Gout
We're sorry to hear you have gout (or may have gout).
The goal of this guide is to provide information while awaiting evaluation with your doctor or additional information after you have seen him or her. Please keep in mind that this guide is not intended to replace a face-to-face evaluation with your doctor.
First, some background information about this guide and about the condition itself:
Gout is a condition in which one or more joints become inflamed when crystals of urate (also called uric acid) deposit there. Urate is a byproduct of normal bodily functions and is removed from the body by the kidneys.
This guide will ask you a series of questions and depending on your answers, information will be provided and additional questions asked until the conclusion.
Would you first like more general information about gout? Or, would you prefer information more specific to your own situation?
Okay. The information below is organized into the following sections:
1) How is gout diagnosed?
2) How severe is your gout?
3) What are the treatment options?
4) What happens over time?
Let's get started!
The definitive diagnosis of gout is usually made when your doctor takes a sample of joint fluid and sees gout (urate) crystals under the microscope. The diagnosis does not absolutely require a sample of joint fluid, however. Sometimes, the diagnosis can be made based on your symptoms alone. For example, if you have repeated episodes of severe first toe pain and swelling that get better over days, it is very likely that you have gout. You cannot make the diagnosis of gout from a blood test, even though most persons with gout have a high blood uric acid level. Other ways to make the diagnosis include x-rays or microscopic analysis of a lump of crystals (called tophi), which may complicate more severe forms of the condition.
Click on the appropriate link below to learn more about how the severity of gout is assessed, to learn more about how your particular symptoms might be treated, or to quit.
Gout can range from mild or severe, episodic or chronic. Persons with gout usually start out with occasional episodes of attacks that get better over a few days (with or without treatment). Over time, however, they may become more severe: more than one joint may be inflamed at the same time, attacks may last longer and respond less well to treatment, and lumps of gout (called tophi, or if there is only one lump, a tophus) may form under the skin or in joints (detectable by x-rays). When tophi are present or when joints are inflamed for weeks at a time, gout is considered "chronic."
Click on the appropriate link below to learn more about the general treatment options for gout, to learn more about how your particular symptoms might be treated, or to quit.
The major options for sudden attacks of gout include
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non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen or indomethacin
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corticosteroids such as prednisone pills or by injection
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colchicine--often high doses are required, whether in pill form or intravenously; diarrhea is common with this approach and persons with kidney and/or liver disease should not take high dose colchicine
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pain medications.
These treatments are usually necessary only "as needed," for a few days or a week, until the attack subsides. In fact, even without any treatment, most attacks of gout will subside in a short amount of time.
For more severe or chronic forms of gout, medicines to reduce the blood urate level, including allopurinol, probenecid or sulfinpyrazone may be prescribed. These medications are typically taken long-term, but can prevent future attacks and reduce the chances of complications, such as joint damage.
Click on the appropriate link below to learn more about the course of gout over time, to learn more about how your particular symptoms might be treated, or to quit.
The course of gout is variable but usually falls into one of a few patterns:
1) acute attacks - perhaps once or twice a year
2) frequent attacks - for example, every 2-3 months
3) chronic gout - including the development of tophi, joint damage as detected on x-rays, or long-term joint pain and swelling
4) disfiguring gout - if left untreated, large tophi may form, causing disfigurement and loss of joint function.
Treatment can alter the progression of gout from occasional sudden attacks to more chronic disease. Talk with your doctor about your diagnosis, the severity of your condition and how it is best treated.
Would you like to learn more about how your particular symptoms might be treated? Or, would you prefer to quit now?
Great. The first thing to do is determine whether or not gout has been confirmed, is suspected or is actually unlikely.
The best way to prove that gout is present is to see gout crystals (actually urate crystals) under the microscope. The most common way this is done is by removing fluid from a joint through a needle. However, certain symptoms make gout very likely even without joint fluid analysis. For example, repeated episodes of severe first toe pain and swelling that resolves over a few days is very likely to be due to gout.
Has gout been diagnosed by analysis of joint fluid removed from one of your joints?
Okay. This raises the possibility that your joint pain is due to something other than gout. It's worth considering other possibilities (to be considered below). Certain facts make gout more or less likely. For example, gout is unlikely if you are a premenopausal woman. Gout tends to occur in women only when they are at least seven to ten years post-menopausal. It can occur in men of any age, though it is unusual in teenagers and is more common in older men or in people with a family history of gout.
