Overview
Gout is a form of inflammatory arthritis. When there is too much urate, also called , in the blood, needle-shaped crystals can form in and around a joint. The body's reaction to those crystals causes a sudden, very painful attack, known as a flare.
Flares come and go. Between them the joint usually feels normal, but the urate stays high and crystals keep collecting, which is why treatment looks further than the attack itself.
Symptoms
A flare usually starts suddenly, often at night, and the pain can be severe enough to wake a person. The big toe is affected most often, but gout can also strike the foot, ankle, knee, hand, wrist or elbow.
The joint swells, and the skin over it becomes hot, red and so tender that light touch hurts. Without treatment a flare lasts about one to two weeks and then settles. Over years, hard lumps of crystals called tophi can appear under the skin.
When to see a doctor
See a doctor within the next few days for a first attack, for attacks that keep returning or are becoming more frequent, for an attack that is not settling on the usual treatment, or if hard lumps appear under the skin near the joints or the ears.
Causes
Urate is made when the body breaks down substances called purines, which come both from the body's own tissues and from food. Normally urate passes out in the urine.
Gout develops when more urate is made than the body can remove, most often because the kidneys do not clear enough of it. A flare is then often set off by a large meal, a lot of alcohol, dehydration, an illness with fever, an injury to the joint, or a change in medicines.
Risk factors
- Being a man, with risk rising with age
- Being a woman after the menopause
- Being overweight
- Drinking alcohol regularly
- Sugary drinks, and foods high in purines, mostly from animal sources
- Chronic kidney disease
- High , high , diabetes and heart failure
- Some medicines, including water tablets, certain blood pressure medicines and low-dose aspirin
- A close relative with gout
- A recent operation or joint injury
Complications
Flares that are not treated tend to become more frequent and to last longer. Crystals gather into hard lumps under the skin, called tophi, which can damage the joint and the bone around it.
Gout can leave lasting joint damage and a long-term arthritis. Urate can also form kidney stones.
Prevention
- Reaching and keeping a healthy weight, losing weight gradually
- Limiting alcohol
- Cutting down on sugary drinks
- Drinking enough water, especially in hot weather or during an illness
- Eating less red meat, offal and shellfish, which are high in purines
- Staying physically active
- Not smoking
- Taking urate-lowering medicine regularly when it has been prescribed
Diagnosis
A doctor asks about the pattern of attacks and examines the joint. Blood tests measure the urate level and check how the kidneys are working, and a urine test may be added.
The surest test is to take a little fluid from the joint with a needle and look at it under a microscope for urate crystals. The same sample shows whether the joint is infected instead. X-rays or may be used to look at joint damage and crystal deposits.
Treatment
A flare is treated to settle the inflammation quickly, with anti-inflammatory painkillers, a medicine called colchicine, or steroids, while the joint is rested and kept raised. Treatment works best when it is started as soon as the flare begins.
Long-term treatment lowers the urate in the blood, so that existing crystals dissolve and new ones do not form. A urate-lowering medicine is taken every day and continued between attacks. It takes time to work, and blood tests are used to check that the dose is right.
Alongside this, weight, alcohol and sugary drinks are reviewed, as are any medicines that push the urate level up, and conditions such as high , diabetes and kidney disease.
Myths and facts
Things people often say about this. Open each one to see what is true.
Myth“Gout comes from eating tomatoes or dal, so cutting them out will cure it.”What is true?
Fact
Gout comes from urate building up in the blood over time. Diet plays a part, mainly alcohol, sugary drinks and purine-rich foods that are mostly from animal sources, but for many people diet alone is not enough and a medicine that lowers urate is needed.
Myth“Once the attack settles, the gout has gone.”What is true?
Fact
Between attacks the joint usually feels normal, but the urate in the blood stays high and crystals keep collecting. Left untreated, flares become more frequent and longer, hard lumps called tophi can form, and the joint can be permanently damaged.
Myth“Urate-lowering tablets are for the days when the joint is painful.”What is true?
Fact
A urate-lowering medicine is not a painkiller. It works by bringing the urate level down over months so that crystals dissolve and new ones do not form, which means it is taken regularly, including at times when the joints feel fine.
Myth“Gout only happens to men who drink alcohol, and only in the big toe.”What is true?
Fact
The big toe is the commonest site, but gout can affect the foot, ankle, knee, hand, wrist or elbow. Men are at higher risk, yet women get gout too, particularly after the menopause, and people who never drink alcohol get it, especially with kidney disease, high blood pressure or certain medicines.
Questions to ask your doctor
Tick the ones you want answered and take them with you.
Common questions
My uric acid is high but I have never had an attack. Do I need treatment?
Not everyone with a high urate level gets gout. A doctor looks at the level alongside kidney function, blood pressure, weight and other medicines, and often starts with lifestyle changes and monitoring. Treatment decisions are individual, so this is worth discussing rather than assuming either way.
Should I stop my urate-lowering tablet during an attack?
Do not change it on your own. These medicines are meant to be taken continuously, and stopping and restarting can unsettle the urate level. Ask the doctor who prescribed it. The flare itself is treated with separate medicines aimed at the inflammation.
Will giving up all dal and tomatoes stop my gout?
Unlikely on its own. The foods most linked to gout are red meat, offal, shellfish, alcohol and sugary drinks. Weight, kidney function and some medicines matter at least as much. Diet helps, but many people also need a medicine that lowers urate to prevent further attacks.
How do I know whether this is gout or a joint infection?
You often cannot tell from the outside, because both give a hot, red, swollen, very painful joint. Fever, being sick or feeling very unwell make an infection more likely, and that needs urgent assessment. A doctor can take fluid from the joint to tell the two apart.