Gout

By Mayo Clinic staff

Definition
Gout is a complex form of arthritis characterized by sudden, severe attacks of pain, redness and tenderness in joints, often the joint at the base of the big toe. Gout can affect anyone. Men are more likely to get gout, but women become increasingly susceptible to gout after menopause. An acute attack of gout can wake you up in the middle of the night feeling like your big toe is on fire. The affected joint is hot, swollen and so tender that even the weight of the sheet on it seems intolerable. Fortunately, gout is treatable, and there are ways to reduce the risk that gout will recur.

Symptoms
Gout

The signs and symptoms of gout are almost always acute, occurring suddenly often at night and without warning. They include:

Intense joint pain. Gout usually affects the large joint of your big toe, but it can occur in your feet, ankles, knees, hands and wrists. The pain is likely to be most severe within the first 12 to 24 hours after it begins.

Lingering discomfort. After the most severe pain subsides, some joint discomfort may last from a few days to a few weeks. Later attacks are likely to last longer and affect more joints.

Inflammation and redness. The affected joint or joints become swollen, tender and red. When to see a doctor If you experience sudden, intense pain in a joint, call your doctor. Gout that goes untreated can lead to worsening pain and joint damage. Seek medical care immediately if you have a fever and a joint is hot and inflamed, which can be a sign of infection.

Causes

Gout occurs when urate crystals accumulate around your joint, causing the inflammation and intense pain of a gout attack. Urate crystals can form when you have high levels of uric acid in your blood. Your body produces uric acid when it breaks down purines substances that are found naturally in your body as well as in certain foods, such as organ meats, anchovies, herring, asparagus and mushrooms. Normally, uric acid dissolves in your blood and passes through your kidneys into your urine. But sometimes your body either produces too much uric acid or your kidneys excrete too little uric acid. When this happens, uric acid can build up, forming sharp, needle-like urate crystals in a joint or surrounding tissue that cause pain, inflammation and swelling.

Risk factors
You're more likely to develop gout if you have high levels of uric acid in your body. Factors that increase the uric acid level in your body include:

Lifestyle factors. Choices you make in your everyday life may increase your risk of gout.
Excessive alcohol use generally more than two drinks a day for men and more than one for women increases the risk of gout.

Medical conditions. Certain diseases and conditions make it more likely that you'll develop
gout. These include untreated high blood pressure (hypertension) and chronic conditions such as diabetes, high levels of fat and cholesterol in the blood (hyperlipidemia), and narrowing of the arteries (arteriosclerosis).

Certain medications. The use of thiazide diuretics commonly used to treat hypertension
and low-dose aspirin also can increase uric acid levels. So can the use of anti-rejection drugs prescribed for people who have undergone an organ transplant.

Family history of gout. If other members of your family have had gout, you're more likely
to develop the disease.

Age and sex. Gout occurs more often in men than it does in women, primarily because
women tend to have lower uric acid levels than men do. After menopause, however, women's uric acid levels approach those of men. Men also are more likely to develop gout earlier usually between the ages of 40 and 50 whereas women generally develop signs and symptoms after menopause.

Complications
People with gout can develop more-severe conditions, such as:

Recurrent gout. Some people may never experience gout signs and symptoms again. But others may experience gout several times each year. Medications may help prevent gout attacks in people with recurrent gout.

Advanced gout. Untreated gout may cause deposits of urate crystals to form under the skin in nodules called tophi (TOE-fi). Tophi usually aren't painful, but they can become swollen and tender during gout attacks.

Kidney stones. Urate crystals may collect in the urinary tract of people with gout, causing kidney stones. Medications can help reduce the risk of kidney stones.

Preparing for your appointment

Make an appointment with your doctor if you have symptoms that are common to gout. After an initial examination, your doctor may refer you to a specialist in the diagnosis and treatment of arthritis and other inflammatory joint conditions (rheumatologist). Here's some information to help you get ready for your appointment, and what to expect from your doctor. What you can do

Write down your symptoms, including when they started and how often they occur. Write down key personal information, including any recent changes or major stressors
in your life.

Make a list of your key medical information, including any other conditions for which
you're being treated and the names of any medications, vitamins or supplements you're taking. Your doctor will also want to know if you have any family history of gout.

