Gout

An attack of gout generally happens overnight, which is so sharp and sudden that it often wakes up the affected person in the middle of the night with a burning sensation in the affected area. Acute gout attacks can last between 3 and 10 days, and if you do not receive uric acid treatment in time, it can become chronic, causing permanent damage to your joints. Some of the common symptoms and signs of high uric acid include:

• Severe joint pain: Gout generally causes severe pain in the joint of the big toe, but the attack can occur in other joints as well, such as the knee, ankle, foot, wrist, hand, elbow, or even fingers. This pain is caused by high uric acid in the joints, which can spread to the space between the bones and end up running against the soft lining of the joints, causing unbearable inflammation. This scenario is referred to as a gout attack. The pain peaks within the first 4 to 12 hours of the attack and generally occurs either early in the morning or after midnight.
• Prolonged discomfort: Even after the episode of the gout attack, joint discomfort can last for days or weeks, although the pain subsides. However, any future gout attack on the same joint generally lasts longer, causing sharper pain. Such later gout attacks can also affect other joints that were not involved in previous episodes.
• Swelling and redness: The area affected by gout swells and becomes red with a feeling of tenderness, making it extremely sensitive to any sort of touch or weight. In cases of severe gout attacks, high uric acid can also turn the affected area purple in color.
• Trouble in movement: As gout attacks become more frequent in one joint, high amounts of uric acid crystals get deposited, reducing the ease and comfort of movement, which can lead to abnormal joint movement. This is one of the common symptoms of chronic gout.
• Tophi: The presence of high uric acid can lead to crystallization in the affected joint, resulting in the formation of small, firm lumps called tophi. These visibly large urate crystals are white and generally form near the toes, knees, elbows, fingers, wrists, or ears. Tophi, which typically occur in chronic tophaceous gout, can swell to the point of breaking down or bursting, leaking a pus-like fluid. The fluid generally does not cause pain but can hinder normal daily activities. In some cases, tophi can also potentially damage cartilage and bone, leading to extreme pain during routine activities.

In addition to the above-mentioned symptoms, another common symptom of gout in the ankle includes shiny and flushed skin. This is an externally visible symptom that can aid in the early detection of gout. Additionally, there may also be a burning pain in the ankle.

Gout arises from the deposition of urate crystals in joints. Urate crystals are formed due to high levels of uric acid in the body. Uric acid is produced by the breakdown of purines, which are natural substances found in the body and in certain foods. Typically, uric acid is excreted via the kidneys into the urine. However, due to either overproduction of uric acid or reduced excretion, it can accumulate, forming sharp, needle-like urate crystals. Once the blood is saturated with urate crystals, they are deposited in the bones and joints, leading to pain, inflammation, and swelling. The main factors affecting serum urate concentration include:

• Overproduction of uric acid

This condition is known as hyperuricemia, where uric acid levels in the blood rise above the normal level of 6.8 mg/dL (milligrams per deciliter). The causes include:

• Diet: Foods rich in purines, such as cooked or processed food from animal and seafood sources, are key elements in increasing uric acid precursors. They include:
• Red meat
• Fish
• Alcohol (particularly beer and spirits)
• Endogenous urate production: The turnover of urate crystals increases in the following conditions:
• Chronic hemolytic anemia
• Hemoglobinopathies
• Secondary polycythemia
• Thalassemia
• Glucose-6-phosphate dehydrogenase (G6PD) deficiency
• Lesch-Nyhan syndrome
• Malignancies (cancer)
• Lead poisoning
• Drugs: Some medications are linked with the overproduction of uric acid, including:
• Diuretics
• Low-dose salicylates
• Pyrazinamide
• Ethambutol
• Cytotoxics

• Decreased excretion of uric acid

Most urate excretion occurs in the kidneys, while the rest is excreted through the gastrointestinal tract (GIT). Reduced renal excretion is seen in the following:

• Hypertension
• Hypothyroidism
• Sickle cell anemia
• Hyperparathyroidism
• Chronic renal disease

Based on the causes, gout can be classified into two categories:

• Primary gout: Caused by either overproduction or underexcretion of uric acid.
• Secondary gout: Caused by chronic kidney disease or prolonged medications that affect the kidney's ability to remove uric acid from the body.

Stages of gout

Gout can progress through four stages:

• Asymptomatic gout: The individual experiences no symptoms of the condition; however, uric acid levels continue to rise in the body.
• Acute gout: This stage is characterized by severe pain and redness, lasting for a few weeks.
• Intercritical gout: Recurring gout attacks occur without pain in between episodes.
• Chronic tophaceous gout: This final stage can lead to other medical complications, especially kidney disease.

