This is an arthritic condition that occurs primarily on the feet, although it certainly can manifest itself in other parts of the body. It affects about 3% of the population and is predominantly a male disorder with only 5% of the cases affecting females, generally post menopause.
This condition is associated with hyperuricemia which is an increased amount of uric acid crystals circulating through the blood, however, not all people with hyperuricemia experience gout attacks.
Unlike osteoarthritis or the “wear and tear” arthritis we all suffer, the symptoms of excessive uric acid production are different in that it is manifested by an acute onset of severe pain, redness and swelling, many times for no apparent reason.
Many patients will complain of a sudden onset of pain occurring early in the morning while asleep. The theory behind this is that when sleeping, the feet are elevated and there is a slight diminishment of blood to the feet which in turn decreases the temperature of the feet just enough for the uric acid to crystallize in the joint of the foot and create pain.
Other factors that may precipitate this attack include:
These attacks most commonly occur in the foot, primarily in the big toe joint. The next most common locations are the middle of the foot followed by the ankle joint. They can also occur at the attachment of tendons such as the Achilles tendon into the heel. It is possible to have these attacks in more than one area at the same time.
Below are common sites for the attacks.
Diagnosis is generally on clinical appearance and the presenting history because it is not uncommon for a patient’s uric acid level to be normal during an attack. in fact, the only way to confirm a diagnosis of gout is to actually test for uric acid crystals in the synovial fluid (joint fluid).
In some instances gouty arthritis may be mistaken for a cellulitis as an infection in the great toe joint will also present with what appears as a red hot swollen joint. The difference is, in a cellulitis there is almost always a local point of open skin where bacteria has invaded and caused an infection.
Analysis of the joint fluid for uric acid crystals vs. bacteria is the treatment of choice in making the proper diagnosis.
Lab work may be helpful to differentiate between the two conditions. This would include a white blood count (wbc), erythrocyte sedimentation rate (esr) and renal function studies.
Colchicine is the drug of choice in acute attacks and is almost diagnostic for gout if the pain is alleviated by the drug. This drug should not be used in individuals with kidney or liver disease, nor in those on dialysis.
Anti-inflammatory class of drugs may also be used, but it is important to note that they all do not work for this problem. In fact, low doses of aspirin will actually worsen an attack. The two anti-inflammatories I use are Indocin and Naprosyn. Consultation with your foot specialist is essential.
Steroids may be used in individuals who cannot tolerate NSAID's. They can be administered both orally and injected into the joint. When injected your doctor must make absolutely sure that you are suffering from gout and not a septic joint as an injection will only make matters worse.
The pain generally lasts a few days, and then begins to diminish. The problem is when a person experiences multiple attacks over short periods of time. Aside from the pain of the attack, each attack does damage to the affected joint and a person can reach the point where there is so much damage from the repeated attacks, the joint now becomes constantly painful and surgical intervention is usually necessary.
In those individuals experiencing repeated attacks of gout it is necessary to find out why. Generally speaking, it is usually from either the body overproducing too much uric acid or the kidneys excreting too little uric acid. In either event there is too much uric acid circulating throughout the body. Consultation with your family doctor is necessary to determine the cause. There is medication available to treat both causes.
Allopurinol In situations where a person is having attacks on a repeated basis, he or she should be on oral medication to control uric acid production, rather than medication to reduce the inflammation of an individual attack. This way destruction to the joints of the feet and ankle are minimized and of course there is less overall pain.
Uricosurics Where it is determined that the kidneys are under excreting uric acid, this class of medication helps improve the removal of uric acid from the kidneys.
Diet modification Patients who are prone to attacks should modify their diets in regards to a low purine diet and should abstain from organ meats such as sweetbread, liver, kidney, anchovies, sardines, rich gravy and alcohol.
Recent research has shown that there is a correlation between elevated uric acid levels and excessive intake of fructose (sugar). People who eat way too much sugar in their diets will tend to have elevated uric acid levels. The significance of this is that even though these individuals may not suffer gout attacks, the elevated uric acid becomes a marker for poor health secondary to poor eating habits. People who eat too much sugar in their daily diets are subject to what is known as metabolic syndrome. This increases their risk of diabetes, hypertension, and stroke just to name a few of the serious problems that can develop.
Cherry juice? A simple treatment that has been mentioned in various sources is that of eating cherries or drinking cherry juice on a regular basis. This may diminish the attacks. It is postulated that the anthrocyanins in cherries reduces the amount of uric acid circulating in the blood.
In an article published in the ARCHIVES OF INTERNAL MEDICINE (2009) it has been suggested that increasing your intake of vitamin C may reduce the incidence of gouty arthritis. click here for the article.
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