Gout is a metabolic disease that causes the joints to become inflamed. When gout occurs, certain joints swell within a few hours and become very painful. The inflammation is triggered by tiny, needle-shaped crystals of uric acid, which are mainly deposited in the joints. Such crystals can form when there is too much uric acid in the body. Normally, the inflammation subsides completely by itself within one to two weeks. The pain can be alleviated with medication.
Most people with gout have acute attacks now and then. Months or even years can pass between attacks. However, attacks of gout can also be more frequent. There are several ways to prevent them. Some people already find it helps to avoid certain foods and other possible triggers. For others, drugs that permanently lower uric acid levels are useful. They are particularly useful for frequent attacks of gout and for secondary diseases such as gout nodules or kidney stones.
Many people have elevated uric acid levels, but no symptoms. Whether this has a health significance is controversial. They do not need to be treated.
A gout attack often begins at night or early in the morning with a sudden, very painful swelling of the joints. The inflamed joint is sensitive to pressure, overheated and reddened. In most cases, swelling and discomfort are most pronounced after six to twelve hours. Often the joint becomes so sensitive that even the pressure of the duvet is hardly bearable. When the swelling subsides after a few days, the skin around the joint can peel off a little.
The first attack of gout often affects only one joint, usually the base joint of the big toe. Other joints that can become inflamed are the metatarsal and ankle joints, knees, elbows, wrist and finger joints. Gout attacks in the shoulders and hips occur only rarely. In chronic gout, the joints are permanently slightly inflamed. Over time, they can become deformed and are then restricted in their mobility.
If the blood contains too much uric acid, gout can develop. According to estimates, however, only about a third of all people with an elevated uric acid level develop gout.
Uric acid is a breakdown product of the so-called purines, a component of important basic substances of the body, the nucleic acids.
Normally a part of the uric acid is excreted with the urine. However, in some people the kidneys do not excrete enough uric acid. This causes the uric acid level in the body to rise. When it exceeds a certain limit, the uric acid can form crystals that are deposited in the body tissues. The crystals usually collect in the joints, where they can trigger a gout attack.
Certain diseases can also contribute to the accumulation of too much uric acid in the body. These include blood formation disorders or certain cancers such as leukemia. Gout rarely develops because the body produces too much uric acid. The reason for this can be, for example, a hereditary disease in which the function of certain proteins (enzymes) that are involved in the metabolism of uric acid is disturbed.
Apart from an increased uric acid level, other factors also play a role – including the fluid balance in the joints. For example, uric acid crystals are more likely to form in joints if their tissue contains little fluid. The acidity (pH) of the synovial fluid and the joint temperature also have an influence.
All factors that increase uric acid levels can also promote gout. In people who already have gout, they increase the risk of further attacks. Risk factors for gout that have been proven in scientific studies include
Drugs that increase uric acid levels: These include diuretics, acetylsalicylic acid (ASA) and certain drugs used after organ transplantation. The Parkinson’s drug levodopa and cancer drugs can also promote gout.
-Meat, fish and seafood: These foods contain many purines. If they are consumed in large quantities, they easily increase the risk of developing gout. Some vegetable foods are also rich in purines. However, studies have shown that they have no effect on the development of gout.
-Alcohol: Alcoholic drinks promote the formation of uric acid and have a dehydrating effect. In addition, alcohol causes the kidneys to secrete less uric acid. Beer, in particular, also contains a relatively large amount of purines. Studies have shown that beer and high-proof alcohol can promote gout. Wine (in moderation) apparently has no effect.
-Sugar-containing drinks: Drinks that contain a lot of (fruit) sugar can also slightly increase the risk of gout. This applies both to sugary drinks such as cola and fruit juices. Lemonades that contain sweetener instead of sugar are not associated with gout.
-Overweight: The risk of developing gout is higher when you are overweight – and it increases with increasing body mass index.
Although certain foods and other factors may slightly increase the risk of gout or attacks of gout: The most important thing is that the kidneys function well and can reliably excrete an excess of uric acid.
Gout is the most common inflammatory joint disease (arthritis) in industrialized countries such as Germany. It is estimated that 1 to 2 % of the population is affected. Men have a significantly higher risk of gout: they fall ill about five times as often and also earlier than women. While gout usually occurs in men from the age of 40 onwards, in women it usually only occurs after the menopause. The reason for this is hormonal influences on the kidneys.
After an attack of gout, the joint usually recovers on its own within one to two weeks. Most people who have had a gout attack experience another one six months to two years later. Repeated attacks can last a little longer and affect several joints.
