Have You Noticed These Signs of Gout?

Did you know that gout is the most common form of joint inflammation (inflammatory arthritis)?

Studies in 2012 estimate that the prevalence of gout in Singapore was about 4.1% of the local resident population. The condition usually affects men in their 40s, but can also affect women during their post-menopausal years, due to reduced oestrogen levels.

Gout is caused by the build-up of uric acid crystals in the joint, causing pain, inflammation and swelling. It usually affects the lower limb joints, such as the joint of one of your big toes, but can also affect other joints such as the joints of your foot, ankle, knee or elbow, and less commonly, the joints in your fingers and hands.

Risk factors for gout

Gout has often been regarded as a disease that affects individuals who consume a diet rich in meat and alcohol.

However, there are many other risk factors for gout. These include having a family history of the condition, taking certain medications, and having underlying medical conditions. Besides meat and alcohol, foods such as certain types of seafood and the consumption of sweetened beverages and fructose-containing foods have also been associated with increasing one's risk of gout.

Risk factors for gout can be classified into 2 main groups: modifiable risks that can be managed, and non-modifiable factors that cannot be avoided.

Let's take a closer look at some of the common risk factors that can be managed.

Dietary risk factors for gout

Uric acid is produced when our bodies break down purine compounds. Patients with gout should control the consumption of foods which contain moderate to high levels of purine.

Having a diet rich in red meat, seafood, beer, spirits and sugar-sweetened beverages, especially those with high fructose content, can increase the risk of having gout.

Foods with very high purine levels include:

• Meat: organs such as brain, kidneys and liver, minced meat, sweetbread
• Seafood: anchovies, sardines, mackerel, herring, mussels
• Yeast and meat extracts

Foods with moderate purine levels include:

• Meat: bacon, beef, lamb, duck, goose, mutton, pork, venison
• Poultry: chicken
• Seafood: oysters, crab, tuna, lobster, shellfish, salmon
• Vegetables: asparagus, cauliflower, kidney beans, lentils, lima beans, mushrooms, peas, spinach

Medication and medical conditions associated with gout

Certain medications such as diuretics, which are used to treat hypertension and heart disease, can increase the risk of having symptoms of gout.

Other medications associated with increased risk of gout are medications that control blood pressure, such as ACE-inhibitors, angiotensin-receptor blockers (except Losartan) and beta-blockers.

Medical conditions that may lead to gout include:

• Chronic kidney disease (CKD)
• Obesity
• High blood pressure
• High cholesterol
• Heart failure
• Obstructive sleep apnoea
• Psoriasis
• Blood cancers

Are high uric acid levels a definite sign of gout?

Many patients with elevated blood uric acid levels may never have clinical gout. Having a high blood uric acid level is also associated with other conditions such as metabolic syndrome, diabetes, high blood pressure, kidney disease and cardiovascular disease.

It is important to review with your doctor to identify the risks factors and take active steps to address them in order to reduce your risk of developing gout.

How to manage acute gout and gout flare-ups

Acute gout typically presents as sudden painful swelling over a joint. The main aim of treatment is to reduce the acute inflammation.

In the event of a flare-up, a doctor will typically advise patients to rest the joint and limit physical activities, as well as prescribe medications such as non-steroidal anti-inflammatory medications (NSAIDS) and colchicine.

For patients who may be unable to tolerate these medications, steroids may be prescribed to help ease the inflammation. Some patients may require steroid injections into the joints (intra-articular steroids) to help control the inflammation.

Most of the time, gout is diagnosed clinically, and your doctor may order blood tests to check your uric acid levels. In some cases, fluid may be drawn out from the joint with a needle (joint aspiration) to rule out other causes of joint swelling.

Here's a closer look at some of the common treatments for gout and their effects:

Colchicine

How it works: Anti-inflammatory effect, commonly used in gout and other inflammatory conditions.

Common side-effects: Diarrhoea, nausea, vomiting.

Dosage/frequency of use: Usual dose of 0.6mg tablets 3 times per day (depending on underlying medical conditions).

NSAIDs such as Ibuprofen, diclofenac, or naproxen tablets

How it works: Reduce inflammation by inhibiting an enzyme called COX (cyclooxygenase)

Common side-effects: Gastric discomfort. Used with caution in patients with gastric, kidney and heart conditions.

Dosage/frequency of use: 2 to 3 times a day

Steroids such as prednisolone and dexamethasone tablets

How it works: Reduce inflammation and reduce the body's immune system activity

Common side-effects: Gastric discomfort. Frequent and high doses may cause systemic side effects such as weight gain, raised blood pressure, raised blood sugar, skin thinning and weakening of bones.

Dosage/frequency of use: To be advised by a doctor

Reducing gout flares and complications of chronic gout

Contrary to popular belief, the daily medications prescribed by a doctor are safe for long-term use and should be taken as directed. Untreated gout can cause more harm, especially if long-term chronic complications develop, such as kidney stones and kidney disease.

If left untreated over time, recurrent gout can become more difficult to manage. The condition can affect more joints in the body with a longer duration of pain and swelling. It may even cause progressive joint damage.

Your doctor will assess for risk factors such as your age, blood uric acid levels, and other medical conditions (such as kidney disease, high blood pressure, heart disease) before recommending treatment.

The most common medication used is allopurinol, which reduces the production of uric acid in the body. Other medications used for long-term management of gout are febuxostat and probenecid. Febuxostat also works by reducing the production of uric acid in the body, while probenecid increases the excretion of uric acid in the urine. Under guidance from a certified doctor, these medications are safe to be taken for the long term.

Upon starting these medications, your doctor may review your condition more frequently – once every few weeks – to check for any allergies or side effects, and may order blood tests to monitor your condition.

Indications for starting daily medication for gout (urate-lowering therapy) include:

• Recurrent flares of gout (2 or more times in a year)
• Presence of any hardened deposits of uric acid crystals under the skin (tophi)
• Signs of joint damage caused by gout, either from clinical examinations or on X-rays
• Kidney stones

Other options for treatment of chronic gout include pegloticase, which helps to break down the uric acid in the body to a state that can be excreted in the urine. It can be given to patients who are unable to tolerate or fail to respond to the more common therapies, and is administered in a healthcare setting as an infusion medication, once every 2 weeks. This is not suitable for patients with a G6PD deficiency.

Should you notice any symptoms of gout, or have concerns about your risks of getting gout, do visit our website or speak with a general practitioner at a Parkway Shenton medical clinic near you.