2. It typically starts in the big toe with symptoms such as intense joint pain especially at night, swelling and redness. This sudden episode is also called a “flare” or an “attack”. 

  3. Males are three times more likely to be affected with gout than females. Other key risk factors include obesity, hypertension, high alcohol and seafood intake.

  4. Diagnosis of gout is mostly clinical.  Joint fluid analysis which shows urate crystals and ultrasound are used to confirm the diagnosis. 

  5. An acute attack of gout can be relieved by anti-inflammatory agents like NSAIDs, Colchicine and Corticosteroids which is followed by long term management – uric acid lowering agents, lifestyle, weight and dietary management. 

Keywords

Gout uric acid NSAID Cochicine Rheumatologist
Karki, A., & Manandhar, L. (2024). Understanding Gout – Pathogenesis, Diagnosis and Management. The American Journal of Patient Health Info, 1(2). https://doi.org/10.69512/ajphi.v1i2.63
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References
  1. GE BMa. What do I need to know about gout? The Journal of family practice [Internet]. 2014 [cited 2024 Nov 13];59(6 Suppl). Available from: https://pubmed.ncbi.nlm.nih.gov/20544070
  2. Cross M, Kanyin Liane Ong, Culbreth GT, Steinmetz JD, Cousin E, Lenox H, et al. Global, regional, and national burden of gout, 1990–2020, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. The Lancet Rheumatology. 2024 Jul 1;6(8). Available from: https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(24)00117-6/fulltext
  3. Shoheera Punjwani, Jani C, Liu W, Loukas Kakoullis, Salciccioli I, Omar Al Omari, et al. The burden of gout among different WHO regions, 1990–2019: estimates from the global burden of disease study. Scientific Reports [Internet]. 2024 Jul 10 [cited 2024 Aug 7];14(1). Available from: https://www.nature.com/articles/s41598-024-61616-z
  4. Evans PL, Prior JA, Belcher J, Mallen CD, Hay CA, Roddy E. Obesity, hypertension and diuretic use as risk factors for incident gout: a systematic review and meta-analysis of cohort studies. Arthritis Research & Therapy. 2018 Jul 5;20(1). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6034249/
  5. Nieradko-Iwanicka B. The Role of Alcohol Consumption in Pathogenesis of Gout. Critical Reviews in Food Science and Nutrition. 2021 Apr 19;62(25):1–9. Available from: https://www.tandfonline.com/doi/full/10.1080/10408398.2021.1911928
  6. Helget LN, Mikuls TR. Environmental Triggers of Hyperuricemia and Gout. Rheumatic Disease Clinics of North America. 2022 Nov;48(4):891–906. Available from: https://pubmed.ncbi.nlm.nih.gov/36333002
  7. Roddy E, Choi HK. Epidemiology of Gout. Rheumatic Disease Clinics of North America [Internet]. 2014 May [cited 2019 Nov 16];40(2):155–75. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4119792/
  8. JR; A. Gout: Rapid Evidence Review. American family physician [Internet]. 2020 [cited 2024 Nov 13];102(9). Available from: https://pubmed.ncbi.nlm.nih.gov/33118789
  9. Eggebeen AT. Gout: an update. American family physician [Internet]. 2023 [cited 2024 Nov 13];76(6). Available from: https://pubmed.ncbi.nlm.nih.gov/17910294
  10. Urano W, Yamanaka H, Hiroshi Tsutani, Nakajima H, Matsuda Y, Taniguchi A, et al. The inflammatory process in the mechanism of decreased serum uric acid concentrations during acute gouty arthritis. The Journal of Rheumatology [Internet]. 2002 Sep [cited 2024 Aug 15];29(9):1950–3. Available from: https://www.jrheum.org/content/29/9/1950
  11. Oliviero F, Mandell BF. Synovial fluid analysis: Relevance for daily clinical practice. Best Practice & Research: Clinical Rheumatology. 2023 Jul 1;101848–8. Available from: https://pubmed.ncbi.nlm.nih.gov/37429800/
  12. Iwona Sudoł-Szopińska, P Diana Afonso, Jacobson JA, Teh J. Imaging of gout: findings and pitfalls. A pictorial review. 2020 Jan 1;45(1):20–5. Available from: https://pubmed.ncbi.nlm.nih.gov/32572014/
  13. Davies J, Riede P, van Langevelde K, Teh J. Recent developments in advanced imaging in gout. Therapeutic Advances in Musculoskeletal Disease. 2019 Jan;11:1759720X1984442. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6469273/
  14. Qaseem A, Harris RP, Forciea MA. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine [Internet]. 2016 Nov 1;166(1):58. Available from: https://annals.org/aim/fullarticle/2578528/management-acute-recurrent-gout-clinical-practice-guideline-from-american-college
  15. Shekelle PG, Newberry SJ, FitzGerald JD, Motala A, O’Hanlon CE, Tariq A, et al. Management of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline. Annals of Internal Medicine. 2016 Nov 1;166(1):37. Available from: https://pubmed.ncbi.nlm.nih.gov/27802478/
  16. Robinson PC, Terkeltaub R, Pillinger MH, Shah B, Karalis V, Karatza E, et al. Consensus Statement Regarding the Efficacy and Safety of Long-Term Low-Dose Colchicine in Gout and Cardiovascular Disease. The American Journal of Medicine [Internet]. 2022 Jan;135(1):32–8. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8688259/
  17. Holland B, Schlesinger N, Detry M, Holland B, Baker D, Beutler A, et al. Local Ice Therapy During Bouts of Acute Gouty Arthritis [Internet]. Available from: https://www.jrheum.org/content/jrheum/29/2/331.full.pdf
  18. FitzGerald JD, Dalbeth N, Mikuls T, Brignardello‐Petersen R, Guyatt G, Abeles AM, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care & Research. 2020 May 11;72(6):744–60. Available from:https://pmc.ncbi.nlm.nih.gov/articles/PMC10563586/
  19. Zhang Y, Chen S, Yuan M, Xu Y, Xu H. Gout and Diet: A Comprehensive Review of Mechanisms and Management. Nutrients [Internet]. 2022 Jan 1;14(17):3525. Available from: https://www.mdpi.com/2072-6643/14/17/3525/htm
  20. Stevens PE, Ahmed SB, Juan Jesus Carrero, Foster B, Francis A, Hall RK, et al. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International [Internet]. 2024 Apr 1;105(4):S117–314. Available from: https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf
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Aakriti Karkia, Lumanti Manandharb

