Gout (Gouty Arthritis)

Gout is a form of arthritis that strikes in sudden attacks. It happens when uric acid, a normal waste product, stays too high in the blood and forms needle-shaped crystals in and around a joint, most often the big toe. A flare can go from nothing to severe pain quickly, settle, then return.

What gout is, and what it is not

Gout has carried a reputation for centuries as a disease of rich food and drink. That reputation is unfair: uric acid is shaped by genetics, age, sex, kidney function and some common medicines as much as by anything on a plate. Gout is the most common form of inflammatory arthritis in Canada, not a verdict on someone’s habits.

It is also not the same as other kinds of arthritis. Osteoarthritis comes from changes in the joint tissues over years, and rheumatoid arthritis is an immune attack on the joint lining. Gout is crystal-driven: between flares it can seem completely gone, yet if uric acid stays high the crystals keep building quietly, attacks tend to become longer and more frequent, and hard lumps called tophi can form under the skin.

Signs and symptoms

• A sudden attack of intense pain in one joint, classically the big toe, where even the weight of a bedsheet can be hard to bear
• Swelling, redness and heat around the affected joint
• Flares in the ankles, knees and other lower-limb joints, not only the toe
• Attacks that settle and then return, becoming longer and more frequent without treatment
• Small, hard, whitish lumps under the skin (tophi) after years of high uric acid
• No symptoms at all between flares, for many people

How often flares come, and how hard they hit, varies from person to person and over time.

What raises the risk

Some things cannot be changed:

• Being male: gout affects about 4% of males and about 1% of females in Canada
• Getting older, with more than 8% of British Columbians aged 60 to 69 affected in 2012
• Family history of gout
• Kidney disease, which makes it harder for the body to clear uric acid

Others can often be worked on, usually with support from a health care team:

• High blood pressure, and some diuretic medicines used to treat it
• Carrying extra body weight
• Drinks and foods that raise uric acid, including alcohol (especially beer), sugary drinks, red meat, shellfish and oily fish
• Dehydration, which concentrates uric acid in the blood

How gout is diagnosed in Canada

Gout is usually assessed by a family doctor or nurse practitioner from your description of the attacks, your medical history and an examination of the joint. Blood tests can measure the level of uric acid. The definitive test is taking a small sample of fluid from the joint during a flare and examining it under a microscope for urate crystals. Some people are referred to a rheumatologist, especially when attacks keep returning or the diagnosis is unclear.

Treatment and day-to-day management

Gout care has two separate jobs: settling the flare you are in, and keeping uric acid down so the crystals stop accumulating. A health care team may discuss:

• Flare medicines: non-steroidal anti-inflammatory drugs, colchicine, or corticosteroids
• Self-care during a flare: resting and elevating the joint, cold packs, and drinking water rather than alcohol
• Long-term urate-lowering medicines, allopurinol and febuxostat, with other options for gout that has not responded
• Care for the conditions that often travel with gout, including high blood pressure, kidney disease and diabetes, and a review of medicines that can raise uric acid
• Changes to food and drink patterns, worked out with support from a clinician or dietitian rather than as a list of banned foods

Whether long-term treatment makes sense, and which route fits, is a decision for you and your own clinician.

When to talk to a doctor

• If a joint suddenly becomes very painful, hot, red or swollen and you also feel feverish or unwell, get medical care the same day. Go to an emergency department or call 911 if you feel very unwell, because a joint infection can look like gout and needs urgent treatment.
• If you have never had a flare before, see a health care provider so the cause can be confirmed rather than assumed.
• If flares are coming back more often, lasting longer, or reaching new joints, book an appointment to talk about long-term treatment.
• If you notice hard lumps under the skin on your toes, heels, knees, fingers, ears or elbows, have them assessed.

Why clinical research matters for gout

Gout can usually be managed with existing medicines, yet most people who could use long-term treatment are not on it: in the British Columbia study, only about 22% received urate-lowering therapy, a share that did not improve over 12 years, while the number of people living with gout keeps rising in Canada and worldwide. Researchers are testing new urate-lowering medicines, comparing flare treatments, studying how to help people start and stay on long-term therapy, and examining the links between gout, kidney disease and cardiovascular disease.

Studies are how those questions get answered. Taking part is voluntary, informed consent comes first, and you can withdraw at any time without affecting your regular care. No one can say in advance whether a study will help you personally.

Learn more from Canadian sources

• Arthritis Society Canada: gout
• Arthritis Research Canada: gout
• Canadian Rheumatology Association