Gout

Overview

Gout is a common form of inflammatory arthritis caused by tiny crystals of a substance called urate forming inside a joint. Urate comes from the everyday breakdown of purines, which are found in the body’s own cells and in some foods. When the level of urate in the blood stays high over time, it can crystallise, and the crystals trigger sudden, intense bouts of joint inflammation known as attacks or flares.

The classic attack affects the base of the big toe, but gout can strike other joints too — the midfoot, ankle, knee, and later the hands. Between attacks many people feel completely well, which can give the false impression that the problem has gone away when in fact the underlying urate is still high.

Gout is important to treat properly because it is one of the few forms of arthritis that can be genuinely controlled and, in effect, cured — by lowering the urate level so that the crystals dissolve and stop forming. Left untreated, it tends to return more often, affect more joints, and cause lasting damage.

Symptoms

A gout attack usually comes on rapidly, often overnight, reaching its peak within a few hours. The affected joint becomes intensely painful, swollen, red, warm, and so tender that even the weight of a bedsheet can be unbearable. The skin over the joint may look shiny and later peel as the attack settles.

An untreated attack typically lasts several days to a couple of weeks and then resolves completely. Over years, if the urate remains high, attacks tend to become more frequent and prolonged, and firm lumps of crystals called tophi can build up under the skin around joints, the fingers, or the ears.

Causes and risk factors

Gout develops when the blood urate level is persistently high, which happens either because the body produces too much urate or, more commonly, because the kidneys remove too little. Both an inherited tendency and lifestyle contribute.

Recognised risk factors include increasing age, being male, excess weight, and kidney disease. Diet plays a part — red meat, shellfish, sugary drinks, and alcohol (especially beer and spirits) can raise urate — but genetics and kidney handling are usually more important, which is why diet alone often cannot control gout. Certain medicines, including some water tablets (diuretics), can also raise urate. Gout is frequently accompanied by high blood pressure, diabetes, and heart and kidney disease, so finding gout is a prompt to check for these as well.

Diagnosis

Gout is often diagnosed from its very typical story and appearance — a rapid, severe attack in the big toe or another lower-limb joint. The most certain way to confirm it, however, is to take a small sample of fluid from the joint and examine it under a microscope for urate crystals, which also helps rule out a joint infection that can look similar.

A blood urate level supports the diagnosis, but it needs careful interpretation: the level can be normal or even low during an acute attack, so a normal result at that moment does not exclude gout. It is most useful measured once the attack has settled, and for guiding long-term treatment.

Investigations

Investigations may include a blood urate level (best checked away from an acute attack), kidney function tests, and, where the diagnosis is uncertain, examination of joint fluid for crystals. Blood sugar, blood pressure, and cholesterol are often checked because of gout’s close links with these conditions.

Ultrasound and specialised CT scanning can show urate deposits and are sometimes used when the diagnosis is unclear or to assess the crystal burden. In long-standing gout, X-rays may reveal joint changes caused by tophi.

Treatment

Treatment has two distinct parts, and understanding the difference is the key to doing well. The first treats the acute attack, to settle pain and inflammation quickly — using an anti-inflammatory medicine, colchicine, or a short course of steroids, chosen to suit the person’s other health conditions. Started early, these bring an attack under control within days.

The second, and more important for the long term, is urate-lowering treatment. Medicines such as allopurinol steadily lower the blood urate so that existing crystals dissolve and new ones stop forming. The dose is increased gradually to reach a target urate level, and once that target is held, attacks stop and tophi shrink. This treatment is taken every day, long term, even when there is no pain — stopping it is the most common reason gout returns. Because starting it can briefly trigger attacks, a short course of protective anti-inflammatory cover is usually given at the same time.

Living with gout

Taking urate-lowering medicine consistently is the single most effective thing a person can do; when the urate is kept below target, gout can be brought to a complete standstill. Sensible dietary steps support this — moderating alcohol, sugary drinks, red meat and shellfish, and staying well hydrated — but they work alongside medicine rather than replacing it.

Keeping to a healthy weight lowers urate and eases pressure on the joints, and reviewing any medicines that raise urate with the doctor can help. Because gout travels with heart, kidney and metabolic disease, looking after blood pressure, blood sugar and cholesterol is part of overall care. With good control, most people with gout become and stay free of attacks.