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Gout is caused by uric acid crystals in the joint. These are irritating to the joint and cause an inflammatory reaction. This usually causes sudden intensely painful swelling of a single joint, often the big toe. 

It is diagnosed by taking a small amount of fluid from the joint and examining this for crystals of uric acid. These attacks are treated with anti-inflammatory drugs, and further attacks are prevented by lowering the levels of uric acid in the blood by special diets and drugs.

Gout, an acute form of inflammatory arthritis, occurs most often in people who are overweight and/or who indulge regularly in rich foods and alcohol.

Affecting about two million Americans, primarily male, it typically attacks the smaller joints on hands and feet, especially the big toe. 

Uric acid, a waste product of the body, is either overproduced, under-excreted, or both. When a person has too much uric acid in his or her system, some of it forms uric acid crystals. These crystals can end up depositing in the joints, most commonly in the bunion joint of the big toe. 

With gout, however, these deposits also sometimes accumulate in other joints of the feet, as well as those of the fingers, wrists, elbows, knees and ankles. The afflicted joint suddenly becomes hot, painfully swollen and stiff; fever and chills sometimes follow. The skin of the affected area can appear shiny red or purple

What Causes Gout?

Uric acid is a chemical which is a natural part of the normal breaking down and building up of food and body tissues.  The level in the blood can be measured and shows how much there is in the body overall.
The condition of raised blood uric acid is called hyperuricaemia. 

When this is present the uric acid which is normally dissolved in the blood may, from time to time, form microscopic crystals in the joint. These crystals set up the inflammation which is called acute gouty arthritis or acute gout.

It follows that gout may develop in persons whose uric acid is higher than normal. There are many causes of this. The following are some of the more common causes:

• Higher than normal levels of uric acid can be part of the inherited make-up of some families
• Obesity
• High alcohol intake
• High intake of food containing purines (see below)
• Some of the drugs used to treat high blood pressure.
• Less commonly, longstanding kidney disease may result in high blood levels of uric acid.

A number of risk factors are related to the development of hyperuricemia and gout:

• Genetics may play a role in determining a person's risk, since up to 18 percent of people with gout have a family history of the disease.
• Gender and age are related to the risk of developing gout; it is more common in men than in women and more common in adults than in children.
• Being overweight increases the risk of developing hyperuricemia and gout because there is more tissue available for turnover or breakdown, which leads to excess uric acid production.
• Drinking too much alcohol can lead to hyperuricemia because it interferes with the removal of uric acid from the body.
• Eating too many foods rich in purines can cause or aggravate gout in some people.
• An enzyme defect that interferes with the way the body breaks down purines causes gout in a small number of people, many of whom have a family history of gout.
• Exposure to lead in the environment can cause gout.

Some people who take certain medicines or have certain conditions are at risk for having high levels of uric acid in their body fluids. For example, the following types of medicines can lead to hyperuricemia because they reduce the body's ability to remove uric acid:

• Diuretics, which are taken to eliminate excess fluid from the body in conditions like hypertension, edema, and heart disease, and which decrease the amount of uric acid passed in the urine;
• Salicylates, or anti-inflammatory medicines made from salicylic acid, such as aspirin;
• The vitamin niacin, also called nicotinic acid;
• Cyclosporine, a medicine used to suppress the body's immune system (the system that protects the body from infection and disease) and control the body's rejection of transplanted organs; and
• Levodopa, a medicine used to support communication along nerve pathways in the treatment of Parkinson's disease.

Who Is Likely To Develop Gout?

Gout occurs in approximately 840 out of every 100,000 people. It is rare in children and young adults. Adult men, particularly those between the ages of 40 and 50, are more likely to develop gout than women, who rarely develop the disorder before menopause. People who have had an organ transplant are more susceptible to gout.

How Is Gout Diagnosed?

Gout may be difficult for doctors to diagnose because the symptoms may be vague, and they often mimic other conditions. 

Although most people with gout have hyperuricemia at some time during the course of their disease, it may not be present during an acute attack. 

In addition, having hyperuricemia alone does not mean that a person will get gout. In fact, most people with hyperuricemia do not develop the disease.

To confirm a diagnosis of gout, a doctor may insert a needle into an inflamed joint and draw a sample of synovial fluid, the substance that lubricates a joint. 

A laboratory technician places some of the fluid on a slide and looks for monosodium urate crystals under a microscope. 

Their absence, however, does not completely rule out the diagnosis. 

The doctor also may find it helpful to examine chalky, sodium urate deposits (tophi) around joints to diagnose gout. 

