Gout is an inflammation in the joint caused by uric acid crystals. Foods that are rich in purines, such as organ meats and shellfish, breakdown to produce uric acid in the body. When there is too much uric acid in the blood, it crystallizes, and causes inflammation resulting in pain and swelling in the joint. High uric acid levels can be the result of an overload of uric acid in the blood due to consumption of food and beverages that increase uric acid levels or due to an inability of the kidney to get rid of it.
As a rheumatologist I have treated many gout patients over the years, and I have heard the following misconceptions regarding gout. I have decided to clear up some of these misunderstandings.
Myth: Gout only bothers me 3-4 times a year. I don’t need to take medicine all the time for it. High uric acid is not just detrimental to the joints. At levels above 6.8mg/ dl uric acid can crystallize and form needle shaped crystals in the joint. Which then causes severe inflammation, redness and heat that we describe as an acute attack of gout. These are very painful and disabling, however, these episodes resolve, and then the patient may not have a flare for months. During this period, uric acid can continue to deposit in the joint and cause permanent damage to the bone and joints. This phase is described as chronic gout.
Gout crystals can deposit under the surface of the skin and present as large nodule/s also known as a tophus/tophi. Tophi are often seen in the soft tissue, around the ear, near joints, and in the tendons. Although not painful, they can ooze a white substance and get infected. Patients are often very embarrassed by the presence of these tophi. This leads to significant depression and social isolation. Unfortunately, surgically removing the tophi does not always eliminate the disease process. They can reoccur if the uric acid levels remain high.
High uric acid similarly can form kidney stones and potentially deposit on the walls of blood vessels as well. This can cause chronic kidney disease and may be associated with heart disease.
Myth: I went to the ER for my gout. I was told my uric acid levels were normal, so I do not have gout.
Testing the blood uric acid levels is not always a definitive way to prove that you have been diagnosed with gout. Blood uric acid levels, especially early in the disease process, can be normal when you are having a flare in about 25-40% of patients. Unfortunately relying entirely on a blood test can send patients down the wrong path of treatment. Gout often presents as pain and swelling in the big toe. Uric acid is sensitive to low temperatures and crystallizes in the cold. As the toes tend to be cooler than the rest of the body, they become a favorite spot for gout. However, this is not always the case. Gout can affect other joints such as the ankles, knees, fingers etc. About 20% of patients can even present with inflammation in multiple joints at the same time. The best way to diagnose gout is to prove the presence of uric acid crystals in the fluid removed from the joint. Although it sounds unpleasant, when a joint is very swollen and inflamed due to gout, having the fluid taken out relieves the pressure and pain that joint. The fluid can be checked for the presence of the needle shaped uric acid crystals under the microscope. Also having the fluid tested can help rule out other conditions such as pseudogout (calcium based crystal deposition), infection etc.
Myth: Gout medicine makes my gout worse. Sudden lowering of uric acid levels with such as Allopurinol or Uloric will often precipitate a flare of gout. This tends to be a major deterrent for many to start treatment and to stay on it. Your doctor will try to mitigate this by having you take medication that will prevent a flare, in conjunction. Medications used to prevent flares are colchicine, anti inflammatory medicines such as Ibuprofen and in some cases steroids such as prednisone. The choice of medicine will depend on other underlying medical problems you may have. Patients will frequently complain about the number of medicines they have to take to treat one disease. However, it is important to remember that to treat gout successfully combining these medications results in greater success. After about 6 months you will need only the medicine that lowers uric acid. The goal of treatment is to bring uric acid levels to below 5.5 mg/dl, to prevent a gout attack.
Myth: I already have psoriatic arthritis. I can’t possibly have gout too!
Yes! It is possible. Gout and psoriatic arthritis can both cause severe inflammation in the joints and can be hard to differentiate. The analysis of joint fluid as described above can play a crucial role in differentiating gout from psoriatic arthritis. One can have more than one form of arthritis. Psoriasis by itself increases uric acid levels in the blood because of the high rate of skin cell turnover. Also patients with psoriasis and psoriatic arthritis can be overweight, a risk factor that is also common to gout. Gout can be present with Rheumatoid arthritis and also with osteoarthritis. The damage in the joint from osteoarthritis, can provide an ideal environment for gout crystal to deposit, thereby increasing the risk of gout.
Myth: I am taking my meds as my doctor prescribed them. Now I can go back to drinking beer.
There is certainly a role for reducing the frequency of gout attacks by following dietary restrictions in addition to taking medications. Alcohol has high levels of purines. When purines break down they increase blood uric acid levels. Beer has the highest purine content. Soda and iced tea are no better, they generally sweetened with artificial sweeteners such as high fructose corn syrup. Fructose breaks down to release purines. Drinking sugary soda and alcohol also causes weight gain, and obesity is associated with gout.
Consumption of foods high in purines such as red meat, organ meats, shellfish can increase uric acid levels and precipitate gout attacks. Vegetable proteins, such as legumes, tofu, and green leafy vegetables, can be beneficial. Consuming low fat dairy products, such as milk and yogurt can help your body eliminate uric acid and prevent gout flares. If you are having a flare, eating cherries or drinking tart cherry juice can be helpful, because cherries have a pigment called anthocyanins, which decreases inflammation. Also make sure to load up on Vitamin C rich foods, such as oranges and grapefruit, which can reduce uric acid levels as well.