Take a family member or friend along, if possible. Sometimes it can be difficult to soak
up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.

Write down questions to ask your doctor. Creating your list of questions in advance can
help you make the most of your time with your doctor. Questions to ask the doctor at the initial appointment include:

What are the possible causes of my symptoms or condition? What tests do you recommend? If these tests don't pinpoint the cause of my symptoms, what additional tests might I need? Are there any treatments or lifestyle changes that might help my symptoms now? Do I need to follow any restrictions while we're seeking a diagnosis? Should I see a specialist?

Questions to ask if you are referred to a rheumatologist include:

Do I have gout? What treatments are most likely to help me feel better? What are the possible side effects of the drugs you're prescribing? If these drugs don't work or cause serious side effects, what will we try next? How soon after beginning treatment should my symptoms start to improve? Do I need to take medications long term? I have these other health conditions. How can I best manage them together? Do you recommend any changes to my diet? Is it safe for me to drink alcohol? Are there any handouts or Web sites that you'd recommend for me to learn more about my
condition? If any additional questions occur to you during your medical appointments, don't hesitate to ask. What to expect from your doctor Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to talk about in-depth. Your doctor may ask:

What are your symptoms? In what part of your body do your symptoms occur? When did you first experience these symptoms? Do your symptoms come and go? How often? Does anything in particular seem to trigger your symptoms, such as certain foods or physical or emotional stress?

Are you being treated for any other medical conditions? What medications are you currently taking, including over-the-counter and prescription drugs as well as vitamins and supplements?

Do any of your first-degree relatives such as a parent or sibling have a history of gout? What do you eat in a typical day?

Do you drink alcohol? If so, how much and how often? What else concerns you?

Tests and diagnosis

Tests to help diagnose gout may include:

Joint fluid test. Your doctor may use a needle to draw fluid from your affected joint. When
examined under the microscope, your joint fluid may reveal urate crystals.

Blood test. Your doctor may recommend a blood test to measure the uric acid level in your
blood. Blood test results can be misleading, though. Some people have high uric acid levels, but never experience gout. And some people have signs and symptoms of gout, but don't have unusual levels of uric acid in their blood.

Treatments and drugs

Treatment for gout usually involves medications. What medications you and your doctor choose will be based on your current health and your own preferences. Different medications are prescribed to:

Treat acute gout attacks and prevent future attacks Reduce the risk of gout complications, such as the deposits of urate crystals that cause
nodules to form under the skin (tophi) Drugs used to treat acute attacks and prevent future attacks include:

Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs may control inflammation

and pain in people with gout. Your doctor may prescribe a higher dose to stop an acute attack, followed by a lower daily dose to prevent future attacks. NSAIDs include over-the-counter options such as ibuprofen (Advil, Motrin, others) and naproxen (Aleve, others), as well as more powerful prescription NSAIDs such as indomethacin (Indocin). NSAIDs carry risks of stomach pain, bleeding and ulcers.

Colchicine. If you're unable to take NSAIDs, your doctor may recommend colchicine, a
type of pain reliever that effectively reduces gout pain especially when started soon after symptoms appear. The drug's effectiveness is offset in most cases, however, by intolerable side effects, such as nausea, vomiting and diarrhea. After an acute gout attack resolves, your doctor may prescribe a low daily dose of colchicine to prevent future attacks.

 Corticosteroids. Corticosteroid medications, such as the drug prednisone, may control

gout inflammation and pain. Corticosteroids may be administered in pill form, or they can be injected into your joint. Corticosteroids are generally reserved for people who can't take either NSAIDs or colchicine. Side effects of corticosteroids may include thinning bones, poor wound healing and a decreased ability to fight infection. To reduce the risk of these serious side effects, your doctor will try to find the lowest dose that controls your symptoms and prescribe steroids for the shortest possible time. Drugs used to prevent the complications associated with frequent gout attacks include:

Medication that blocks uric acid production. Drugs called xanthine oxidase inhibitors,
including allopurinol (Zyloprim, Aloprim) and febuxostat (Uloric), limit the amount of uric acid your body makes. This may lower your blood's uric acid level and reduce your risk of gout. Side effects of allopurinol include a rash and low blood counts. Febuxostat side effects include rash, nausea and reduced liver function. Xanthine oxidase inhibitors may trigger a new, acute attack if taken before a recent attack has totally resolved. Taking a short course of low-dose colchicine before starting a xanthine oxidase inhibitor has been found to significantly reduce this risk.