a Jalalabad Ragib Rabeya Medical College and Hospital, Bangladesh

b Rajiv Gandhi University of Health Sciences, Bangalore, India

Key Highlights

  1. Gout is one of the most prevalent types of inflammatory arthritis caused by the accumulation of uric acid crystals within joints.
  2. It typically starts in the big toe with symptoms such as intense joint pain, especially at night, accompanied by swelling and redness. These sudden episodes are also called “flares” or “attacks”.
  3. Males are three times more likely to be affected with gout than females.
  4. Joint fluid analysis showing urate crystals helps in diagnosing the condition.
  5. Pain management with NSAIDs and colchicine is the main line of treatment for acute gout, while urate-lowering agents are used for long-term management.

Background

Gout is a type of arthritis caused by the buildup of uric acid crystals in the joints, leading to sudden and severe pain, swelling, and redness. Uric acid is a substance produced during the digestion of certain foods and drinks rich in purine, such as organ meat, seafood, and red meat. Gout most commonly affects the big toe but can involve other joints like the ankles, knees, and wrists. This condition occurs when the body either produces too much uric acid or fails to excrete enough, causing crystallization in joints. Long-term inflammation may cause the destruction of the joint. [1]

In the United States, gout affects approximately 9.2 million adults, i.e., 3.9% of the adult population. Depending on the population studies, the prevalence of gout ranges from less than 1 to 6.8% globally. [2] The prevalence of gout is 3.26 times higher in males than in females, which is directly correlated with age. [3]

Risk Factors of Gout

While gout can affect anyone, certain factors increase the likelihood of developing the condition, including:

Figure 1.

