Gout affects mostly men, starting in their 30s and increases with age. It is less common in women until they reach menopause. Gout is often associated with various other medical conditions such as chronic kidney disease, high blood pressure, obesity and heart disease. Often, patients have family members affected by gout.
Other risk factors for gout include:
• Consuming alcohol and fizzy drinks (containing high amounts of fructose)
• High purine diet – red meat, offal, seafood (including shellfish and certain fish e.g. sardine, anchovies and mackerel)
• Dehydration
• Acute illness
• Other medical conditions with increased cell breakdown (e.g. psoriasis, a scaly skin condition and certain blood disorders)
• Certain medications increase risks of gout
o Diuretics used to treat patients with excessive fluid in the body (e.g. furosemide)
o Medications used to treat tuberculosis, a chronic infection (such as ethambutol and pyrazinamide)
o Certain immune suppression medications which may be used in patients with other autoimmune conditions are after a transplant (calcineurin inhibitors such as cyclosporin and tacrolimus)
Gout can be diagnosed based on clinical history of recurrent episodic acute joint inflammation. The joints in the feet are commonly affected, especially the big toe (also known as podagra). There may be associated triggers preceding the attack or other risk factors for gout. Blood test showing raised uric acid levels is supportive of the diagnosis when combined with clinical history and examination. However, a high serum uric acid in the absence of any joint inflammation does not equal a diagnosis of gout.
X-rays may be performed to look for joint destruction. Other imaging tests such as CT scans (dual energy CT) or ultrasound scans may be performed for select patients.
The confirmatory test for gout involves joint aspiration where a needle is inserted into a swollen joint to remove joint fluid, and visualising gout crystals under the microscope.
1) Management of acute gout attacks
Acute gout attacks can be treated by applying ice packs to the affected joint(s) and taking medications, such as:
• Colchicine
• Nonsteroidal anti-inflammatory drugs (NSAIDs) – E.g. naproxen, diclofenac, indomethacin, etoricoxib, celecoxib
• Corticosteroids – Oral prednisolone, intramuscular steroid injection or steroid injection into affected joints (intra-articular steroids)
It is important to note that the medications above are not suitable for every patient. Factors such as drug allergies and kidney disease may mean that certain medications need to be avoided.
2) Prevention of gout flares
Reduction of uric acid is the mainstay of treatment of gout and will prevent attacks. Urate lowering therapy (ULT) is recommended for patients who have recurrent gout attacks (≥2 in a year) or complications from gout such as joint destruction, tophi, urinary stones due to uric acid, and chronic kidney disease. ULT is given long-term to prevent gout flares and maintain uric acid at target. A good target uric acid level is less than 360µmol/L – or 300µmol/L in patients who have tophi.
ULT include medications such as allopurinol, febuxostat or probenecid. Allopurinol is the most commonly used medication as it is effective, economical and safely used for many years. There is a small risk of allergy reactions with allopurinol use. Hence it is often started at a low dose and increased gradually to ensure any side effects are picked up early. If there are new rashes or oral ulcers that develop while on allopurinol, the medication should be stopped and a doctor should be consulted. There is a common misconception that medications like allopurinol damage kidney function, when in fact they do not.
A low dose of colchicine is often started together with ULT to prevent gout flares when ULT is initiated. It is important to continue ULT during acute gout attacks.
3) Management of associated conditions
Gout is closely associated with high blood pressure, diabetes, high cholesterol, fatty liver, obesity and chronic kidney disease. These conditions should be treated as well to reduce risks of cardiovascular disease.
Lifestyle changes are an important aspect of managing gout and its associated conditions. Some recommended lifestyle changes are to:
• Avoid smoking
• Reduce alcohol and fizzy drinks
• Eat a balanced diet
• Avoid triggers for gout
• Stay active and exercise in moderation
• Stay hydrated
• Lose weight if you are overweight
