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1 Living with Gout

2 Arthritis Ireland helps people with arthritis take their lives back. We provide real solutions by empowering people with arthritis and those caring for them to take positive action to manage the effects of their disease on their lives. Our innovative and life changing education and support programmes including Living Well With Arthritis, Fit for Work and Breaking the Pain Cycle give people with arthritis the knowledge and practical skills they need to live their best possible quality of life. Our helpline provides vital emotional and practical support and, because we know that knowledge is power and central to living well with arthritis, we provide an extensive range of free educational information, such as this booklet. Through our work we campaign for increased levels of funding in rheumatology services to provide a world class service that will positively change the outlook and outcome of patients lives. We also actively support and fund research into arthritis to ensure that Ireland is at the forefront of new breakthroughs leading to possible cures and also fund the training of health professionals through medical students in university to create a direct and positive improvement in patient care.

3 Many people have probably heard the word gout but few people know much about it. Gout has been known for more than 2000 years. It can affect men of any age. It is less common in women and then usually only occurs after the menopause. Luckily, gout is probably the rheumatic disease for which there is the most satisfactory treatment. This booklet will help you understand more about gout, what it is, what causes it and how it can be treated so you can live your best possible life with this condition. 1

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5 Contents What is gout? 4 What causes gout? 4 What are the symptoms? 5 What to look out for before an acute attack 6 What are the long-term risks? 6 How is gout diagnosed? 7 Treatment of acute attacks 8 What you can do to avoid developing gout? 11 FAQs 13

6 What is gout? Gout is a medical condition that causes sudden and severe episodes of joint pain, tenderness, warmth and swelling. It usually affects the joint at the base of the big toe but can affect other joints such as the knee, ankles, hands or wrists. What causes gout? Gout is caused by the high levels of uric acid (also known as urate) that occur as a result of eating foods such as organ meats, anchovies and herring which are high in chemicals called purines. When the human body breaks down purines it produces uric acid. In a healthy individual the body rids itself of any excess uric acid through the kidneys into the urine. However, those who are prone to gout will find that their body may be producing too much uric acid or their kidneys may not be excreting enough uric acid and causing a build up in the body. As the uric acid levels increase, it begins to collect in the joints and crystallises into sharp needle-like, urate crystals. They accumulate in the joints or surrounding tissue and cause pain, inflammation and swelling. 4

7 A tendency to develop gout is influenced by genetics and family history. In saying this, just because it is in your family, does not mean that it will be passed onto you. If you maintain a healthy diet and lifestyle it can be potentially avoided. [You can read Arthritis Ireland s booklet Healthy Eating and Arthritis for further information or visit Gout is more common amongst men as it has been found that they have higher uric acid levels in their blood than women. However, it can cause problems in women, especially after the menopause. What are the symptoms? Signs and symptoms of gout are generally acute they come on suddenly without warning. A significant proportion of people with gout experience them at night. 1 Attacks usually occur in the big toe and any physical contact is painful. The symptoms develop over a few hours and the swelling can very often look like an infection and the skin may peel. 2 Gout may also occur in the ankles, hands, wrists, knees or feet. Many people describe the affected areas as warm/hot. If several joints are inflamed at once this is called polyarticular gout. 3 Urate crystals cause inflammation. This is where the joint becomes intensely painful, red, hot, shiny and swollen. Urate crystals can also collect under the skin and elsewhere, forming small, firm, white pimples called tophi, which are not usually painful. 4 Similar attacks can be caused by calcium crystal deposits in joints. This type of crystal arthritis (termed pseudogout or pyrophosphate arthritis) affects the knee and other joints more than the big toe and is linked with osteoarthritis. 5

8 What to look out for before an acute attack 1 Look out for the early signs of an acute attack in order to start taking treatment as soon as possible. 2 Suspect an acute attack of gout if a joint is unusually painful. 3 Excessive eating of rich foods or drinking alcohol can cause an attack to occur. It really helps to know what triggers to look out for What are the long-term risks? Gout attacks may only occur once and never again, or infrequently. However, some may experience regular attacks after the first episode. The first few attacks of gout may not cause any permanent damage to the joints and you can expect a complete recovery, leaving you with a normal joint. It is only when a joint is repeatedly attacked by gout that the urate crystals can damage the joint and start long-term (chronic) arthritis. One of the most noticeable effects of regular gout attacks is joint damage that is caused by the crystals that are formed. Other consequences of gout are: problems with the kidneys such as kidney stones and deformity and decrease in mobility in the affected joints over time. 6