After about twelve years on average, gout can become chronic and damage the joints. However, acute gout does not become chronic in all people. How high this risk depends, among other things, on how much the uric acid level is increased.
Another possible consequence is uric acid deposits in the soft tissues, so-called gout nodes. They also develop over the years and occur mainly on the elbows, Achilles tendons, toe and finger joints and the ear. Most gout nodes are not painful. If left untreated, about 30 out of 100 people with acute gout develop gout nodules within five years. The nodules can also disappear over time with uric acid-lowering treatment.
When gout becomes chronic and the joints are damaged, it restricts mobility and can also weaken the muscles.
It is rare for uric acid crystals to be deposited in parts of the body that are not typical for gout, such as the spinal cord or the carpal tunnel in the wrist. If gout nodules from there, they can press on the nerves and trigger complications such as carpal tunnel syndrome or paralysis by squeezing the spinal cord.
People with gout also have an increased risk of kidney stones. Kidney stones can be painful and promote urinary tract infections. On average, almost one in 100 men with gout develops kidney stones within a year.
Doctors often recognize acute gout by the typical symptoms and risk factors. Above all, a painful, reddened swelling at the base or end joint of the big toe is a fairly definite sign of gout.
A joint puncture is necessary to clearly detect gout. This involves taking fluid from the joint with a fine hollow needle and then examining it in the laboratory. If uric acid crystals are found in the fluid, the diagnosis is gout. A joint puncture is made if the symptoms are not clear or other possible causes are to be excluded. These include in particular an infection of the joint with bacteria, for example due to an injury. It should be treated quickly.
Determining only the uric acid level in the blood is not meaningful enough, as it often falls into the normal range during an attack of gout.
The treatment of gout has two objectives:
In the short term, it should relieve the pain of a gout attack.
In the long term, it should prevent further attacks and reduce the risk of chronic inflammation and joint damage.
Gout attacks are treated with anti-inflammatory drugs. These include
anti-inflammatory painkillers, for example ibuprofen, indomethacin or naproxen;
cortisone preparations, usually tablets containing the active ingredient prednisolone, and
the gout medicine colchicine. However, it is not used as often as before because of its slower action and possible side effects.
If a single active ingredient does not sufficiently relieve the pain, the treatments can be combined. Cooling the affected joint probably also helps and is perceived as pleasant by many people.
The aim of long-term gout treatment is to prevent gout attacks and subsequent problems by lowering the uric acid level. There are two ways to do this:
Change your diet: above all, eat less meat, fish and seafood and drink less alcohol.
Take uric acid-lowering medication, usually allopurinol.
Not all people with gout need uric acid-lowering drugs. Especially after a first attack of gout, medication treatment is usually not necessary. This is because some people do not have any problems for years afterward, others only rarely.
Uric acid-lowering drugs are particularly useful if the gout attacks are more frequent or particularly stressful. They are also useful if complications such as gout nodules or kidney stones have already occurred, or if the kidney function is restricted. Medicines can also be chosen if a change in diet is not sufficient.
Life and everyday life
The pain of a gout attack can be very stressful and make many everyday activities impossible. Walking, cycling, putting on shoes or grasping and holding something can become a challenge. However, some people develop a feeling for when a gout attack is imminent – for example, because the affected joint pinches, tingles or feels dull or stiff. They then prepare themselves for the gout attack: For example, they carry out certain activities before the pain increases so that they can spare the affected joints during the attack.
However, a gout attack does not only have physical limitations. It can make restful sleep impossible and can affect the mind. In most cases you are unable to go to work or do the household chores. It can be helpful if friends and family members know how painful a gout attack is. Then they can better understand why rest and care are important these days. There is no reason to feel guilty about not being able to work and being less responsive to your partner and family.
In the past, gout was considered a disease of affluence, which mainly affects well-fed older men who were inclined to drink. Some people with gout therefore feel that they are labelled as having a dissolute lifestyle. This is a prejudice – the disease can have completely different causes. In addition, the uric acid level is high in a great many people without any symptoms. So there is no need to blame yourself for the disease – and no need to worry too much about your diet.
Gout attacks can change the image of your own body. Especially for younger people it can be stressful to have an illness that is more likely to be considered an illness of old age. Women with gout sometimes feel unattractive, for example because they are restricted in their choice of shoes. During an attack of gout, any kind of pressure on the affected joints can be painful – including physical exercise and even gentle touches.