  • Obesity: Being overweight or obese increases your chances of getting gout. If your BMI is over 30, you’re more likely to develop it because extra fat raises uric acid levels in your body. [4]
  • High Blood Pressure: If you have high blood pressure, you are 1.64 to 2.11 times more likely to develop gout. This is because high blood pressure can affect how well your kidneys work, making it harder to remove uric acid from your body. [4]
  • Medications: Medications such as low-dose aspirin, cyclosporin, and diuretics can increase your risk of gout. They reduce your kidney’s ability to get rid of uric acid. [4]
  • Alcohol: Drinking alcohol, especially beer and spirits, can raise your risk of gout. For every ten g/day increments of alcohol consumption, the risk of gout increases by 1.21 times. It makes it harder for your kidneys to remove uric acid. [5]
  • Diet: Eating a lot of purine-rich foods like red meat and seafood or sugary drinks can increase uric acid levels and contribute to gout. [6]
  • Chronic Kidney Disease: If you have kidney disease, your kidneys won’t work as well to clear uric acid, which can lead to gout. [7]
  • Genetics and Gender: Your family history plays a role. Certain genetic factors can make it harder for your body to manage uric acid, increasing your chances of getting gout. Similarly, it is more common in men than women because men tend to have higher uric acid levels. [8]

Symptoms of Gout

Some of the most common presentations of an attack include the following features.

Figure 2.

  • Intense Joint Pain of Acute Flare: Gout often strikes suddenly, usually at night, with intense pain in the joint at the base of your big toe. Other joints, like your ankles, knees, elbows, wrists, and fingers, can also be affected, and the pain is sharp and severe. [8]
  • Swelling and Redness: You’ll notice the affected joint becoming visibly swollen, red, and even shiny. The area can feel tender to the touch, making any pressure, even from clothing or bedsheets, uncomfortable.[9]
  • Warmth in the Joint: The joint may feel unusually warm, almost like it’s radiating heat. This warmth is due to increased blood flow from the inflammation in the area.[8]
  • Lingering Discomfort: Once the intense pain starts to ease, you may still feel a dull ache in the joint that can last several days to a few weeks. Each flare can bring longer-lasting discomfort. [1]
  • Limited Range of Motion: When gout flares, moving the affected joint can be difficult, and you might feel a reduced range of motion. Even after the worst pain subsides, stiffness or soreness may make it challenging to use the joint fully. [8]

Diagnosis of Gout

Figure 3.

  • Blood Tests: You may undergo blood tests to measure levels of uric acid. High uric acid levels can increase the risk of gout, though not everyone with high levels will develop symptoms. Also, some people who do not have gout can also have increased uric acid levels. Blood tests, however, help rule out other causes of joint pain. However, it is important to note that uric acid levels can be normal during an acute attack. [10]
  • Joint Fluid Test: In this test, your doctor uses a needle to take fluid from the affected joint to look for urate crystals under a microscope. Seeing these needle-like crystals in the fluid is a clear sign of gout. [11]This is the definitive test for gout.
  • Imaging Tests: If needed, imaging tests like an X-ray, ultrasound, or CT scan can help visualize urate crystal buildup around the joints. Ultrasound is often used to detect early stages of crystal deposits. [12]However, radiography findings are unspecific for acute gout [13] but can depict tophi and their local destructive effect on surrounding tissues.

Treatment of Gout

Treatment is tailored to individual patients based on the number of joints affected, the nature and frequency of attacks, kidney functions, and other comorbidities.

Figure 4.

