Gout

Gout occurs when uric acid in the blood precipitates out into a joint, forming crystals, causing extreme pain.  The most common joint is the big toe, followed by ankle, knee, and wrist.  Pain lasts for a week, goes away, and recurs, sometimes every couple of months, sometimes almost never again.  When gout is chronic, people may have pains in lots of joints, but that’s not so common.

The way to diagnose gout is by “tapping” the joint — aspirating fluid from the red, hot, swollen joint (like “tapping” a maple tree for syrup).ย  Finding a specific type of crystals under a special microscope makes the diagnosis.ย  This is easy to do from the knee, but most clinicians can’t really tap smaller joints.ย  Even rheumatologists may find it hard.

So lots of clinicians count on a blood test for uric acid, which is prone to error.  It’s not rare for people to have high uric acid even though they’ll never get gout.  And in the midst of a gout attack, the blood uric acid is often normal.  It’s best to wait a few weeks after the attack subsides before drawing a test.

Mild gout, with rare attacks, is easy to deal with.  But repeated attacks in numerous joints does permanent damage.  Even worse, ongoing low-grade gout can permanently damage kidneys & other organs.  One sign of chronic gout are tophi — firm clumps (of crystals) we can touch in the ear or around joints, that don’t hurt.  X-rays and ultrasounds can help diagnose chronic gout, but not early acute attacks.

Treatment of an acute attack is easy, but the question is whether or not to prescribe daily medications to prevent future attacks.  Usually this is done when attacks are frequent, maybe even just twice a year.  However, if there is any suggestion of tophi, it’s important to reduce uric acid to prevent joint destruction even when there are no symptoms.  It’s also important to give daily treatment if there’s uric acid in the urine.

What about diet to prevent attacks?  Even though purines (a chemical in food) play a role in causing gout, it’s hard to say that struggling to avoid them will accomplish anything.  Weight loss may help, and maybe avoiding too much fatty and sugary foods (which cause weight gain), and maybe avoiding too much meat and seafood.  Alcohol can cause attacks, and should be avoided.  However, if uric acid remains high in the blood, and there’s concern for chronic joint or kidney disease, medications will achieve much more than trying to change lifestyle.

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