About Gout | Knowledge is Power

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Gout is a type of inflammatory arthritis that causes painful swelling in the joints. It is a chronic condition, however, with medical treatment and self-care, a person with gout can reduce painful flare-ups and reduce destruction of the affected joints.

by Kimberly Madison Kimberly Madison, BSN, MSN (New)

Specializes in Analytics, Quality, Trauma, Clinical Registries. Has 13 years experience.

What Do You Know About Gout?

About Gout | Knowledge is Power

Inflammatory Arthritis

According to the Centers for Disease Control and Prevention (CDC) National Statistics, around 58.5 million people in the United States (U.S.) have a form of arthritis1. Non-inflammatory and inflammatory are the two major categories of arthritis2. Gout is a common form of inflammatory arthritis1.

What is gout?

Gout is a type of inflammatory arthritis. Intense pain, along with red, hot, swollen joints, characterizes the condition. Stiffness and immobility can also occur in the affected joints. Unlike other forms of inflammatory arthritis, an acute gout attack or gout flare will initially affect a single, unilateral joint1.

Hyperuricemia, or high levels of uric acid, causes gout. However, not all people with hyperuricemia will develop gout. Uric acid, or urate, is the waste product of purine. Our bodies produce the organic compound, purine2. Red meats, organ meats, shellfish, fructose, and alcoholic beverages, especially beer, also contain purines.

The kidneys excrete urate through urine. If the kidneys cannot filter enough urate, the excess builds up and continues to circulate through the body. About one-third of uric acid breaks down in the intestines3.

The under excretion of uric acid by the kidneys is the most common cause of hyperuricemia. Monosodium urate (MSU) deposits form in the presence of hyperuricemia6. These needle-like crystals can settle in any area of the body, particularly in joints, bursa, tendon sheaths, and kidneys.

Phases of gout

Gout progresses through the following three phases if not treated4,5.

Acute gout

A gout attack, or flare, is a sudden onset of excruciating pain and swelling of the joints. Commonly, starting in the big toe, gout flares affect a single joint of the lower extremities at a time. However, gout can show up in other joints, too.

Without treatment, a gout flare can last for days, or possibly weeks. A gout flare happens suddenly, usually at night when a person is lying down. Because fluid leaves joints faster than uric acid while lying flat, acute pain episodes occur at bedtime. An intercritical period, or time in between flare-ups, usually follows an acute gout attack.

Recurrent gouty arthritis

Over time, acute attacks increase in frequency. At this phase, there is bilateral joint involvement. Gouty arthritis can be mistaken for rheumatoid arthritis because smaller joints are involved with some joint deformity.

Tophaceous gout

Tophi are stone-like masses in the soft tissues and joints. They can appear anywhere in the body and bring about destruction of the joints, bones, and surrounding tissue. Tophaceous gout is the most chronic form of the disease.

Who gets gout?

Risk Factors

Men between the ages of 30 to 40 years old account for over half of the cases in the U.S. Women’s risk increases after menopause1.

Genetics

The risk for gout also increases if a person has a family history or the disease.

Diet

High purine foods can trigger a gout attack. Foods such as certain meats, shellfish, fructose, and alcohol are high in purines that break down to uric acid.

Preexisting Conditions

Health issues like chronic kidney disease, type 2 diabetes, obesity, hypertension, and some cancers put a person at risk for gout.

Medications

Certain medications, such as loop diuretics, ethambutol, low-dose aspirin, pyrazinamide and cyclosporine, can increase a person’s risk for gout.

How is gout diagnosed?

Gout can be difficult to diagnose because the symptoms are like those of other diseases. Your primary healthcare provider or rheumatologist will want to know your symptoms, complete a medical history and physical exam. The provider may also order lab tests and imaging1.

Signs and Symptoms

Most people who seek treatment for gout usually do so while experiencing an acute pain crisis. The excruciating pain starts in one or more joints and worsens with movement or when touched. Some people experience chills, fever, and feel ill. A person with gout may report pain with warmth, redness, swelling, and stiffness of the joint.