Gout is likely if you have had repeated episodes of sudden first (big) toe pain and swelling that gets better without antibiotics over a few days, even if joint fluid has never been removed or examined.
Most experts agree that it is not always necessary to prove the diagnosis of gout by removing joint fluid; symptoms and examination alone may be so compelling that proof is unnecessary. On the other hand, you cannot diagnose gout from a blood test and often it is very helpful to prove the diagnosis by removing a bit of fluid.
Talk with your doctor about how certain the diagnosis of gout is.
Mimics of gout include certain infections and other types of arthritis including pseudogout, psoriatic arthritis, arthritis associated with inflammatory bowel disease, Reiter's syndrome and ankylosing spondylitis.
The next questions deal with the severity of your gout or problems that might be related to gout.
Is one or more of the following statements true for you?
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I've had gout in more than one joint at the same time.
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I have frequent attacks (4 or more times in a year).
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I have lumps under the skin (or have been told I have tophi).
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I have had one or more kidney stones.
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My gout has been hard to treat, taking more than a day or two to get under control and/or has required steroid pills.
Okay, that's helpful, because it makes the diagnosis much more certain.
The next questions deal with the severity of your gout or problems that might be related to gout.
Is one or more of the following statements true for you?
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I've had gout in more than one joint at the same time.
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I have frequent attacks (4 or more times in a year).
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I have lumps under the skin (or have been told I have tophi).
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I have had one or more kidney stones.
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My gout has been hard to treat, taking more than a day or two to get under control and/or has required steroid pills.
Good! That means your gout is more likely to be mild and may not need continuous, daily treatment. You might be able take medicines "as needed" to treat your infrequent attacks of gout.
Here's one more question about the severity of gout. Sometimes x-rays are performed to see whether gout has caused damage (or erosions). When gout causes this joint damage, it's called a tophus which is a lump of gout crystals that can form under the skin (especially on the outside of the ear, near joints, and near the elbow) but sometimes is located within joints, causing these erosions.
Have you ever been told that your x-rays show gout-related joint damage or that you have tophi?
Okay. Your answer suggests that your gout is severe enough to warrant treatment to prevent attacks and reduce the risk of complications (such as joint damage or kidney stones). You'll also need information about how to treat attacks of gout.
First, let's talk about prevention, then about how to treat sudden attacks.
Have you had or do you have either of the following?
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kidney stone
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chronic kidney disease (also called chronic renal failure or chronic renal insufficiency).
Yes, I have had a kidney stone or have chronic kidney disease.
Excellent. So, you've been told you have gout but you've never had a kidney stone or chronic kidney disease.
Based on your answers, treatment to reduce the uric acid may be appropriate. This therapy tends to prevent attacks of gout and reduce the risk of its complications.
There are two ways to reduce uric acid and you may be a candidate for either one:
1) Reduce the body's creation of urate. Allopurinol is highly effective for this purpose; new medicines may soon be approved to do the same thing.
2) Increase the removal of uric acid from the body -- probenecid and sulfinpyrazone are drugs that can increase the kidney's capacity to remove urate from the body and into the urine.
Because you have no kidney disease or past kidney stones, any one of these three medicines to lower urate, including allopurinol, sulfinpyrazone and probenecid, could be considered. (Persons over the age of 55 or who have significant kidney disease may get little benefit out of sulfinpyrazone and probenecid; in addition, these medicines may increase the risk of stones). Check with your doctor to confirm that you have no reason to avoid one or more of these medicines.
Click on the link below to learn more about medicines that can prevent attacks of gout and its complications. Or, if you prefer to read more general information about gout, choose that link. Or, you can choose the "quit" link if you are all done.
Okay. From your answers, a medicine to lower blood urate level may be a good idea. This will help prevent sudden attacks of gout and will help to prevent complications of gout such as joint damage.
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allopurinol - this medicine reduces the synthesis of uric acid. It's a highly effective medicine and the dose can be adjusted to get the uric acid level down to where attacks of gout and complications (such as joint damage seen on x-rays or kidney stones) become very unlikely. Typical doses are 100 to 300 mg daily and monitoring includes measurement of blood counts and liver tests. Serious side effects are rare but include hepatitis, abnormal blood counts or allergic reactions.