9 How is gout diagnosed? Gout can be difficult for doctors to diagnose because the symptoms may be non-specific and they often mimic other conditions such as joint infections. A doctor who suspects a joint infection will have to rule out infectious arthritis and establish a diagnosis of gout. As a result of this, it is important for doctors to carry out certain tests in order to be sure of the right course of treatment and correct diagnosis. n n n Blood test this test measures your levels of uric acid. It is not definitive as some people with high uric acid levels do not show gout symptoms while others who have gout symptoms do not have high levels of uric acid in their blood at the time of the attack. Joint fluid test in some cases a needle may be used to collect synovial fluid from the affected joint. The liquid is then examined under a microscope to see whether urate crystals are present. This test is usually only carried out in hospital or special clinics. X-rays of joints X-rays of the affected joints maybe be examined to identify deposits of urate crystals. X-rays show soft-tissue swelling and places where the bone has been eroded as thinning of the bone can occur. Without treatment, an initial acute attack of gout will run its course within several days or a week, by which time all outward evidence of the disease disappears. However, approximately 50% or more of people with gout will have a second attack which may not occur for months or years. Subsequent attacks, however, are likely to be more frequent, more severe, and more destructive to joints and other tissue unless the problem is treated.

10 I tried so many things at different times just to get rid of the pain Treatment of acute attacks There are a number of possible treatments for acute attacks: 1 NSAIDs Non-Steroidal Anti-Inflammatory Drugs Acute attacks can be treated with non-steroidal antiinflammatory drugs (NSAIDs). NSAIDs are the most commonly used medication for gout. NSAIDs help to relieve the pain of gout and reduce inflammation. It is advisable to take an NSAID prescribed by your doctor at the very first sign of an attack as any delay in treating an acute attack of gout delays relief. NSAIDs can cause side effects including indigestion, diarrhoea, a rash, headache, dizziness or aggravate asthma. If NSAIDs are used for a long period of time, they may produce other side effects, such as stomach ulcers, heartburn, bleeding of the stomach lining or kidney damage. Those with a history of peptic ulcers should be especially careful and if possible, avoid taking NSAIDs. Most NSAID should be taken with a stomach protector such as a proton pump inhibitor. More recently, NSAID s have been associated with heart attacks and strokes in some individuals. 8

11 2 Colchicine Colchicine is commonly prescribed for the treatment of gout. Colchicine works to reduce the inflammation and swelling in the affected joints and these greatly reduce the pain caused by gout. Side effects, such as nausea, vomiting, and diarrhoea may occur with colchicine. 3 Steroids If an acute attack of gout doesn t improve with NSAIDs or colchicine, or if you are not suitable for treatment with these drugs, your doctor may prescribe a steroid injection into the joint or a short course of steroid tablets by mouth (usually no more than a few days). 4 Urate-Lowering Therapy (ULT) The goal of urate-lowering therapy is to encourage urate crystals to dissolve and to prevent further crystal formation. Urate-lowering therapy may prevent disease progression, reduce the frequency of acute attacks or eliminate gout attacks altogether. Allopurinol Allopurinol is a xanthine oxidase inhibitor. It reduces the production of uric acid in your body. The safest option is to start on a low dose (100mg/day) and increase the dose gradually to lower the risk of gout flares and side effects. Achieving full therapeutic benefit may involve an increased dose of 300mg/day or greater. If a rash develops while taking allopurinol, the drug should be discontinued, as this can be a precursor to severe systemic hypersensitivity. 9

12 Do not use this medication if you have ever had a serious allergic reaction to allopurinol. Stop taking allopurinol and call your doctor at once if you have any signs of skin rash, no matter how mild. Take each dose with a full glass of water. To reduce the risk of kidney stones forming, drink eight to ten full glasses of fluids every day. Febuxostat Febuxostat is a newer treatment for gout and works in the same way as allopurinol by lowering uric acid production. It is usually recommended to start febuxostat therapy after the gout flare has subsided. The recommended starting dose of febuxostat is 80mg once daily. Some patients may need a dose increase to 120mg depending on the changes in serum uric acid levels. Treatment with febuxostat is not recommended in patients with ischaemic heart disease or congestive heart failure; in patients in whom the rate of urate formation is greatly increased; in patients taking azathioprine/mercaptopurine; and in patients intolerant to lactose. 10