The root cause of gout is high uric acid concentration in the body, and thus the factors leading to a higher level of uric acid in the body are also the risk factors of gout, which primarily include:

Non-modifiable factors

• Family history: If there is a history of gout attacks in the family, the chances of a person inheriting genes that impair the kidney's ability to eliminate uric acid increase, even if the kidneys are healthy. This is particularly true if parents or grandparents have suffered from gout during their lifetime.
• Gender and age: Men are more prone to developing gout due to naturally higher levels of uric acid, with risk peaking between the ages of 30 and 50. Women generally have lower uric acid levels, but after menopause, their levels can reach those of men, increasing their risk of developing gout.
• Surgery or trauma: Individuals who have undergone surgery or experienced trauma have an increased risk of developing gout, especially after organ transplants due to the effects of anti-rejection medications.
• Race/ethnicity: The risk of developing gout varies across populations. Studies indicate that African Americans have a twofold increased risk compared to other ethnic groups.
• Genetic factors: Genetic variations in genes such as SLC22A12, which are crucial for uric acid absorption, can predispose individuals to gout.
• Other chronic diseases: Conditions such as high blood pressure, diabetes, heart diseases, and kidney-related diseases increase vulnerability to gout. Therefore, individuals with any medical condition should consult a doctor to mitigate the risk of developing gout.

Modifiable factors

• High purine diet: Foods and beverages high in purines, such as red meat, shellfish, and beer, can elevate uric acid levels in the blood, increasing the risk of gout. A balanced diet low in purines is advisable to reduce uric acid levels.
• Obesity: Being overweight increases uric acid production, placing stress on the kidneys to excrete it. This can lead to elevated uric acid levels in the blood. Maintaining an active lifestyle and a healthy body mass index (BMI) can help mitigate this risk.
• Certain medications: Some medications, including those for hypertension, low-dose aspirin, and beta-blockers, can raise uric acid levels. It is important to discuss potential side effects with a doctor to find ways to manage uric acid concentrations.
• Alcohol consumption: Alcohol intake has been linked to an increased risk of gout. It raises lactate levels, which inhibit uric acid excretion, and promotes purine degradation, leading to higher uric acid levels.
• Fructose/sweetened sugar beverages: High consumption of fructose and sugar-sweetened beverages contributes to the risk of developing gout.

A diagnosis of gout is usually simple as it is externally visible due to inflammation and redness of the skin of the affected joint. Any person experiencing symptoms like swelling, sharp pain, redness, and tenderness over their joints should consult a doctor to check for the presence of gout and receive appropriate uric acid treatment. A diagnosis for gout is usually done in any of the following ways:

• Physical Examination: Depending upon the case, a doctor might be able to confirm the presence of gout via a physical examination of the patient as the effects of a gout attack are visible near and over the affected skin area. During physical examinations, the most commonly and easily found gout is on the top of the foot.
• Blood Test:
  • Uric Acid: This test checks the concentration of uric acid in the blood, which can indicate the possibility of gout. A uric acid level in the blood over 6.8 mg/dL (milligrams per deciliter) is considered high. However, not everyone with a high uric acid level has gout.
• Urine Test:
  • Uric Acid: The uric acid urine test measures the level of uric acid in urine. A 24-hour urine sample is needed for this test.
• Imaging Tests:
  • X-ray of Affected Joint: This examination helps detect the presence of uric acid crystals and bone damage in the affected area.
  • Ultrasound: This is used for the detection of joint effusion, synovitis (inflammation of soft tissues lining the joint spaces), and evaluation of cartilage, bone contour, and crystal deposition.
  • Conventional CT (CCT): CCT is characterized by excellent resolution and high contrast, making it the best technique for assessing and characterizing urate crystals.
  • Dual-energy CT (DECT): This new imaging technique allows for the differentiation of deposits in the diagnosis of gout.
  • Magnetic Resonance Imaging (MRI): MRI assists in assessing inflammation, synovial thickening, and erosion of joints.
  • Nuclear Scintigraphy: This technique uses very small tracer amounts of radioactive molecules to diagnose diseases involving bone and soft tissues.
  • Positron Emission Tomography (PET): This technique is helpful when gout presents in unusual locations.
• Other Tests:
  • Synovial Fluid Analysis: Synovial fluid is a thick, straw-colored liquid found in small amounts in the joints. Its analysis aids in diagnosing and treating joint problems like gout.
  • Synovial Biopsy: The synovial membrane is the tissue lining a joint. Examination of this tissue helps in diagnosing gout or ruling out other infections.

