Gout Management

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Epidemiologic Factor
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A practical approach to gout

Current management of an 'old' disease

What do Alexander the Great, Charlemagne, Henry VIII, Nostradamus, Leonardo da Vinci, John Milton, Isaac Newton, Alfred Lord Tennyson, Thomas Jefferson, and Benjamin Franklin have in common? They are just a few famous men who suffered from gout.

As early as the fourth century BC, Hippocrates recognized gout as an affliction of old men and a product of high living. Although this painful condition promises to accompany humanity into the 21st century, fortunately remedies have improved since Hippocrates' day. Modern medicine has identified the underlying physiologic mechanisms of gout and developed medications to reduce or alleviate their effects.

Historically, gout has been described as the "disease of kings," because the foods that contribute to the development of gout were available in quantity only to the wealthy. The traditional stereotype of a gout sufferer was a sedentary, obese, middle-aged man who habitually overindulged in rich foods and alcohol. Today's picture is not much different. Gout is still predominantly a disease of men

| What Is Gout? | What is the different between Pseudo Gout and Gout? | What Causes Gout? | How Is Gout Diagnosed? | How Is Gout Treated? | What Can People With Gout Do to Stay Healthy? | What Research Is Being Done on Gout? |

What is Gout?

Gout and pseudo gout are the 2 most common crystal-induced arthropathies. They are debilitating illnesses in which pain and joint inflammation are caused by the formation of crystals within the joint space.

Gout is one of the most painful forms of arthritis. It occurs when too much uric acid builds up in the body. The buildup of uric acid can lead to:

  • Sharp uric acid crystal deposits in joints, often in the big toe

  • Deposits of uric acid (called tophi) that look like lumps under the skin

  • Kidney stones from uric acid crystals in the kidneys.

The most commonly affected sites for gout attack are the first metatarsophalangeal joint, the ankle, and the soft tissue of the midfoot. However, gouty arthritis may affect the joints and soft tissues of any extremity. 

For many people, the first attack of gout occurs in the big toe. Often, the attack wakes a person from sleep. The toe is very sore, red, warm, and swollen.

Gout can cause:

  • Pain

  • Swelling

  • Redness

  • Heat

  • Stiffness in joints.

In addition to the big toe, gout can affect the:

  • Instep

  • Ankles

  • Heels

  • Knees

  • Wrists

  • Fingers

  • Elbows.

Hyperuricemia is key to the development of gout, either because too much uric acid is produced or too little excreted, but other factors are also involved:

Gout predictors:

  • Serum urate level

  • Hypertension

  • Use of thiazide and loop diuretics

  • Obesity

  • High alcohol intake

  • Cyclosporine therapy for organ transplant

  • Insulin resistance

  • Old age


What is the different between Pseudo Gout and Gout?

Gout is inflammation caused by monosodium urate monohydrate (MSU) crystals.

Pseudo gout is inflammation caused by calcium pyrophosphate (CPP) crystals and is sometimes referred to as calcium pyrophosphate disease (CPPD)

Pseudo gout, which may be clinically indistinguishable from gout, was recognized as a distinct disease entity only in 1962

  • Presents with acute gout like episode in about 30%

  • Attack develops over 12 - 36 hours and persists for 1-2 weeks

  • 5% pseudo-rheumatoid appearance

  • 50% chronic disease with progressive joint degeneration (ordinary degenerative osteoarthritis or degenerative spondylosis)

  • The remainder remain asymptomatic

  • Knee is usual site (accounts for ~ 50%) but other larger joints may be affected

  • Inflammation of one or more joints lasting several days and usually less severe than gout.

  • May present in association with true gout

  • Seldom affects the great toe

  • Diagnosis confirmed by positively birefringent crystals in synovial fluid (Gout negative)

  • Chronic chondrocalcinosis is usually asymptomatic but may lead to poly-articular osteoarthritis

As with gout, pseudo-gout has been associated with a variety of metabolic disorders as well as with aging and trauma. Treatment of the acute phase of pseudo gout is identical to that of gout.

Pseudo-gout usually occurs after the age of 60, and becomes increasingly more common with age. People who take diuretics to eliminate excess fluid, are frequently dehydrated, or are bedridden are at a higher risk for developing pseudo-gout. It affects both men and women equally

However, unlike gout treatment, no specific therapeutic regimen exists to treat the underlying cause of pseudo gout, and no known prophylactic therapy for pseudo gout exists


History and physical examination alone cannot reliably determine the cause of new-onset acute monoarticular arthritis.

Septic arthritis, gout, and pseudo gout can present in very similar ways.

The spontaneous onset of pain, edema, and inflammation in the metatarsal-phalangeal joint of the great toe (podagra) is highly suggestive of acute crystal-induced arthritis because this is the most common presentation of gout.

