All about gout

It was once a condition typically associated with rich, overweight, port-drinking men and was grossly misunderstood. Nowadays, due to changes in diet and lifestyle, gout is much more common within the general population. Fortunately, we have the knowledge and means to manage it in an effective way, and we don’t have to resort to trying the bizarre ‘remedies’ of bygone times!

“Roast a fat old goose and stuff with chopped kittens, lard, incense, wax and flour of rye. This must all be eaten, and the drippings applied to the painful joints” - Lorenz Fries, 1518 (1)

What is gout?

Gout is a form of arthritis (inflammation of the joints) which affects up to one in fifty people in the UK, mostly men over 30 and post-menopausal women. It typically occurs in the joints at or towards the extremities of the body – the toes, fingers, ankles and wrists – but it can develop in any joint. (2) In people affected by gout, the inflammation is caused by build-up of crystals composed of sodiumurate within and around the joints. (3) This leads to joints becoming painful, swollen and hot, with associated tenderness. The skin surrounding the affected joints may also take on a shiny appearance. Attacks of gout come on all of a sudden, with symptoms peaking after a few hours. This persists for three to ten days, after which symptoms subside. However, the gout will most likely recur at some point. (2)

What causes gout?

Uric acid is a metabolite (breakdown product) of purines, which are substances occurring naturally in the body. Purines are also found in certain foods. The more purine-containing foods a person eats, the higher the levels of uric acid in their blood. Excess uric acid can be filtered out of the body via the kidneys, but if there is too much for the kidneys to deal with, it can begin to be deposited at the joints as sodium urate crystals. Unbeknown to them, a gout sufferer will have had these crystals developing in their joints for years previous to their first attack. It is only when the hard crystals build up so much that they invade the joint cavity and come into contact with the soft tissue within the joint that symptoms develop. Over time, the crystals may grow to such a size that they form tophi that can disfigure the joint and be seen through the skin, occasionally even erupting through the skin. (3)

Gout can run in families due to a genetic link, so if you have a relative who suffers with gout you may be more likely to develop the condition yourself. (2)

How can gout be treated?

The aim of treatment during an attack of gout is to provide symptomatic relief (reduce pain and inflammation).

• Non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac, etoricoxib and naproxen are the first port of call in treating an attack of gout. They ease the inflammation and reduce pain. They should be taken as soon as symptoms start to develop and should be continued throughout the attack and for the following 48 hours once symptoms have subsided.

• Colchicine also reduces pain and swelling in affected joints and can be used as an alternative to NSAIDs if they are unsuitable or have failed to provide relief.

• Corticosteroids also target inflammation and pain as a last resort for severe gout or if other treatments are unsuitable. They may be administered in tablet form, or as an injection to provide instant relief. (4)

How can gout be prevented?

Both medication and lifestyle modifications can provide protection from gout attacks.

• Allopurinol taken once daily is the first choice preventative medication for gout. It works by decreasing uric acid production in the body, thereby decreasing blood uric acid levels. However, once started, it may trigger an attack of gout and attacks may continue for up to two years before the preventative effects of allopurinol kick in.

• Febuxostat is an alternative once daily medication that also lowers uric acid production. Like allopurinol it can cause an attack of gout at the beginning of therapy.

• Benzbromarone and sulfinpyrazone can be initiated by a specialist if other preventative medication has failed or is unsuitable. (4)

Lifestyle changes play an important role in preventing gout. Steer clear of foods containing high levels of the purines which raise uric acid levels such as red meat, offal (liver, kidneys, heart and sweetbreads), game, seafood, oily fish and meat or yeast extracts (Marmite, Bovril and gravy). Cutting down on alcohol will help as not only does alcohol stimulate the production of uric acid, it is also metabolised to lactic acid which slows the filtration of uric acid out of the body by the kidneys. Beer in particular should be avoided, as the fermentation process used in its production results in a high purine content. Maintaining a healthy weight will also help to keep attacks at bay, as being overweight increases uric acid levels and puts more strain on some of the joints that can be affected by gout. Additionally, drink plenty of water, as this can help your kidneys to flush out the excess uric acid and to stop it turning into crystals. (5)

Visit your GP if you think you may have gout, or if you do have gout and your medication hasn’t eased your symptoms within two days.

References

1. Fries L (1518). Spiegel der Artzny. Strasbourg: Grüninger.

2. National Health Service. Gout [cited 18 September 2017]. Available from: http://www.nhs.uk/Conditions/Gout/Pages/Introduction.aspx

3. Arthritis Research UK. What causes gout? [cited 18 September 2017]. Available from: https://www.arthritisresearchuk.org/arthritis-information/conditions/gout/causes.aspx

4. National Health Service. Gout – Treatment [cited 18 September 2017]. Available from: http://www.nhs.uk/Conditions/Gout/Pages/Treatment.aspx

5. UK Gout Society. All about gout and diet. Available from: http://www.ukgoutsociety.org/docs/goutsociety-allaboutgoutanddiet-0113.pdf

   Author: Gabby Gallagher MPharm

   Medically reviewed by: Superintendent pharmacist Margaret Hudson BSc(Hons)MRPharmS 20/09/17