DR TARIQ JAGNARINE
FAMILY MEDICINE, ENDOCRINOLOGY/ DIABETES
Gout is a very painful form of arthritis caused by crystals that form in and around the joints. It is the most common type of inflammatory arthritis, more common in men, and frequently seen in persons as they get older. Gout occurs in people who have high levels of urate in their blood. Urate is created every day when our bodies break down purines. These chemicals are naturally created in our body and converted to uric acid. Uric acid functions as antioxidants and neurone protectors, but they are also present in certain foods. 
On any day, about three-quarters of the urate in our bodies comes from the breakdown of purines produced within our body, while only about a quarter comes from the breakdown of purines in the food and drink we consume.
As urate levels build up, our body gets rid of any extra through the kidneys. However, if too much urate is produced at any given time, or the kidneys are unable to get rid of enough of it, then levels start to rise. If urate levels stay too high, urate crystals can slowly start forming. They mainly occur in and around firm joint tissues, such as the cartilage. Crystals can also appear under the skin and may even occur in internal organs, such as the kidneys causing kidney stones.
CAUSES
There are two different types of gout:
* Primary gout: Cause is unknown
* Secondary gout: can be caused by either:
o Chronic kidney disease
o Long-term use of medications that affect how well the kidneys can remove urate from the body.
RISK FACTORS
* Family history: Family members with Gout, Kidney Disease
* Being overweight: Gout is much more common in people who are overweight which results in a higher production of Urates as well as impaired renal excretion.
* Gender and age: Gout is about four times more common in men than women. It can affect men of any age, but the risk is greater in older persons.
Women rarely develop gout before the menopause. This is because the female hormone oestrogen increases how much urate the kidneys filter out. However, after the menopause, oestrogen levels go down and urate levels go up.
* Taking certain medications: Some medications can reduce the kidneys’ ability to get rid of urate properly. These include diuretics, also known as water tablets, and several tablets for high blood pressure, including beta-blockers and ACE inhibitors.
* Other conditions
Several different conditions are linked to increase urate levels. Common conditions associated with gout include:
* Chronic kidney disease
* High cholesterol and fats in the blood
* High blood pressure
* Type 2 diabetes
* Osteoarthritis.
SYMPTOMS
In Gout Arthritis, urate crystals can build up in joints for years without causing any symptoms. However, when these crystals become too much, some of them can spill out from the cartilage into the space between the two bones in a joint. The tiny, hard, sharp crystals can rub against the soft lining of the joint, called the synovium, causing a lot of pain, swelling and inflammation, resulting in a Gout Attack or Flare.
During an attack of Gout, the affected joint becomes:
* Very painful
* Tender
* Red
* Hot
* Swollen.
* The skin over the joint often appears shiny and may peel off a little as the attack settles.
Attacks usually come on very quickly, often during the night. The attack usually settles after about five to seven days, but it can go on for longer. If gout is left untreated, attacks can become more common and may spread to new joints.
Attacks typically affect the joint at the base of the big toe and often start in the early hours of the morning. The symptoms develop quickly and are at their worst within just 12 to 24 hours of first noticing that anything is wrong. Any light contact with the affected joint is very painful – even the weight of a bedsheet or wearing a sock can be unbearable. Although gout most often affects the big toe, other joints may also be affected. It is not common to have gout in joints such as the spine, shoulders or hips.
* TOPHI
Urate crystals can also collect outside of the joints and can be seen under the skin, forming small, firm lumps called tophi. The white colour of the urate crystals can be observed under the skin.
The most common areas for tophi are:
* Over the top of the toes
* Back of the heel
* Front of the knee
* Backs of the fingers and wrists
* Around the elbow
* The ears
Tophi are not usually painful, but they can get in the way of normal daily activities. They can sometimes become inflamed, break down and leak pus-like fluid with gritty white material – these are the urate crystals. Tophi can also grow within the joints and cause damage to cartilage and bone. This can lead to more regular, daily pain when activities are done.
GOUT TRIGGERS
Several things can cause the crystals to shake loose into the joint cavity, triggering an attack. These include:
* A knock or injury to the joint
* Fever
* Surgery
* Fatty Meals- Over eating
* Drinking too much alcohol
* Dehydration
* Starting urate lowering therapy, especially at a high dose, or not taking the treatment regularly each day.
DIAGNOSIS
Diagnosing gout is usually straightforward, especially if the symptoms of the condition are typical. However, gout can sometimes be more difficult to diagnose.
* Blood tests
* Blood tests to measure the urate levels can be helpful to support a diagnosis of gout, but are not enough on their own to confirm it.
* High urate levels in blood tests can suggest gout, but this will need to be considered alongside accompanying symptoms. It is possible to have high levels of urate, but not have any other symptoms of the condition.
* Imaging tests
Ultrasound and CT scans can be good at spotting joint damage, crystals in the joints and early signs of gout. X-rays are generally used to pick up the bone and joint damage caused by having gout for a long time.
* Synovial fluid examinations
These are a good way to rule out other crystal conditions and make a diagnosis.
The emotional effects of gout can have just as much impact as the physical symptoms. Long-term damage and severe pain from the attacks of gout can affect one’s daily life, disturbing sleep and mood. From time to time, gout may even cause restrictions and mental challenges. Speak to a health care professional.
The following week’s article will discuss treatment options for Gout, common food triggers, complications and life adjustments.
