What Is Gout?
Gout is a form of arthritis caused by the slow but progressive accumulation of uric acid crystals within joints spaces as well as the surrounding soft tissues. For several reasons, the presence of these crystals has the ability to provoke the immune system and activate severe bouts of inflammation, often at a rapid rate.
What are the symptoms of gout?
As compared to other causes of joint inflammation, acute attacks of gout are characterised by agonising pain. The most common symptom of gout is pain and swelling in the first joint of the big toe. This symptom is called ‘podagra’ in medical terms and occurs in about 50% of cases of gout. Other regions that gout may affect are the insteps, ankles, heels, knees, wrists, fingers, and elbows. Episodes of pain are intermittent, and may take weeks or months to reoccur. In a more advanced stage, gout may become chronic and cause permanent symptoms.
What is uric acid?
Uric acid is a natural by-product of the metabolic breakdown of purines, protein-based substance found in DNA and RNA. Uric acid on its own may not pose a problem, but the crystallisation of uric acid within a joint or the adjacent soft tissue leads to gout. This process is directly dependant on blood uric acid levels.
What influences blood uric acid levels?
After production, uric acid is dissolved in the blood and passed through the kidneys where it is eliminated from the body as a natural waste product. If there is an increase in the rate of production of uric acid, or if the kidneys do not eliminate enough uric acid from the body, uric acid blood levels increase, resulting in a condition called hyperuricemia. Uric acid blood levels are therefore dependent on both the production as well as excretion of uric acid.
What causes high blood levels?
Under-excretion of uric acid by the kidney is by far the primary cause of high blood uric acid levels (hyperuricemia) and accounts for about 90% of cases. Various factors contribute to under-excretion, including genetics, diet and certain medication. Overproduction only causes about 10% of cases of hyperuricemia. In this case hyperuricemia may result when a person eats too much high-purine containing food, or eats too much food in general.
How does gout develop?
Based on the blood uric acid levels and the presence of symptoms, gout can be divided into stages:
- Stage 1 – Asymptomatic hyperuricemia. (meaning without symptoms)
This is the early stage where a person has elevated uric acid blood levels (hyperuricemia), but displays no other symptoms suggestive of gout. Depending on blood uric acid levels, treatment is usually not required at this stage. This is because hyperuricemia is not considered a disease in itself and may not pose a health risk until symptoms develop.
- Stage 2 – Acute gout / acute gouty arthritis.
By now chronically elevated uric acid blood levels has led to the deposition and crystallisation of uric acid within the joint spaces and surrounding soft tissues. This triggers bouts of severe inflammation resulting in intense pain of sudden onset. Acute attacks commonly occur at night and can be triggered by a variety of factors including stressful events, a minor injury, excess alcohol intake, certain medication, or the presence of another illness. Attacks usually subside within 3 to 10 days, even without treatment, and the next attack may not occur for months or even years. As increasing quantities of uric acid crystals start to accumulate within joints and soft tissues over time, attacks occur more frequently and last longer, and may eventually become persisting and chronic. If left untreated, recurrent bouts of inflammation triggered by gout will cause progressive and permanent damage to a joint.
- Stage 3 – Chronic tophaceous gout.
If preventative treatment of stage 1 and 2 gout is neglected, the accumulation of uric acid crystals may progress to such a degree that visible lumps of uric acid deposits start forming under the skin. This may also lead to the distortion of a joint. Subcutaneous uric acid deposits are called tophi, hence the term tophaceous gout. When surgically drained, tophi exude a chalky white substance similar to toothpaste in consistency. Chronic tophaceous gout is the most disabling stage of gout. At this stage the disease would most likely have caused permanent damage to the affected joints. High uric acid levels may also affect the kidneys where uric acid kidney stones are formed.
What is “Pseudo-gout”?
Gout is sometimes confused with other forms of arthritis because the symptoms are very similar. One of these conditions is “pseudo-gout” where the pain, swelling, and inflammation also presents in a sudden and severe manner, and thus mimics the symptoms of gout. However, pseudo-gout is caused by the accumulation of calcium phosphate crystals within a joint, not uric acid.
What are the risk factors for gout?
A number of risk factors are associated with hyperuricemia and gout. They include:
- Genetics – There is a strong family history of the disease. In most of these cases these individuals excrete less uric acid via their kidneys.
- Gender – Men are more commonly affected than women.
- Weight – Being overweight increases the risk of developing hyperuricemia and gout through providing more tissue for turnover or breakdown, leading to excess uric acid production.
- Alcohol consumption – Too much alcohol can lead to hyperuricemia, since alcohol blocks uric acid excretion by the kidneys.
- Diet – Eating too many foods that are rich in purines or eating too much food in general can increase blood uric acid content. (See below)
- Medical Conditions – Some diseases may cause an excessively rapid turnover of cells, increasing uric acid waste. Some examples are psoriasis, haemolytic anaemia and some forms of cancer.
- Medications – Diuretics, aspirin, cyclosporine and levodopa may affect uric acid excretion by the kidneys
Which foods are high in purine content?
Purines are found in high concentration in meat and meat products, especially internal organs. In general, plant-based diets are low in purines. Specific examples of high-purine foods include anchovies, sardines, herring, mackerel, scallops, liver, kidneys, brains, meat extracts (e.g., Oxo, Bovril), game meats, beer (from the yeast), and gravy.
A moderate amount of purine is also contained in beef, pork, poultry, other fish and seafood, asparagus, cauliflower, spinach, mushrooms, green peas, lentils, dried peas, beans, oatmeal, wheat bran and wheat germ.
How is gout treated?
With proper treatment, most people who experience gout are able to control their symptoms and prevent further deterioration. Treatment aims to ease the pain associated with acute attacks as well as to prevent future episodes. Since gout may also lead to the formation of tophi and kidney stones, focus should also be placed on avoiding the development of these conditions.
Step I – dealing with acute attacks
- Prescription medication
The severe pain caused by acute attack of gout can be treated with nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, or colchicine. In severe cases these can be used in combination. Although effective with reducing inflammation and controlling pain caused by the deposition of uric acid crystals, these drugs have no effect on the amount of uric acid present with the blood stream, soft tissue or joints.
Step 2 – preventing future attacks and protecting your joints from permanent damage
- Prescription medication
Since hyperuricemia and gout are chronic conditions, the ideal approach is to lower uric acid levels through either increasing the rate of excretion of uric acid by the kidney, or by lowering the production of uric acid in the body. The drugs probenecid and allopurinol are commonly used for this purpose.
- Supplements that help prevent inflammation
In addition to lowering blood uric acid levels with prescription drugs, several natural molecules derived from plants are highly effective in suppressing certain pathways involved in chronic inflammation. These generally have a low side-effect risk, making them an attractive approach when compared to other pharmaceuticals. RheumaLin™ is a novel multi-modal, multi-target anti-inflammatory supplement that consists of two plant extracts, Boswellia bark extract and resveratrol. These naturally derived phytochemical (plant based) compounds are widely recognised. They combat inflammation via biochemical mechanisms that are different to those of existing anti-inflammatory drugs. Read more about RheumaLin