Gout can be prevented in several ways. Usually, a combination of these methods can lead to a reduced level of uric acid in the body and thus provide gout pain relief. Some effective strategies to relieve gout knee pain, gout pain in the foot, and other joints include:

• Avoid or limit alcohol: Alcohol consumption affects the body's ability to excrete uric acid, increasing its concentration in the blood and raising the risk of a gout attack. Fructose-sweetened drinks should also be avoided or limited to reduce this risk.
• Increase intake of water: Drinking more water helps the kidneys flush out uric acid through urine, reducing the likelihood of urate crystals forming in the body. The ideal amount of water varies by individual, depending on factors such as age, sex, and fitness level.
• Maintain a healthy body weight: Individuals with a healthy body weight are less susceptible to gout attacks, as obesity can lead to higher uric acid levels, making it harder for the kidneys to eliminate it. Weight loss should be gradual to avoid complications.
• Avoid a high purine diet: Certain foods contain high levels of purine, which can elevate uric acid levels. Foods such as red meat, tuna, turkey, bacon, and alcoholic beverages should be limited. Healthier options include nuts, olive oil, berries, dark leafy greens, garlic, and onion.
• Avoid certain medications: Medications like diuretics can lead to hyperuricemia, which is an elevated uric acid concentration in the blood. Individuals taking such medications should consult their doctor for potential alternatives, as continued use may contribute to urate crystal formation.

A gout pain relief can be treated on the basis of the following:

Treatment of gout attacks

• Nonsteroidal anti-inflammatory drugs (NSAIDs): These drugs reduce both pain and inflammation. However, in some cases, they may cause side effects, including ulcers, bleeding, and stomach pain. Common examples include:
  • Naproxen
  • Indomethacin
  • Ibuprofen
  • Celecoxib
• Corticosteroid medications: Corticosteroids help reduce gout pain and inflammation. They are available as both oral pills and injections. Corticosteroids used for gout include:
  • Dexamethasone
  • Methylprednisolone
  • Prednisolone
  • Prednisone
  • Triamcinolone
• Colchicine: This drug is effective in reducing inflammation that causes pain, swelling, and other symptoms of gout. However, it is contraindicated in severe cases of chronic kidney disease.
• IL-1 blockers: Canakinumab, a long-lasting antibody to IL-1 beta, is considered for managing gout flares in patients with frequent flares who are contraindicated to NSAIDs, colchicine, and steroids (oral or injectable).

Treatment of chronic gout

• Xanthine oxidase inhibitors (XOI): XOI works by inhibiting uric acid synthesis. This class includes:
  • Allopurinol
  • Febuxostat
• Non-steroidal anti-inflammatory drugs: Long-term treatment with NSAIDs is sometimes used to prevent recurrent gout.
• Urate lowering drugs: These drugs act by reducing serum urate concentration. Initiation of urate lowering drugs is associated with an increased risk of gout flares due to crystal mobilization, which should be explained to the patient before treatment. These include:
  • Losartan
  • Flurbiprofen
  • Probenecid
• Uricosurics: Uricosuric drugs should not be used in patients with significant kidney impairment or a history of kidney stones. Drugs used are:
  • Sulfinpyrazone
  • Benzbromaron

Gout is a rare medical condition known to cause high levels of pain and discomfort. If someone at your home is experiencing sudden gout attacks and pain outbreaks, you can practice the following do’s and don’ts, especially regarding food choices for gout.

Do’s

• Drink at least 9-10 glasses of water to stay well-hydrated.
• Include citrus fruits such as oranges and lemons in your diet.
• Eat more cherries to help reduce inflammation in the body.
• Drink coffee to lower uric acid levels.
• Elevate the affected joint to reduce swelling.
• Avoid stress, as it can increase inflammation in the body.

Don’ts

• Do not consume alcohol.
• Do not consume fructose-sweetened drinks.
• Do not consume foods high in purines.
• Do not delay seeking medical consultation for gout.
• Do not starve yourself to lose weight.
• Do not consume sugar-rich foods.