Medication that improves uric acid removal. Probenecid (Probalan) improves your
kidneys' ability to remove uric acid from your body. This may lower your uric acid levels and reduce your risk of gout, but the level of uric acid in your urine is increased. Side effects include a rash, stomach pain and kidney stones.

Lifestyle and home remedies

Medications are the most proven, effective way to treat gout symptoms. However, making certain changes to your diet also may help. The American Dietetic Association recommends following these guidelines during a gout attack:

Drink 8 to 16 cups (about 2 to 4 liters) of fluid each day, including at least half water. Avoid alcohol. Eat a moderate amount of protein, preferably from healthy sources, such as low-fat or fat-free dairy, tofu, eggs, and nut butters.

Limit your daily intake of meat, fish and poultry to 4 to 6 ounces (114 to 170 grams).

Alternative medicine

If gout treatments aren't working as well as you'd hoped, you may be interested in trying complementary and alternative treatments for your gout. Discuss these treatments with your doctor first. Your doctor can help you weigh the benefits and risks and tell you if the treatments will interfere with your gout medications. Though you may be reluctant to discuss complementary and alternative medicine with your doctor, many mainstream doctors are becoming more open to discussing these options. But, since few of these treatments have been extensively studied in clinical trials, it's difficult to assess whether these treatments are helpful for gout pain. In some cases, the risks of these treatments aren't known. Some complementary and alternative treatments that have been studied include:

Coffee. Studies have found an association between coffee drinking both regular and decaffeinated coffee and lower uric acid levels, though no study has demonstrated how or why coffee may have an influence on uric acid in your body. The available evidence isn't enough to encourage noncoffee drinkers to start, but it may give researchers clues to new ways of treating gout in the future.

Vitamin C. Supplements containing vitamin C may reduce the levels of uric acid in your blood. However, vitamin C hasn't been studied as a treatment for gout. Don't assume that if a little vitamin C is good for you, then lots is better. Megadoses of vitamin C may increase your body's uric acid levels. Talk to your doctor about what a reasonable dose of vitamin C may be. And don't forget that you can increase your vitamin C intake by eating more fruits and vegetables, especially oranges.

Cherries. Cherries have been associated with lower levels of uric acid in studies, but it isn't clear if they have any effect on gout signs and symptoms. Adding cherries and other darkcolored fruits, such as blackberries, blueberries, purple grapes and raspberries, to your diet may be a safe way to supplement your gout treatment, but discuss it with your doctor first. Other complementary and alternative medicine treatments may help you cope until your gout pain subsides or your medications take effect. For instance, relaxation techniques, such as deep-breathing exercises and meditation, may help take your mind off your pain.

Prevention
Medications If you experience several gout attacks each year or if your gout attacks are less frequent but particularly painful, your doctor may recommend medication to reduce your risk of future gout attacks and of gout-related complications. You usually begin taking preventive medications once your acute gout attack has subsided. Options include:

Low-dose NSAIDs

 Low-dose colchicine Allopurinol or febuxostat Probenecid

Dietary changes During symptom-free periods, these dietary guidelines may help protect against future gout attacks:

Keep your fluid intake high. Aim for 8 to 16 cups (about 2 to 4 liters) of fluid each day, including at least half water.

Limit or avoid alcohol. Talk with your doctor about whether any amount or type of alcohol is safe for you. Recent evidence suggests that beer may be particularly likely to increase the risk of gout symptoms, especially in men.

Eat a balanced diet following the Dietary Guidelines for Americans. Your daily diet should emphasize fruits, vegetables, whole grains, and fat-free or low-fat milk products.

Get your protein from low-fat dairy products. Low-fat dairy products may actually have a protective effect against gout, so these are your best-bet protein sources.