13 What you can do to avoid developing gout? Weight management If you are overweight, losing weight will help to prevent gout attacks and improve overall health. 1 Diet When too many purine-rich foods are consumed, uric acid levels rise which leads to the formation of uric acid crystals around the joints. It s these sharp, needle-like crystals that cause the pain of gout. Overproduction of or excess uric acid may be the result of particular beverages and food. Try to reduce or eliminate foods high in purines from your diet. Examples of foods high in purines are: n n n n Red meat, organ meats like kidneys, liver and sweetbreads Shellfish Gravy, meat extracts e.g. Oxo, Bovril Fructose sweetened soft drinks Sudden dramatic changes in diet and weight gain/loss can be associated with gout attacks. It really helps to know what foods trigger my gout attacks so I can take positive action 11

14 2 Alcohol Excessive consumption of alcohol has been linked to gout. Large consumptions of alcohol such as beer, wine and spirits can lead to a build-up of uric acid in the blood which can cause gout. If you are having a gout attack, alcohol should be avoided. 3 Fluids A simple but effective way to reduce the risk of urate crystallising in the joints is to drink lots of fluids, in particular water. Sugary soft drinks should be avoided, especially if you are trying to lose weight. When I feel the slightest tinge of a possible gout attack, I triple my water intake 4 Cold Applying cold to the area affected can provide temporary pain relief 5 Exercise Moderate stretching exercises can help keep the muscles and tendons around the affected joint more flexible and strong. Always consult a doctor or physiotherapist before beginning an exercise programme. For more ideas on exercising when you have gout, check out Arthritis Ireland s Be Active with Arthritis exercise DVD and booklet specifically designed for people with arthritis available to purchase on 12

15 FAQs Can women get gout? Gout is more common among men; however it can occur in women especially after the menopause. Is gout curable? It cannot be completely cured. But it can be prevented by administering medication which can prevent further attacks. Will I need to take gout medication forever? It depends on the type and severity of your gout. Gout is different for each individual and some patients can just have one or two gout attacks. They may be treated only when attacks occur and/or some may require more long-term, regular treatment. Should I continue to take my urate-lowering therapy should I experience a flare? Urate-lowering therapy is not usually started during a flare, however if you are already taking urate-lowering therapy and you experience a flare it should NOT be stopped. 13

16 Can gout cause serious joint disease? If the condition is left untreated, the results can sometimes be serious. The attacks can be acute at first and the joint returns to its normal state but eventually the deposits of urate can lead to deformity and disability. However preventative treatment can be taken as mentioned in this leaflet. Is urate deposited in places other than the joints? Yes, urate can be deposited under the skin, for example on the ears, fingers and toes. It can also be deposited in internal organs particularly the kidneys. Can it be harmful to take the drugs that lower urate over a long period of time? It is unlikely the drugs in question will cause side effects but occasionally may have to be discontinued depending on the individual. Adverse effects such as a rash or indigestion may arise occasionally, but otherwise they can be taken indefinitely without side effects. I am vegetarian and don t drink. I thought it was only drinkers and meat and fish eaters who got gout it just goes to show you 14

17 Supports from Arthritis Ireland Arthritis Ireland runs a range of self-management programmes including Living Well with Arthritis, Fit for Work and Breaking the Pain Cycle, to enable people to manage their condition more effectively, dramatically improve their quality of life and help build their confidence. The Arthritis Ireland Helpline is a confidential service for people with arthritis, their families, friends and carers. We provide emotional support, practical support and information by phone on LoCall , by at helpline@arthritisireland.ie and by letter through The Arthritis Ireland Helpline, 1 Clanwilliam Square, Grand Canal Quay, Dublin 2. Arthritis Ireland s vibrant network of local branches provide support to people with arthritis and an opportunity to meet others in your area with the same condition. For further information on how Arthritis Ireland can help you live your best possible quality of life, contact us on LoCall or visit our website at

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