Gout

Related Terms

• Animal proteins, arthritis, corticosteroids, gouty arthritis, hyperuricemia, kidney disease, kidney failure, kidney stones, nonsteroidal anti-inflammatory drugs, NSAIDs, podagra, pseudogout, purines, tophi, urate crystals, uric acid.

Background

• Gout is an intensely painful form of arthritis that causes the joints to become red, swollen, and stiff. Symptoms are most likely to develop in the big toe. Other commonly affected joints include the ankles, heels, knees, wrists, fingers, and elbows. Individuals typically experience acute attacks of gout. In other words, symptoms develop suddenly and go away after a couple weeks.
• This type of arthritis occurs when there is too much uric acid in the blood. Uric acid is a waste product that forms when the body breaks down purines, which are chemicals commonly found in red meat, poultry, and fish. In healthy people, uric acid is continuously broken down in order to maintain normal levels in the blood. A person’s gender, genetic makeup, hormonal changes, diet, and some medications may cause may cause the body to produce too much uric acid or prevent it from being properly broken down.
• The first gout attack typically goes away after one to two weeks without treatment or one to two days with treatment. If the person does not receive treatment, a second attack may occur anywhere from six month to two years later. If individuals still do not receive treatment, they may continue to have attacks that will probably last longer, affect more joints, and be more painful.
• Symptoms of gout can be treated, and medications and lifestyle changes can help prevent gout attacks from recurring.
• Pseudogout is a medical condition that causes symptoms very similar to gout. However, pseudogout occurs when there is too much calcium phosphate in the blood, not uric acid. Although the risk of experiencing pseudogout appears to increase with age, most cases have no known cause. Other factors, including genetics, excess iron storage, low magnesium levels in the blood, and an overactive parathyroid gland, may contribute to the development of pseudogout.

Causes

• Gout occurs when there is too much uric acid in the body. Having high levels of uric acid in the blood is also called hyperuricemia. A combination of factors, including alcohol consumption, gender, genetics, hormonal changes, eating a purine-rich diet, and certain medications, may cause the body to produce too much or excrete too little uric acid.
• The excessive uric acid forms sharp crystals (called urate) inside the joints. Urate causes the joints to become swollen, painful, and red.
• Uric acid is a waste product that forms when the body breaks down purines, which are substances naturally found in the body and in certain foods (especially anchovies, mushrooms, asparagus, and organ meats, such as liver and kidneys). In healthy individuals, uric acid dissolves in the bloodstream, is filtered through the kidneys, and is excreted in the urine.

Risk Factors

• Alcohol:
  Consumption of alcohol, especially beer, increases the risk for gout.
• Gender: Gender may also play a role because men are more likely to develop the condition than women.
• Genetics: Children of parents with gout have a 20% chance of developing the condition. This suggests that genetics may be involved.
• Hormonal changes: Uric acid levels increase at puberty in men and at menopause in women. This means men are more likely to develop gout when they are 30-50 years old, while women are more likely to develop the condition when they are 50-70 years old. Gout is extremely uncommon in pre-menopausal women.
• Purine-rich diet: There are many factors that may cause excessive uric acid to build up in the body. Eating a purine-rich diet that includes large amounts of red meat, organ meat, and oily fish (such as salmon, sardines, and herring), may lead to the development of gout. This is because uric acid forms when purines are broken down in the body.
• Some medications: Some medications, including certain diuretics, niacin (a B-complex vitamin), aspirin (taken in low doses), cyclosporine (e.g. Neoral® or Sandimmune®), and some anti-cancer drugs, may cause gout.

Signs and Symptoms

• Symptoms of gout almost always occur suddenly, especially at night. Gout causes the joints to become red, swollen, and stiff. The big toe is most commonly affected because gout symptoms typically develop in areas of the body that experience the most trauma. When the toe is affected, the symptom is often called podagra. Other commonly affected joints include the ankles, heels, knees, wrists, hands, fingers, and elbows. The pain may be so severe that a bed sheet touching the affected skin is unbearable. Symptoms generally subside after one to two weeks. Once symptoms are gone, the affected joints are not painful. However, if the patient does not receive treatment, attacks will come back (with increased frequency), and they will usually last longer and affect more joints.

Complications

• Chronic arthritis and tophi: Some patients with gout develop long-term arthritis. After several years, these patients may also develop tophi, which are discolored deposits of uric acid crystals in the joints. Tophi causes areas of swelling to develop in the joints, particularly the toes, fingers, hands, elbows, earlobes, and ankles. Tophi are usually not painful, but they can help doctors diagnose the condition. Tophi may be painful if they develop inside the fluid-filled sacs (called bursae) that cushion the joints.
• Joint damage: Long-term arthritis may eventually lead to permanent joint damage.
• Kidney disease and kidney stones: Long-term gout may lead to decreased kidney function and possibly kidney stones. This can happen if the tubes inside the kidneys become blocked with uric acid crystals. In very severe cases, the condition may lead to kidney failure.

Diagnosis

• If gout is suspected, a healthcare provider will take a sample of synovial fluid from the affected joint. This sample is analyzed to look for uric acid crystals in the white blood cells. If crystals are present, a positive diagnosis is made.
• If gout is diagnosed, a healthcare provider may also take a urine sample to determine how much uric acid is being excreted. This is because some cases of gout occur when individuals do not excrete enough uric acid. The patient is asked to collect his/her urine over a 24-hour period. The sample is then analyzed in a laboratory to determine if the person has higher-than-normal uric acid levels in the urine.
• A uric acid blood test may also be performed to determine if the patient has high levels of uric acid in the blood.

