What is Gout?
Gout is a type of inflammatory arthritis that occurs in response to a build-up of crystals that are deposited in joints, soft tissue or bone. The crystals are formed as a byproduct of purine breakdown that occur naturally in the body. About 5.1 million Americans are affected by gout. It affects men older than 40 more than women, although after menopause, both men and women are equally affected.
What Causes Gout?
Uric acid is a natural byproduct of purine breakdown which is then eliminated by our kidneys. Our bodies are not very efficient however in eliminating uric acid and thus a build-up occurs which is known as hyperuricemia. Hyperuricemia is the precursor to gout although not everyone who has hyperuricemia will get gout for reasons that are not well understood. This uric acid leads to crystal formations that are deposited in joints, bones and soft tissue. These needle-like crystals can cause excruciating pain that is often likened to breaking a bone.
4 Stages of Gout
1. Asymptomatic hyperuricemia
During this period, the person has no symptoms of gout but none-the-less, crystals are deposited and accumulate which then leads to a gout attack. Again, why this occurs in some people with hyperuricemia and not others is not well understood.
2. Acute gout attack
Left untreated, an acute attack resolves spontaneously in 3 to 10 days. It is believed that the inflammation and lower pH that occurs during the attack eventually causes the crystals to dissolve. In addition, some of the crystals become walled-off in tissue while other types of cells known as macrophages may elicit an anti-inflammatory response. Finally, specific proteins are thought to coat the crystals which also suppress inflammation. These processes lead to a resolution of symptoms within 3-10 days.
3. Intercritical period
This is the period between attacks. Generally, about 68% of people will experience another gout attack or flare within the first year, 78% within 2 years and 84% within 3 years. A small minority will never experience another gout attack. During this intercritical period the individual remains pain free despite the fact that damage to the underlying structures can still occur.
4. Advanced Gout
Over time, the persistence of crystals cause chronic low-level inflammation that leads to joint damage and build up of crystal deposits that are known as tophi. These deposits lead to joint erosion and deformities that are clearly evident on X-ray or MRI.
How is Gout Diagnosed?
The gold standard for diagnosis is to take a sample of joint fluid during an acute flare to analyze it for monosodium urate crystals. However this is not always practicable during a medical exam. If the joint is not aspirated, a very detailed history is taken, the affected joint is carefully examined and blood work is ordered because gout can mimic other diseases.That is why it is very important to see your provider during an acute attack.
How is Gout Treated?
During an acute flare, treatment focuses on eliminating pain and disability as quickly as possible. To this end several types of medications can be used. Since inflammation is an underlying condition, medications that target inflammation are often used.
Treatment of advanced gout focuses on reducing the level of uric acid since gout does not occur without hyperuricemia. The goal is to prevent erosive changes to bones, soft tissue and joint spaces that otherwise occur. Talk to your provider about treatment options that are best for you.
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