What is gout?

Gout is a disease usually caused by having too much uric acid in your body. This excess of uric acid may not cause symptoms for years, but usually it eventually causes painful joint inflammation (arthritis). The most common first site of the arthritis is the joint between the foot and the big toe. This painful inflammation of the first toe joint is called podagra. Subsequent attacks often affect other joints of the foot and leg, and, less frequently, the arms and hands.

In addition to the arthritis, gout causes the formation of tophi. Tophi are lumpy deposits of uric acid crystals just under the skin. Common places for tophi to develop are in the outer edge of the ear, on or near the elbow, over the fingers and toes, and around the Achilles tendon.

Gout can also cause kidney stones made of uric acid.

Most people who have gout are middle-aged men. Only 5% of cases of gout occur in women.

How does it occur?

Gout usually occurs because too much uric acid is circulating in your blood. This may happen when your body produces too much uric acid or when your kidney does not eliminate enough uric acid from your body. In most cases the cause is the latter, inadequate elimination by the kidney. A few people have gouty arthritis even though they have normal uric acid levels.

Your body may produce too much uric acid if you have certain uncommon genetic defects. Overproduction of uric acid may also happen if you have a disease such as cancer and certain types of red blood cell disorders. A diet high in alcoholic drinks and purine-containing foods can also cause your body to produce an excess of uric acid.

When gout is caused by poor elimination of uric acid by the kidneys, it can be difficult to determine why this is happening. Although underexcretion of uric acid is the most common cause of gout, it is not well understood. The specific kidney defect in such cases of gout is usually never identified.

Certain conditions can cause excess levels of uric acid, such as dehydration. Diuretics, a type of medication, can increase levels of uric acid. Other medications can also affect the level of uric acid in the blood. It is important to make sure your health care provider knows all the medications you are using, both prescription and nonprescription.

What are the symptoms?

Some people have high uric acid blood levels for years and never have any symptoms. Only 10% to 20% of people with high levels of uric acid develop the symptoms of sudden, severely painful arthritis, especially of only one joint at a time, with redness and swelling. The arthritis usually occurs before tophi or kidney stones develop. These sudden attacks are sometimes related to physical illness, trauma, or excessive alcohol use.

The tophi do not cause any symptoms unless they open and drain. They are often not painful, but, depending on their location, they can limit the movement of joints.

The symptoms of uric acid stones are like those of other kidney stones. They are likely to cause abdominal pain and sometimes nausea, vomiting, fever, or blood in the urine.

How is it diagnosed?

Your doctor will suspect that you have gout if

• Your first toe joint is inflamed.

• The level of uric acid in your blood is high.

• The arthritis responds to the drug colchicine. (Colchicine, an anti-inflammatory drug, is effective only in gouty-type arthritis.)

To confirm the diagnosis, your doctor may take a sample of fluid from the affected joint or joints and send it to the lab for microscopic examination. The presence of uric acid crystals in the fluid shows that you have gout.

What is the treatment?

Because only some individuals with high uric acid levels develop problems, it is usually not necessary to treat everyone before symptoms develop. In special circumstances (for example, if you have a strong family history of gouty arthritis or kidney stones) you may be treated for gout even though you do not have any symptoms.

The first goal of treatment, if you do have symptoms, is to treat the gouty arthritis or kidney stones. The second goal is then to try to prevent the recurrence of these problems by controlling the uric acid levels.

Treatment of the arthritis initially involves the use of anti- inflammatory medications, such as colchicine or indomethacin. Sometimes a corticosteroid drug, such as prednisone, is used. These medications are sometimes used on a daily basis to prevent recurrent attacks of gouty arthritis.

If the gouty arthritis becomes chronic (frequently recurring), one of two additional drugs may be used to prevent damaging deposits of uric acid in the joints. These drugs are allopurinol and probenecid.

What can be done to prevent gout?

There is no sure way to prevent gout. However, you can take these steps to lessen the possibility that you will have elevated uric acid levels:

• Eat a diet low in purines and do not overindulge in alcohol. Purine-containing foods include organ meats (such as sweetbreads, liver, and kidney), shrimp, anchovies, sardines, and dried legumes. Your consumption of alcoholic beverages should not exceed 3 ounces a day.

• Drink lots of fluids.