Laboratory tests and imaging

A healthcare provider may order the following tests to help diagnose gout5:

  • blood test to measure uric acid level
  • aspiration of synovial fluid for laboratory analysis
  • ultrasound or Xray of affected joints

How is gout treated?

A rheumatologist or other healthcare provider will treat gout with medical interventions and recommended self-management strategies. The first concern for treatment is pain management during an acute flare.

To manage pain and inflammation, a healthcare provider may prescribe non-steroidal anti-inflammatory (NSAIDS) medications like ibuprofen, corticosteroids, or colchicine. A person can take corticosteroids orally or by injection in the affected joint1.

Besides pain management interventions, a healthcare provider will prescribe medication to reduce uric acid. Allopurinol is the gold standard uric acid-reducing medication. Healthcare providers may also prescribe febuxostat, probenecid, or pegloticase. These medications lower or prevent urate formation.

By lowering uric acid, medications also decrease damage to the joints by reducing tophi formation. A healthcare provider can aspirate excess synovial fluid to decrease swelling of the joint. In some cases, a surgeon will remove larger tophi1.

Self-management activities, such as lifestyle changes, can also help reduce painful flares. These activities include1:

  • consuming a healthy diet and limiting purine-rich foods
  • decreasing alcohol consumption
  • drinking enough water
  • engaging in physical activity
  • changing medications that provoke gout attacks

Unfortunately, many people with gout wait until they have an acute pain crisis before seeking medical attention.

Final thoughts

If you or someone you know has gout, it’s important to follow a plan of treatment. Medications and self-management activities help reduce acute pain crises and reduce further destruction to involved joints. The following steps can help a person live better with gout6:

  1. Join an online support group. People with gout can feel isolated, especially during a pain crisis. Making connections in a supportive environment with others who share your experience can boost your emotional well-being. The Alliance for Gout Awareness is a non-profit organization with a community of people living with gout6.
  2. Schedule routine appointments with your healthcare provider. Routine follow-up is important to ensure you receive proper treatment. Your healthcare provider can monitor your symptoms and make adjustments to your treatment plan if necessary.
  3. Manage your pain and uric acid levels. Manage your gout by taking prescribed medications to prevent flares and destruction of your joints, bones, and surrounding tissues. Remember, if uric acid levels remain elevated over a long period, tophi can form, leading to immobile joints and disability.
  4. Adopt lifestyle changes to reduce your gout flares. Physical activity, maintaining a healthy weight and eliminating purine-rich foods from your diet can prevent flare-ups. Understandably, if you need to lose weight, changing your diet while managing your weight loss can be hard to do on your own. Be sure to let your provider know you would like to lose weight so they can help you1.

Have you cared for patients during an acute gout attack?

What pain management strategies worked best for them?

Share your stories in the comments.


References

1 CDC: Gout

2Inflammatory Arthritis, Purine

3Urinary excretion of uric acid is negatively associated with albuminuria in patients with chronic kidney disease: a cross-sectional study

4Clinical manifestations and diagnosis of gout

5Gout and Hyperuricemia

6Alliance for Gout Awareness: Gout Guides

Kimberly Madison, MS, RN, has over 12 years of experience in telemetry, med-surg, acute rehabilitation, orthopedics, emergency medicine, trauma, pediatrics, quality and patient safety, analytics, and performance improvement. She enjoys writing about health and medical topics for consumer and clinician audiences.

3 Articles   8 Posts

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11 Comment(s)

amoLucia

Specializes in retired LTC. 7,641 Posts

Good article. As one who experiences 'the rich man's disease', I better understand now why my toes are so blanket sensitive at HS. I tolerate my status. I have my meds, food avoidances, etc. 