Chronic tophaceous gout can lead to the following medical complications:

1. Joint damage and deformation: Chronic gout can result in swelling in the joints, deformation of joints, permanent joint damage, and movement disabilities. In severe cases, individuals may require joint replacement surgery due to gout pain in the foot and other joints.
2. Tophi: Lumps of urate crystals, known as tophi, can harden the skin over and near the joints, damaging cartilage. In rare cases, tophi may also develop on the ears. While these pointed crystals typically do not cause gout pain in the foot or other joints, they can lead to severe damage, permanently restricting movement.
3. Kidney stones: Uric acid and gout are closely related. Consequently, individuals with gout are more susceptible to developing kidney stones in their urinary tract as the kidneys filter uric acid.
4. Kidney damage and chronic kidney diseases: The high concentration of uric acid passing through the kidneys can cause damage and lead to various chronic kidney diseases (CKDs), including loss of kidney function, glomerulonephritis, and chyluria.
5. Psychological and emotional breakdown: Chronic tophaceous gout can result in permanent walking issues due to chronic knee pain and discomfort in other joints. This can adversely affect the mental and emotional well-being of individuals, potentially leading to severe issues such as anxiety and depression. Therefore, if you are experiencing uric acid and gout issues, it is advisable to seek medical help to maintain your physical and emotional health.

You can make use of the following home remedies for gout pain relief and its treatment.

Naturotherapy

• Cherries: Consumption of cherries, including strawberries, blueberries, and red cherries, helps prevent gout attacks and relieve knee pain and discomfort in other affected joints.
• Ginger (adrak): Ginger is a great culinary ingredient for reducing inflammation in joints. It can be consumed grated in vegetables, tea, or raw. Studies have found ginger to be effective in reducing gout pain and it ranks significantly among foods beneficial for arthritis and gout.
• Celery (ajmoda): Celery is known for treating urinary issues. Its extract, sticks, and seeds can be consumed to reduce inflammation in joints.
• Hibiscus (gudhal): Hibiscus is a traditional herb that can be consumed in tea or with regular food to treat gout at home. The flower has been found to potentially reduce uric acid levels in the body.
• Hot/cold packs: Applying hot or cold water bags may help reduce joint inflammation and pain caused by gout.
• Dandelion: Dandelion is a flowering plant known for improving kidney and liver function. Research has shown that consuming its extract in tea or as a supplement may reduce uric acid levels in the body.
• Lemon water: Drinking two liters of water with two freshly squeezed lemons helps reduce uric acid levels in the body. Lemon effectively neutralizes uric acid and provides relief from pain.

Yoga

Yoga poses can also help manage gout. You can try the following poses along with meditation to alleviate sudden pain:

• Ardha matsyendrasana: The spinal twist pose can help reduce uric acid levels. Sit with legs stretched in front, bend your left leg so that its heel touches your right hip, place your right leg over your left knee, and twist your waist, shoulder, and neck.
• Dhanurasana: The bow pose can be performed by lying on your stomach with your knees and elbows folded backward to hold your ankles.
• Salabhasana: The locust pose can be performed by lying on your stomach with arms by your side. Inhale and exhale for at least 20 seconds.
• Ananda balasana: The happy baby pose can be performed by lying on your back and bringing your knees close to your chest. Keep your arms inside your knees and gently hold your big toes.
• Viparita karani: The legs-up-the-wall pose can be performed by sitting next to a wall with legs pressed against it. Lie on your back and breathe gently for around 5 minutes.

Traditional Chinese Medicine (TCM)

TCM has also been used as an alternative therapy for managing gout. The main mechanisms of TCM treatment during the remission stage include:

• Benefiting Qi (the force that binds together all things in the universe)
• Nourishing blood
• Tonifying spleen and kidney
• Inhibiting inflammatory factors in joint fluid
• Reducing blood uric acid levels
• Promotion of uric acid excretion
• Enhancing immune function
• Blocking the sensation of peripheral nerves

However, TCM requires more research and in-depth studies for scientific backing.

Living with gout can be painful and difficult. However, you can manage and reduce its effects by adopting the following lifestyle recommendations:

• Follow your medication diligently: Medication plays a significant role in the treatment of gout. You should adhere to your medication schedule timely and without fail. If you start experiencing relief after following the prescribed medication, do not discontinue it without seeking your doctor’s permission.
• Check your uric acid levels every 6 months: Monitor your uric acid levels regularly. Ideally, check your uric acid concentration twice a year and maintain it below 6 milligrams per decilitre.
• Maintain a healthy body weight: Aim to maintain a healthy body weight according to your body mass index (BMI). Avoid fad diets, as they can strain your health and lead to adverse effects instead of benefits.
• Follow a 30-minute walk regimen: Engage in a 30-40 minute walking routine to keep your body active. This will also assist you in achieving your ideal body weight.
• Drink at least 7-8 glasses of water: Staying hydrated may help remove excess uric acid from the blood. Aim to drink at least 7-8 glasses of water each day.