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febuxostat - this medicine reduces the synthesis of uric acid. It is usually reserved for people who have had or at high risk for an allergic reaction to allopurinol. Typical doses are 40 to 80 mg per day. Febuxostat may have a higher risk of liver injury and clearly has a greater risk of cardiovascular events compared to allopurinol.
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probenecid - this medicine lowers blood urate by encouraging the kidney's excretion of urate into the urine; typical doses are 500 to 1000 mg once or twice daily and monitoring includes measurement of the urinary urate to be sure it is not so high that it increases the risk of a kidney stone. Fortunately, side effects are rare and include headache, upset stomach and allergic reactions.
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sulfinpyrazone - this medicine lowers blood urate by encouraging the kidney's excretion of urate into the urine; typical doses are 200 to 600 mg daily; monitoring includes measurement of the urinary urate to be sure it is not so high that it increases the risk of a kidney stone. Side effects are unusual but include upset stomach and allergic reactions.
Some doctors routinely start with allopurinol for this situation, while others measure a 24-hour urine collection to see how much urate is being removed in the urine to help make the decision between these agents.
When any urate-lowering therapy is started and until the urate level is low and stable, there is an increased risk of an attack of arthritis; for this reason, colchicine (in a low dose) or an anti-inflammatory medicine (such as ibuprofen, again, in a low dose) are often prescribed. However, once the urate is low (in the range of six mg/dl or less) and stable, the colchicine or NSAID can usually be stopped.
Would you like to learn more about treating sudden attacks of gout?
Or, are you ready to quit?
Okay, sorry to hear that.
The reason for all the kidney questions is that people with kidney problems are unlikely to get much benefit (and may be at increased health risks) from medicines that increase urate removal by the kidney.
Because you've had a kidney stone or have chronic kidney disease, allopurinol is probably the best choice to lower your blood urate level. Once it is low enough, attacks of gout should stop and the complications of gout (such as another kidney stone or joint damage) should be markedly reduced or even eliminated. When allopurinol is first started, it is usually accompanied by low dose colchicine or a nonsteroidal anti-inflammatory drug (NSAID) -- be sure to talk to your doctor about the specifics if and when you begin taking allopurinol.
Would you like to learn now about treating sudden attacks? Or would you prefer to quit now?
Okay.
Unless there is a reason to avoid these medicines (such as a current or previous stomach ulcer or significant chronic renal failure), the first choice for treating a sudden attack of gout is a nonsteroidal anti-inflammatory drug (NSAID).
There are more than 25 approved NSAIDs and each would probably work for gout; the most commonly used for this condition, however, are ibuprofen, naproxen and indomethacin. They tend to work very well if started at the first hint of an attack. However, some people should not take these medicines and, there are important side effects to consider. The most important ones are
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stomach ulcers
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kidney disease
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thinning the blood
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allergies.
A number of less common reactions are also possible.
Although "as needed" NSAIDs are usually the first choice for gout treatment, there are other options when NSAIDs cannot be taken or when they do not work.
Click below to learn more about these other treatments. Or, if you're ready to quit, choose that link.
Click here to learn more about how attacks of gout are treated.
There are a number of treatment options for sudden (acute) attacks of gout other than NSAIDs, including
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steroid pills
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steroid injections
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colchicine
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pain medications
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splinting
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time.
In addition, there are preventative measures that can make attacks less likely, including
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avoid diuretics (often called "water pills" because they increase urination)
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avoid alcohol, especially binge drinking
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avoid dehydration
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long-term medications (including allopurinol, probenecid and sulfinpyrazone) that can prevent attacks and lower the risk of complications.
These are usually reserved for those who have attacks of gout that are particularly severe, frequent, difficult to treat or involve more than one joint at the same time.
Talk with your doctor about your history of gout and which approach -- intermittent treatment for sudden attacks or long-term treatment to prevent attacks--makes the most sense for you.
At this point, would you like to see more general information about gout? Or, would you prefer to quit now?
Okay, that's fine.
Remember:
1) Gout is usually not difficult to diagnose.
2) A number of treatment options are available that effectively control gout in most cases.
3) Treatment can alter the course of gout, even preventing attacks altogether.
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