Gout, a form of inflammatory arthritis, is a particularly painful condition that affects millions of Americans. The pain is caused by inflammation in the joint induced by the deposition of sharp uric acid crystals. These crystals have a unique growth pattern which causes them to from in needle-like structures. Uric acid is created when purines are metabolized or broken down by the body. Uric acid in and of itself is not harmful; it only becomes worrisome when the body is unable to properly process the acid or if the body is experiencing unusually high levels of the acid. Gouty arthritis is unique in that it primarily only affects a single joint at a time. The big toe is the most commonly affected joint, but gout is also found in the mid-foot joints, ankles, knees, and wrists. When left untreated, gout can develop into chronic, recurring symptoms that spread to multiple joints and can cause permanent bone, nerve, and tissue damage.
If you suspect you have gout, your primary care physician will begin by taking a medical history. The two primary factors to be evaluated are which joint or joints are involved (e.g. the big toe) and whether the episode began explosively or developed slowly over time. If the joint pain developed over days or weeks, it is unlikely to be gout. The most accurate diagnostic test examines the synovial fluid of the affected joint through a procedure known as arthrocentesis. Your physician will use a needle to extract a sample of your synovial fluid, and then it will be sent to a laboratory to be examined for the presence of uric acid crystals. If these crystals are found, there is a very high likelihood that you have gout. The removal of fluid and crystals, known as aspiration, may also temporarily reduce some of the painful symptoms of gout. A less accurate, but also less invasive, diagnostic tool is a blood test to examine uric acid levels. This is a less accurate diagnostic tool because the level of uric acid in the blood can fluctuate throughout a gout attack. It is more often done after an attack has passed, when the levels of uric acid are more likely to be stable and therefore a high level will be more indicative of gout. Imaging tests, such as x-rays, can also be used as a diagnostic tool when chronic gout is suspected. If you are having your first suspected gout attack, it is unlikely that any indicators will be found on an x-ray. X-rays are particularly useful in identifying tophi before they are visible to the naked eye, allowing treatment to begin before the tophi becomes severe.
WHO IS AT RISK OF GOUT?
There are several factors that increase your risk of developing gout. (a) Diet: Consuming purine rich foods and beverages, such as those sweetened with high fructose corn syrup, red meat, organ meat, and certain seafood and oily fish, will increase the production of uric acid and therefore may contribute to the development of gout. (b) Sex: Women naturally have lower levels of uric acid, causing gout to be more common in men. The risk of gout in women raises after menopause. (c) Age: Gout risk tends to increase with age, although men are more likely to develop of it earlier than women. Men often develop gout between the ages of 30 and 50, while women are more susceptible post-menopausal and especially at 60 years of age or older. (d) Family history of gout: There seems to be a genetic component that affects the likelihood of developing gout, and if members of your family have gout, you are at a higher risk of developing it yourself. (e) Obesity: Your body produces more uric acid when you are overweight, and the kidneys tend to have a reduced capacity to process the uric acid. Some researchers believe that the added strain on joints also increases the likelihood of MSU crystal formation. (f) Medical conditions: Certain medical conditions are associated with a higher risk of gout development, including untreated hypertension (high blood pressure), kidney disease, heart disease, and diabetes. Interestingly, this increase of risk often works both ways; a study found that individuals diagnosed with gout had a significantly higher likelihood of developing diabetes later in life. (g) Medications: The most common type of medications that give rise to hyperuricemia are diuretics. Diuretics increase the frequency of urination, which reduces your fluid levels and increases the concentration of uric acid. Some diuretics also affect the kidneys’ ability to break down uric acid.
TREATMENTS & MEDICATIONS FOR GOUT
There are several stages of treatment that vary depending on acute gout vs. chronic gout, as well as how individual patients tolerate and respond to treatment. (a) NSAIDs: NSAIDs, or non-steroidal anti-inflammatory drugs, are the first line of defense when it comes to treating gout. By reducing the level of inflammation in the joint, they not only protect against joint and bone damage, they also assist with pain relief. You can find some NSAIDs, such as ibuprofen (Advil or Motrin) or naproxen (Aleve) as over the counter medications. Your doctor can prescribe a higher strength dose of these NSAIDs, or other NSAIDs such as Celecoxib (Celebrex) or Indomethacin (Indocin), among others. (b) Corticosteroids: When NSAIDs are not well tolerated, cannot be taken with other medications that you are on, or are not effective in relieving symptoms, corticosteroids may be used. These can be administered orally (commonly prednisone) or through an injection directly into the joint. Injections are only used if the gout is contained to one or two joints, and they must be done by a highly trained physician. These injections tend to only provide short term relief. (c) Gout-specific medications: In the case of recurrent symptoms, or chronic gout, your physician may prescribe gout-specific medications, such as allopurinol (Aloprim or Zyloprim) or colchicine (Colcrys), which help to manage and control the levels of uric acid within the body. In the most severe cases, when no other treatment has been successful, your physician may administer pegloticase (Krystexxa) intravenously. (d) Low purine diet: In addition to medicinal treatment, sticking to a low purine diet can contribute to lowering uric acid levels in the body. This primarily means avoiding high purine foods and drinks, as mentioned above, however adding cherries, lemons, apples, and/or baking soda to your diet may assist in lowering uric acid levels further. It is also important to stay well hydrated! Dehydration can contribute to an excess of uric acid.
HOW PLUSHCARE WORKS
1. Video chat with a doctor and tell them about your blood pressure and medication you are on.
2. The doctor can prescribe a refill, or start a new medicine if needed. They can also recommend ways to lower your blood pressure without medicine.
3. Pick up any prescriptions at your pharmacy, and follow up with your PlushCare doctor for refills going forward, or even bloodwork as needed.