Kimberly Madison, BSN, MSN

Specializes in Analytics, Quality, Trauma, Clinical Registries. Has 13 years experience. 3 Articles; 8 Posts

Thanks for commenting, amoLucia. I am glad you found this article informative😊

traumaRUs, MSN, APRN, CNS

Specializes in Nephrology, Cardiology, ER, ICU. Has 30 years experience. 164 Articles; 21,102 Posts

Good article with solid info. Just want to add that as a nephrology APRN, allopurinol and colchicine need to be dosed for renal function. 

Kimberly Madison, BSN, MSN

Specializes in Analytics, Quality, Trauma, Clinical Registries. Has 13 years experience. 3 Articles; 8 Posts

Thanks for reading, traumaRUs. I appreciate your valuable feedback 😊.

Kitiger, RN

Specializes in Private Duty Pediatrics. Has 43 years experience. 1,639 Posts

My mother had gout, which started after she began taking Bumex. I want to tell you about one episode she had.

She had gout in her fingers and toes, for which she took Allopurinol. It was an ongoing problem. One day, she showed me her elbow. It was swollen, soft, discolored (darker) and painful. Thinking it was infected, I took her to Prompt Care. The doctor also thought it was infected and he lanced it. Flat crystals, 1 to 1 1/2 inches in diameter were pushed out, along with a lot of serous drainage! I had never before seen crystals pop out of a person's flesh!

Seeing the crystals, the doctor said it was gout. He bandaged it up and sent us home. Two or three weeks later, her rheumatologist asked us whether an antibiotic had been ordered. He had looked up her records and saw that the culture & sensitivity had come back positive. (We didn't even know that a C & S had been ordered.)

The elbow healed after she started the antibiotic.

Is it common to have flat crystals pop out of a wound? 

Extremely informative I have gout, my mother’s  was indeed the worst ,I have ever seen crystals actually pushing through her skin in her toes turned her feet very very dark My 40 year old son in his knee and husband had his first flare a month ago it is the most painful thing I had ever felt, I thought my foot was broken it was my toe I couldn’t even have a sheet on my foot the pain was unbearable it has attacked my thumb leaving my hand painful swollen . Thank you for your informative article .

Kimberly Madison, BSN, MSN

Specializes in Analytics, Quality, Trauma, Clinical Registries. Has 13 years experience. 3 Articles; 8 Posts

@Kitiger, RN That sounds terribly painful! I hope your mother is doing better. While I don't know how common it is for crystals to break through the skin, I understand monosodium urate crystals can be large enough to see in a synovial fluid sample. I appreciate you taking the time to read this article and sharing your personal experience.

Edited by Kimberly Madison
spacing

Kimberly Madison, BSN, MSN

Specializes in Analytics, Quality, Trauma, Clinical Registries. Has 13 years experience. 3 Articles; 8 Posts

@sandee Oceans

I am glad you found this article informative. Thanks for sharing your personal experience with gout. 

amoLucia

Specializes in retired LTC. 7,641 Posts

Over the years, I've been 'full of rocks & dirt'. I've had a chole for gall stones, I currently have kidney stones (inoperable), and a past right parotid that had calcifications that abcessed. And I have uric acid gout.

I'M FULL OF ROCKS!

Orca, ASN, RN

Specializes in Corrections, psychiatry, rehab, LTC. Has 27 years experience. 2,056 Posts

I have had tophi in strange places. About a year and a half ago I had olecranon bursectomies on both elbows (done one at a time about a month apart) because my elbows protruded abnormally. Prior to the surgeries the elbows would periodically become infected and I had to have them drained. I had what appeared to be a cyst on my left Achilles tendon that yielded tophi when drained. I have a deformity in the distal joint of my left index finger that may also be related. And this is with me taking allopurinol.

When I have had breakthrough joint pain, indomethacin is my rescue drug of choice. During a period when there was a national shortage, I also had some success with naproxen.

Edited by Orca

Kitiger, RN

Specializes in Private Duty Pediatrics. Has 43 years experience. 1,639 Posts

My mom took Alopurinol until she couldn't. She went into Aplastic Anemia, presumably caused by the Alopurinol. That is very rare.