Gout attacks may mimic joint infections, and a doctor who suspects a joint infection (rather than gout) may check for the presence of bacteria.

Signs and Symptoms of Gout Hyperuricemia Presence of uric acid crystals in joint fluid More than one attack of acute arthritis Arthritis that develops in 1 day, producing a swollen, red, and warm joint Attack of arthritis in only one joint, usually the toe, ankle, or knee

How Is Gout Treated?

With proper treatment, most people with gout are able to control their symptoms and live productive lives. Gout can be treated with one or a combination of therapies. 

The goals of treatment are to ease the pain associated with acute attacks, to prevent future attacks, and to avoid the formation of tophi and kidney stones.

 Successful treatment can reduce both the discomfort caused by the symptoms of gout and long-term damage of the affected joints. 

Treatment will help to prevent disability due to gout.

The most common treatments for an acute attack of gout are high doses of nonsteroidal anti-inflammatory drugs (NSAIDs) taken orally (by mouth) or corticosteroids, which are taken orally or injected into the affected joint. 

NSAIDs reduce the inflammation caused by deposits of uric acid crystals but have no effect on the amount of uric acid in the body. 

The NSAIDs most commonly prescribed for gout are indomethacin (Indocin*) and naproxen (Anaprox, Naprosyn), which are taken orally every day. 

Corticosteroids are strong anti-inflammatory hormones. The most commonly prescribed corticosteroid is prednisone. 

Patients often begin to improve within a few hours of treatment with a corticosteroid, and the attack usually goes away completely within a week or so.

* Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

When NSAIDs or corticosteroids do not control symptoms, the doctor may consider using colchicine. This drug is most effective when taken within the first 12 hours of an acute attack. 

Doctors may ask patients to take oral colchicine as often as every hour until joint symptoms begin to improve or side effects such as nausea, vomiting, abdominal cramps, or diarrhea make it uncomfortable to continue the drug.

For some patients, the doctor may prescribe either NSAIDs or oral colchicine in small daily doses to prevent future attacks. The doctor also may consider prescribing medicine such as allopurinol (Zyloprim) or probenecid (Benemid) to treat hyperuricemia and reduce the frequency of sudden attacks and the development of tophi.

What Research Is Being Conducted To Help People With Gout?

Scientists are studying which NSAIDs are the most effective gout treatments, and they are analyzing new compounds to develop safe, effective medicines to lower the level of uric acid in the blood and to treat symptoms. 

They are studying the structure of the enzymes that break down purines in the body to achieve a better understanding of the enzyme defects that can cause gout.

Scientists are studying the effect of crystal deposits on cartilage cells for clues to treatment. They also are looking at the role of calcium deposits in pseudogout in the hope of developing new treatments. The role genetics and environmental factors play in hyperuricemia also is being investigated.

JUST WHAT IS GOUT?

Without warning and, for some reason, in the middle of the night, it strikes - an intense pain in a joint, most often the big toe, but sometimes other joints, including ankles, knees, elbows, hips, thumbs, or fingers. 

Attacks of gout can be unexpected and excruciatingly painful. With prompt treatment, the pain and inflammation disappear after a few days, but they may recur at any time.

Nine out of ten gout sufferers are middle-aged men, and about half of them have a hereditary predisposition to the ailment. 

Gout is uncommon in women and very rare in children. Men who are overweight or suffering from hypertension are particularly prone to gout - especially if they use diuretics to lower the body's water retention.

Gout is actually a form of arthritis; specifically, it is the body's reaction to irritating crystalline deposits in the space between the bones in a joint. 

In spite of extreme pain at onset, gout responds well to prompt treatment; mild cases may be controlled by diet alone. 

Chronic attacks of gout, however, may require long-term medication to prevent damage to bone, tendons, ligaments, and cartilage, as well as deterioration of the kidneys because of excess uric acid production. 

Chronic gout sufferers may feel tiny, hard lumps accumulating over time in the soft flesh of the hands, feet, or earlobes. These deposits, called tophi, are concentrations of uric acid crystals that can eventually cause aching, stiffness, and protrusions. If similar deposits form in the kidneys, they can lead to painful and potentially dangerous kidney stones (a condition called urate, or gouty, nephropathy).

TREATMENTS

The first step wherever possible must be to correct those factors mentioned above which give rise to high uric acid levels. Purines are substances found in food, which, when broken down produce a lot of uric acid. Therefore the following foods which are high in Purines should be restricted or avoided:

• Offal foods such as liver, kidneys, tripe, sweetbreads and tongue.
• Excessive amounts of red meat.
• Shellfish, fish roe and scallops.
• Peas. lentils and beans.
• Alcohol intake should be reduced. Two glasses of beer a day or less is sensible. On special occasions you can drink more.
• Weight loss may be very important.
• Medication for high blood pressure may need to be altered.