Limit your intake of meat, fish and poultry. A small amount may be tolerable, but pay close attention to what types and how much seem to cause problems for you.

Maintain a desirable body weight. Choose portions that allow you to maintain a healthy weight. Losing weight may decrease uric acid levels in your body. But avoid fasting or rapid weight loss, since doing so may temporarily raise uric acid levels.

References
DS00090 Nov. 14, 2009 1998-2010 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. "Mayo," "Mayo Clinic," "MayoClinic.com," "EmbodyHealth," "Enhance your life," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research.

Gout diet
By Mayo Clinic staff

Definition
Gout, a painful form of arthritis, has long been associated with diet, particularly overindulgence in meat, seafood and alcohol. As a result, gout treatment used to include

severe dietary restrictions, which made the gout diet hard to stick to. Fortunately, newer medications to treat gout have reduced the need for a strict gout diet. In many ways, the gout diet resembles the healthy eating plan recommended for most people. Besides helping you maintain a healthy weight and avoid several chronic diseases, this diet may contribute to better overall management of your gout. Gout occurs when high levels of uric acid in your blood cause crystals to form and accumulate around a joint. Your body produces uric acid when it breaks down purines. Purines occur naturally in your body, but you also get them from eating certain foods, such as organ meats, anchovies, herring, asparagus and mushrooms.

Purpose
A gout diet helps to control the production and elimination of uric acid, which may help prevent gout attacks or reduce their severity. The diet isn't a treatment for gout, but may help you control your attacks. Obesity also is a risk factor for gout, so losing weight can help you lower your risk of attacks.

Diet details
A gout diet reduces your intake of foods that are high in purines, which helps control your body's production of uric acid. If you're overweight or obese, lose weight. However, avoid fasting and rapid weight loss because these can promote a gout attack. Drink plenty of fluids to help flush uric acid from your body. Also avoid high-protein diets, which can cause you to produce too much uric acid (hyperuricemia). To follow the diet:

Limit animal protein. Avoid or severely limit high-purine foods, including organ meats, such as liver, and herring, anchovies and mackerel. Red meat (beef, pork and lamb), fatty fish and seafood (tuna, shrimp, lobster and scallops) are associated with increased risk of gout. Because all animal protein contains purines, limit your intake to 4 to 6 ounces (113 to 170 grams) daily.

Eat more plant-based proteins. You can increase your protein by including more plant-based sources, such as beans and legumes. This switch will also help you cut down on saturated fats, which may indirectly contribute to obesity and gout.

Limit or avoid alcohol. Alcohol interferes with the elimination of uric acid from your body. Drinking beer, in particular, has been linked to gout attacks. If you're having an attack, avoid alcohol. However, when you're not having an attack, drinking one or two 5-ounce (148 milliliter) servings a day of wine is not likely to increase your risk.

Drink plenty of fluids, particularly water. Fluids can help remove uric acid from your body. Aim for eight to 16 8-ounce (237 milliliter) glasses a day.

Choose low-fat or fat-free dairy products. Some studies have shown that drinking skim or low-fat milk and eating foods made with them, such as yogurt, help reduce the risk of gout. Aim for adequate dairy intake of 16 to 24 fluid ounces (473 to 710 milliliters) daily.

Choose complex carbohydrates. Eat more whole grains and fruits and vegetables and fewer refined carbohydrates, such as white bread, cakes and candy.

Limit or avoid sugar. Too many sweets can leave you with no room for plant-based proteins and low-fat or fat-free dairy products the foods you need to avoid gout. Sugary foods also tend to be high in calories, so they make it easier to eat more than you're likely to burn off. Although there's debate about whether sugar has a direct effect on uric acid levels, sweets are definitely linked to overweight and obesity.

There's also some evidence that drinking four to six cups of coffee a day lowers gout risk in men.

Results
Following a gout diet can help you limit your body's uric acid production and increase its elimination. It's not likely to lower the uric acid concentration in your blood enough to treat your gout without medication, but it may help decrease the number of attacks and limit their severity. Following the gout diet and limiting your calories particularly if you also add in moderate daily exercise, such as brisk walking also can improve your overall health by helping you achieve and maintain a healthy weight.
March 10, 2010