Other than the great toe, the most common sites of gouty arthritis are the ankle, wrist, and knee. Consider the diagnosis in any patient with acute monarticular arthritis of any peripheral joint except the glenohumeral joint of the shoulder, in which a crystal-induced arthritis is more likely to be due to pseudo gout.

The most common sites of pseudo gout arthritis are the knee, wrist, and shoulder. Case reports have documented carpal tunnel syndrome as an initial presentation of pseudo gout.

Crystal-induced arthritis is most commonly monarticular; however, polyarticular acute flares are not rare, and many different joints may be involved simultaneously or in rapid succession. Multiple joints in the same limb often are involved, as when inflammation begins in the great toe and then progresses to involve the midfoot and ankle.

Although gout and pseudo gout cannot reliably be distinguished on clinical grounds, a tendency exists for gout symptoms to develop rapidly over a few hours, whereas the onset of symptoms in pseudo gout is usually more insidious and may occur over several days.

When a patient presents with an identical recurrent attack of crystal-induced arthritis, the diagnosis is rarely in question, but the possibility of septic arthritis must always be borne in mind.

Fever, chills, and malaise do not distinguish cellulitis or septic arthritis from crystal-induced arthritis because all 3 illnesses can produce these signs and symptoms.

A careful history may uncover risk factors for cellulitis or septic arthritis, such as possible exposure to gonorrhea, a recent puncture wound over the joint, or systemic signs of disseminated infection.


Patients with gout or pseudo gout most often present with a single joint that is hot, erythematous, tender, and affected with asymmetrical edema.

If inflammation is severe, desquamation of overlying skin may be present.

  • Extraarticular deposits of MSU, known as tophi, may be seen along the Achilles tendon or on the ear helix, olecranon bursa, or prepatellar bursa.

  • Migratory polyarthritis is a rare presentation.

  • Inflammatory synovial effusion

  • Carpal tunnel syndrome

  • Kidney stones

Involved areas are exquisitely painful and erythematous. Fever and a toxic appearance may be seen in older patients.

Although mild attacks are usually short-lived (7 to 10 days), severe untreated attacks may last several weeks. Tophi occur in less than 10% of patients.


Although the pathophysiology, clinical presentation, and acute-phase treatment of gout and pseudo gout are very similar, the underlying causes of the 2 diseases are very different.

  • Acute gouty arthritis results from overproduction or reduced secretion of uric acid. Thiazide diuretics and foods that are rich in purines will increase the frequency of attacks.

  • Many cases of pseudo gout are idiopathic, but pseudo gout has also been associated with aging, trauma, and many different metabolic abnormalities, the most common of which are hyperparathyroidism and hemochromatosis.

  • Lead poisoning

  • Hemo-proliferative disorders

  • Renal disease


What Causes Gout?

Gout is caused by the buildup of too much uric acid in the body. Uric acid comes from the breakdown of substances called purines. Purines are found in all of your body's tissues. They are also in many foods, such as liver, dried beans and peas, and anchovies.
Normally, uric acid dissolves in the blood. It passes through the kidneys and out of the body in urine. But uric acid can build up in the blood when:

  • The body increases the amount of uric acid it makes.

  • The kidneys do not get rid of enough uric acid.

  • A person eats too many foods high in purines.

When uric acid levels in the blood are high, it is called hyperuricemia. Most people with hyperuricemia do not develop gout. But if excess uric acid crystals form in the body, gout can develop.

You are more likely to have gout if you:

  • Have family members with the disease

  • Are a man

  • Are overweight

  • Drink too much alcohol

  • Eat too many foods rich in purines

  • Have an enzyme defect that makes it hard for the body to break down purines

  • Are exposed to lead in the environment

  • Have had an organ transplant

  • Use some medicines such as diuretics, aspirin, cyclosporine, or levodopa

  • Take the vitamin niacin.

The disease is often, but not always, associated with elevated serum uric acid levels.

A gout attack can be brought on by stressful events, alcohol or drugs, or another illness. Early attacks usually get better within 3 to 10 days, even without treatment. The next attack may not occur for months or even years.

However, gout symptoms can be far more diverse, spanning the continuum from hyperuricemia to recurrent attacks of acute arthritis.

To sufferers, gout is associated with pain and disability, but to healthcare professionals, the diagnosis of gout is ominous, because it is a known risk factor for coronary artery disease. Several studies are under way trying to establish cause and effect, but, thus far, the link has not been determined


How Is Gout Diagnosed? Epidemiologic factors  <.......more>

The above opinionated views and information serves to educated and informed consumer .  The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. .It should not replaced professional advise and consultation.  A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions 

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