Of course the first order of business for any gout sufferer is to ease the pain.

 Clothing or other covering may only aggravate the discomfort of the swollen, sensitive joint, so most physicians advise keeping the affected area exposed, even during sleep. 

The next priority for treatment is to take an oral pain-killer and possibly a prescribed nonsteroidal anti-inflammatory drug or NSAID.

After the initial discomfort is relieved, the answer to controlling gout is keeping the body's level of uric acid in balance. Even without conventional or alternative treatments to relieve pain and reduce inflammation, the symptoms of gout will diminish in a few days or possibly up to a week. 

All incidents of suspected gout should be diagnosed and treated by a doctor. Left untreated, uric acid deposits can eventually cause irreversible damage to the kidneys and other tissues.

Conventional medicines may include ibuprofen, available in both prescription and over-the-counter versions, or other anti-inflammatory agents such as "colchicine" - a medication that has been in use for centuries. 

Low doses of aspirin, which may have been recommended for other conditions, should be discontinued, as it can slow the elimination of uric acid. 

Sodium salicylate or corticosteroid injections in the affected joint, may be helpful in reducing pain and inflammation in severe attacks or chronic cases. 

However, steroids such as hydrocortisone can have undesirable side effects in some patients. Blood and urine tests during routine checkups will signal potential susceptibility to gout attack.

Keeping the body's level of uric acid in balance can be done through the diet and, if necessary, by one of several drugs, such as allopurinol, that reduce the body's production of uric acid. 

A diet that limits protein-rich foods, especially those high in purines, is a must for gout sufferers. 

These foods include: organ meats such as liver; shellfish and fatty fish such as sardines, herring, and anchovies; asparagus and spinach; poultry; red meats and meat extracts such as gravies and bouillon; yeast and other enzyme-producing products; and most legumes. 

Also, a high intake of water and non-alcoholic liquids is recommended to help the body flush toxins and reduce uric acid levels. 

Foods that appear to suppress the immediate symptoms of gout include complex carbohydrates, particularly from cereals, fruits, and green leafy vegetables (except spinach).

Alternative therapy choices include aromatherapy, acupressure, accupunture, reflexology, herbs and natural nutritional products. 

An effective herbal therapy might include a tea or drink comprised of celery seed, yarrow, nettle, or gravel root mixed with water to help stimulate the elimination of uric acid. 

Herbal teas should not be used if colchicine has been prescribed.

Essential oils can be used in cool or cold compresses to reduce pain and discomfort. For a detoxifying effect, cypress, fennel, juniper, lemon, or pine oils can be tried.

 These may also be used in the bath. 

As the pain and swelling reduce, perhaps switch to oils such as lavender or rosemary for inducing local warmth and flushing toxins out of the joints.

Some practitioners recommend a teaspoon of Activated Charcoal, three times a day, to also help stimulate uric acid elimination in the urine.

Be aware that charcoal (an absorbing agent) may interfere with body's absorption and utilization of any other medications or supplements you may be taking.

Several authorities report favorable results in treating the pain of chronic gout by having patients eat fresh cherries, up to 8 ounces a day or more, or drink cherry juice. 

Similar effects are claimed for strawberries and blueberries.

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Psoriatic arthritis

This diagnosis is suspected if the patient has psoriasis, but sometimes the arthritis can precede the rash. It can mimic many other kinds of arthritis.

"Pitting" of the nails is a clue; the nail looks a bit like the surface of a thimble with little indentations.

Reactive Arthritis

Sometimes arthritis starts after an infection such as gastroenteritis or a sexually transmitted disease. It usually involves only one or two large joints such as knees or ankles.   It may also involve the lower back.

Viral and Post-viral Arthritis

Some viral infections can result in a transient arthritis. Examples are mumps, German measles (rubella) or parvovirus infection.

There may also be a skin rash and the arthritis usually gets better by itself, though this may take several months.

Rarely these can turn into a chronic arthritis such as rheumatoid arthritis.

Spondylarthritis

This type of arthritis involves the spine, usually the lower back, causing extreme back stiffness and inflexibility. It may be associated with arthritis of other joints, usually large joints such as knees and ankles.

It includes a condition called ankylosing spondylitis which tends to run in families.

There are other conditions associated with this type of arthritis including uveitis (painful, red eyes) and colitis (inflammation of the large bowel).