1. NSAIDs and Corticosteroids

For acute gout episodes, doctors typically prescribe NSAIDs like Ibuprofen. [14] These anti-inflammatory medications are effective if they are taken early during a gout attack and help reduce acute pain and swelling. They are usually taken for several days to a few weeks until the gout flare has subsided. Corticosteroids, such as prednisolone, may also be used. They are effective and generally safer, with fewer side effects. [15]

2. Colchicine

It has been used to treat gout effectively for many years. [16] However, some people cannot tolerate it due to its side effects, such as nausea, vomiting, or diarrhea. Your doctor can decrease your colchicine dosage if you have side effects or have pre-existing kidney or liver disease. Resting the affected joint and applying the eyes can help reduce swelling and pain during an attack.[17]

  • Acute Gout Flares: The American College of Physicians recommends using corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine as first-line treatments.
  • Long-Term Management: Once the acute phase subsides, the goal of treatment shifts to lowering uric acid levels to prevent future attacks. The target uric acid level in gout treatment is 6 mg/ dL or less to dissolve existing crystals and prevent new ones from forming.

3. Allopurinol

According to the American College of Rheumatology, allopurinol is the first lien treatment, starting at a low dose and titrating to achieve target serum levels. Febuxost is an alternative to allopurinol but has a cardiovascular risk. [18]

4. Lifestyle Modifications

Changes like dietary modification to reduce the intake of purine, decrease alcohol consumption, and improve weight management are other things that you should do to manage the condition. Hydration is another critical factor to be considered when maintaining low urine levels. [18]

Alcohol and Gout

Alcohol intake can significantly impact gout, as it raises uric acid levels in the blood, which may trigger or worsen gout attacks. Beer is particularly high in purines, which break down into uric acid, making it a common culprit in gout flare-ups. [19] Additionally, other types of alcohol, like wine and spirits, can contribute to increased uric acid production and reduce its elimination through the kidneys. For individuals with gout, limiting or avoiding alcohol is often recommended to reduce the risk of painful flare-ups. People with gout who choose to drink should do it in moderation and stay well-hydrated to help flush excess uric acid. [20]

Questions to ask your doctor

  1. How can I tell the difference between a gout flare and other types of joint pain?
  2. How can I relieve pain quickly if I experience a sudden gout attack?
  3. How often should I get my uric acid levels checked?
  4. Are there any alternative treatments that might help?
  5. What should I do if my gout doesn’t improve with treatment?

Conflict of Interest

Aakriti Karki serves as a non-paid research assistant at eHealthyInfo. Lumanti Manandhar worked as a paid freelance medical journalist with eHealthyInfo from 2022 to 2023. There are no other conflicts of interest to declare.