Treatment

• Nonsteroidal anti-inflammatory drugs (NSAIDs): During gout attacks, patients may benefit from nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (e.g. Advil® or Motrin®) and naproxen (e.g. Aleve®). NSAIDs help reduce inflammation and pain associated with gout.
• The frequency and severity of NSAID side effects vary. The most common side effects include nausea, vomiting, diarrhea, constipation, decreased appetite, rash, dizziness, headache, and drowsiness. The most serious side effects include kidney failure, liver failure, ulcers, heart-related problems, and prolonged bleeding after an injury or surgery. About 15% of patients who receive long-term NSAID treatment develop ulcers in the stomach or digestive tract.
• Colchicine: Patients may also take an alkaloid medication called colchicine. This medication may be taken during a gout attack to reduce swelling and joint pain. It may be taken up to once an hour until symptoms improve, side effects develop, or a maximum of 10 doses is taken. Side effects may include diarrhea, nausea, and vomiting.
• Colchicine may also be taken twice a day to prevent attacks from occurring. Although long-term use of colchicines can effectively prevent the symptoms associated with attacks, it does not prevent uric acid crystal from developing. These crystals can lead to joint damage, even if the joints are not swollen or painful.
• Corticosteroids: Patients that have severe pain and inflammation that does not improve with NSAIDs may benefit from corticosteroid medications. Corticosteroids, such as prednisone, may be taken by mouth or injected into the affected joint(s).
• These drugs are generally very effective when used short-term. However, if these drugs are used for many months to years, they may become less effective and serious side effects may develop. Therefore, injections are generally limited to no more than three each year. Side effects may include easy bruising, thinning of bones, cataracts, weight gain, a round face, and diabetes.
• Maintain a healthy weight: Individuals who are overweight may benefit from losing weight. This puts less strain on the weight-bearing joints, such as the ankles. It may also decrease uric acid levels in the body. However, weight loss should be gradual because sudden weight loss has been shown to temporarily increase uric acid levels and worsen symptoms.
• Limit consumption of animal protein: Patients may also benefit from eating a diet low in animal protein, including red meat, organ meat (such as kidneys are liver), and oily fish (such as salmon, sardines, mackerel, anchovies, and herring). These foods contain high amounts of purine and may worsen gout symptoms. It is generally recommended that all individuals, including those who do not have gout, eat no more than five to six ounces of lean meat, poultry, or fish a day.
• Limit or avoid alcohol consumption: Consuming too much alcohol may prevent the body from excreting enough uric acid. It is recommended that men limit their alcohol consumption to two or less drinks per day, and women limit their alcohol intake to one drink per day. Alcohol should not be consumed at all during a gout attack.
• Drink plenty of fluids: Fluids help dilute uric acid in the blood and urine. Individuals should drink plenty of fluids, especially water, to help reduce gout symptoms and to prevent future attacks from occurring.

Integrative Therapies

C

Unclear or conflicting scientific evidence

• 
  Ash
  : Ash has been used in Europe in combination products for more than 40 years. It has been historically noted for its anti-inflammatory and analgesic properties. There is currently little scientific evidence available to support these uses for treatment of gouty arthritis; however, the results of an equivalence trial are promising. Future randomized, placebo controlled studies are necessary to confirm these initial results.

• Avoid if allergic or hypersensitive to ash (Fraxinus species), its constituents, or to members of the Oleaceae family. Reviews note ash pollen allergic cross-reactivities with pollen from the Fagales order (birch, alder, hazel, hornbeam, oak, and chestnut), Scrophulariales order (olive, ash, plantain, privet, and lilac), Coniferales order (cedar, cypress, and pine), and fruits and vegetables. Use cautiously if sensitive to anticoagulants (blood thinners). Use cautiously if susceptible to hypouricemia (condition where the level of uric acid is below a certain threshold), including but not limited to hyperthyroidism, nephritis (inflamed kidneys), multiple sclerosis, and Fanconi syndrome. Avoid if immunocompromised. Avoid if pregnant or breastfeeding.

Prevention

• General: There is no known method of prevention of gout. However, individuals can reduce their risk of experiencing gout attacks.
• Medications: Individuals who are diagnosed with gout should take their medications exactly as prescribed in order to manage symptoms and lessen the severity of attacks.
• A medication called colchicine may be prescribed to help prevent attacks from occurring. This medication is usually taken twice a day. Although long-term use of colchicines can effectively prevent the symptoms associated with attacks, it does not prevent uric acid crystal from developing. These crystals can lead to joint damage, even if the joints are not swollen or painful. Side effects may include diarrhea, nausea, and vomiting.
• Lose weight gradually: Individuals with gout should lose weight gradually to help reduce uric acid levels in the body. If individuals lose weight too quickly, it may trigger attacks.
• Diet recommendations: Patients may benefit from eating a diet low in animal protein, including red meat, organ meat (such as kidneys are liver), and oily fish (such as salmon, sardines, mackerel, anchovies, and herring). These foods contain high amounts of purine and may worsen gout symptoms of gout. It is generally recommended that all individuals, including those who do not have gout, eat no more than five to six ounces of lean meat, poultry, or fish a day.
• Individuals who have gout are encouraged to eat low-cholesterol and low-fat diets to reduce the risk of developing heart disease.
• Fluids help dilute uric acid in the blood and urine. Individuals should drink plenty of fluids, especially water, to help reduce gout symptoms and to prevent future attacks from occurring.
• Limit or avoid consuming alcohol, especially beer. Alcohol has been shown to increase uric acid levels, which increases the risk of experiencing gout attacks.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

References

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

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