Peer Reviewed by

Anamol Acharya , MD

Parkview Regional Medical Center, Fort Wayne, IN, USA

References

  1. GE BMa. What do I need to know about gout? The Journal of family practice [Internet]. 2014 [cited 2024 Nov 13];59(6 Suppl). Available from: https://pubmed.ncbi.nlm.nih.gov/20544070
  2. Cross M, Kanyin Liane Ong, Culbreth GT, Steinmetz JD, Cousin E, Lenox H, et al. Global, regional, and national burden of gout, 1990–2020, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. The Lancet Rheumatology. 2024 Jul 1;6(8). Available from: https://www.thelancet.com/journals/lanrhe/article/PIIS2665-9913(24)00117-6/fulltext
  3. Shoheera Punjwani, Jani C, Liu W, Loukas Kakoullis, Salciccioli I, Omar Al Omari, et al. The burden of gout among different WHO regions, 1990–2019: estimates from the global burden of disease study. Scientific Reports [Internet]. 2024 Jul 10 [cited 2024 Aug 7];14(1). Available from: https://www.nature.com/articles/s41598-024-61616-z
  4. Evans PL, Prior JA, Belcher J, Mallen CD, Hay CA, Roddy E. Obesity, hypertension and diuretic use as risk factors for incident gout: a systematic review and meta-analysis of cohort studies. Arthritis Research & Therapy. 2018 Jul 5;20(1). Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6034249/
  5. Nieradko-Iwanicka B. The Role of Alcohol Consumption in Pathogenesis of Gout. Critical Reviews in Food Science and Nutrition. 2021 Apr 19;62(25):1–9. Available from: https://www.tandfonline.com/doi/full/10.1080/10408398.2021.1911928
  6. Helget LN, Mikuls TR. Environmental Triggers of Hyperuricemia and Gout. Rheumatic Disease Clinics of North America. 2022 Nov;48(4):891–906. Available from: https://pubmed.ncbi.nlm.nih.gov/36333002
  7. Roddy E, Choi HK. Epidemiology of Gout. Rheumatic Disease Clinics of North America [Internet]. 2014 May [cited 2019 Nov 16];40(2):155–75. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4119792/
  8. JR; A. Gout: Rapid Evidence Review. American family physician [Internet]. 2020 [cited 2024 Nov 13];102(9). Available from: https://pubmed.ncbi.nlm.nih.gov/33118789
  9. Eggebeen AT. Gout: an update. American family physician [Internet]. 2023 [cited 2024 Nov 13];76(6). Available from: https://pubmed.ncbi.nlm.nih.gov/17910294
  10. Urano W, Yamanaka H, Hiroshi Tsutani, Nakajima H, Matsuda Y, Taniguchi A, et al. The inflammatory process in the mechanism of decreased serum uric acid concentrations during acute gouty arthritis. The Journal of Rheumatology [Internet]. 2002 Sep [cited 2024 Aug 15];29(9):1950–3. Available from: https://www.jrheum.org/content/29/9/1950
  11. Oliviero F, Mandell BF. Synovial fluid analysis: Relevance for daily clinical practice. Best Practice & Research: Clinical Rheumatology. 2023 Jul 1;101848–8. Available from: https://pubmed.ncbi.nlm.nih.gov/37429800/
  12. . Iwona Sudoł-Szopińska, P Diana Afonso, Jacobson JA, Teh J. Imaging of gout: findings and pitfalls. A pictorial review. 2020 Jan 1;45(1):20–5. Available from: https://pubmed.ncbi.nlm.nih.gov/32572014/
  13. Davies J, Riede P, van Langevelde K, Teh J. Recent developments in advanced imaging in gout. Therapeutic Advances in Musculoskeletal Disease. 2019 Jan;11:1759720X1984442. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6469273/
  14. Qaseem A, Harris RP, Forciea MA. Management of Acute and Recurrent Gout: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine [Internet]. 2016 Nov 1;166(1):58. Available from: https://annals.org/aim/fullarticle/2578528/management-acute-recurrent-gout-clinical-practice-guideline-from-american-college
  15. Shekelle PG, Newberry SJ, FitzGerald JD, Motala A, O’Hanlon CE, Tariq A, et al. Management of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline. Annals of Internal Medicine. 2016 Nov 1;166(1):37. Available from: https://pubmed.ncbi.nlm.nih.gov/27802478/
  16. Robinson PC, Terkeltaub R, Pillinger MH, Shah B, Karalis V, Karatza E, et al. Consensus Statement Regarding the Efficacy and Safety of Long-Term Low-Dose Colchicine in Gout and Cardiovascular Disease. The American Journal of Medicine [Internet]. 2022 Jan;135(1):32–8. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8688259/
  17. Holland B, Schlesinger N, Detry M, Holland B, Baker D, Beutler A, et al. Local Ice Therapy During Bouts of Acute Gouty Arthritis [Internet]. Available from: https://www.jrheum.org/content/jrheum/29/2/331.full.pdf
  18. FitzGerald JD, Dalbeth N, Mikuls T, Brignardello‐Petersen R, Guyatt G, Abeles AM, et al. 2020 American College of Rheumatology Guideline for the Management of Gout. Arthritis Care & Research. 2020 May 11;72(6):744–60. Available from:https://pmc.ncbi.nlm.nih.gov/articles/PMC10563586/
  19. Zhang Y, Chen S, Yuan M, Xu Y, Xu H. Gout and Diet: A Comprehensive Review of Mechanisms and Management. Nutrients [Internet]. 2022 Jan 1;14(17):3525. Available from: https://www.mdpi.com/2072-6643/14/17/3525/htm
  20. Stevens PE, Ahmed SB, Juan Jesus Carrero, Foster B, Francis A, Hall RK, et al. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney International [Internet]. 2024 Apr 1;105(4):S117–314. Available from: https://kdigo.org/wp-content/uploads/2024/03/KDIGO-2024-CKD-Guideline.pdf

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