Gout: Common, Misunderstood, and Curable

Gout is the most common form of inflammatory arthritis. It affects an estimated 8 million Americans, and many don’t seek treatment, even though gout can be treated and essentially cured. It was once thought that diet and alcohol were the main causes of gout, but scientific advances show that gender and genetics are the more likely disease drivers.

“A common myth about gout is that it is a self-inflicted condition caused by lifestyle choices,” says Chen Xie, MD, Health Sciences Assistant Professor, UCLA Health Downtown Los Angeles Rheumatology. “This misinformation can unfortunately lead to stigma, patient-blaming, and delays in seeking treatment. Diet does play a role, but a person’s genes are the most important factor in determining whether they’ll develop gout.”

Risk Factors

In addition to genetic predisposition to gout, it’s known that gout is more common among men until about age 60, when the risk for gout rises in postmenopausal women. Certain medical conditions can increase the risk of hyperuricemia (excessive uric acid accumulation causes gout), including high blood pressure, hyperthyroidism (underactive thyroid) and chronic kidney disease. Being obese as an adult can also increase gout risk.

Some medications can increase your risk of developing gout, such as diuretics, low-dose aspirin, niacin when taken in large amounts, and cyclosporine, which is an immunosuppressant for people who have organ transplants and a treatment for some autoimmune diseases.

Causes of Gout

Gout is caused by high levels of uric acid, which is a normal waste product produced when your body metabolizes substances known as purines. Purines are found in cells and tissues throughout your body and in a variety of foods. However, most uric acid is produced by your internal metabolism, not from your diet. Normally, the kidneys efficiently filter uric acid from the blood and remove it from the body through urine.

“Your genes influence how effective the kidneys are at removing uric acid,” says Dr. Xie. “If you were born with kidneys that don’t get rid of uric acid efficiently, it will accumulate in the body and increase your risk of gout.”

When uric acid reaches a high level, defined as 6.8 milligrams per deciliter (mg/dL) of blood or higher, it begins to seep from the blood and deposit into joints and other tissues. The deposits can sometimes form needle-shaped crystals, which triggers an inflammatory response, leading to a gout flare (i.e., red, hot, swollen, and painful joints). Any joint can be affected, but it often occurs in the big toe, ankle, or knee.

“Most of the time, gout starts out as bouts of severe pain and inflammation in the big toe,” describes Dr. Xie. “The pain can be so bad that walking becomes difficult, and even lightly touching the area can be unbearable.”

Gout is a disease that can move through several stages:

• Hyperuricemia, when you have elevated levels of urate in your blood and crystals are forming in the joint, but you do not have symptoms.
• Gout flares, when you have an attack of intense pain and swelling in your joints.
• Interval or intercritical gout, which is the time between gout attacks when you do not have any symptoms.

Tophi, a late stage of gout when crystals build up in the skin or other areas of the body. Depending on their location, tophi can permanently damage your joints and internal organs such as the kidneys. Proper treatment, however, can prevent the development of tophi.

Gout vs Osteoarthritis Pain

Dr. Xie says that gout attacks come on quickly, but even without treatment, attacks usually resolve in days or weeks. It is quite different from osteoarthritis pain or pain associated with overusing a joint. These conditions don’t usually trigger severe “attacks” but instead cause ongoing pain or achiness that often gets worse when the joint is used.

This might lead some people to forgo treatment, thinking an occasional gout attack may be tolerable. According to gouteducation.org, most people rank their gout attack pain as a level 9 or 10 on the10-point pain scale (10 being excruciating). Some people describe it as if the joint is trapped in a mechanical device. Others report that even a light bedsheet is painful.

While the attacks may not be frequent (at the start perhaps once a year), subsequent attacks can be more painful and last longer. Left untreated or undertreated, the disease can progress to persistent, chronic pain and permanent joint damage. When uric acid buildup is allowed to run rampant, the uric acid crystals can clump together and form visible lumpy deposits (tophi) under the skin. This is a telltale sign that gout has advanced and is out of control.

Gout May Increase Heart Attack Risk

Experts from the University of Nottingham, in collaboration with experts at Keele University, have found that the risk of heart attacks and strokes temporarily increases in the four months after a gout flare. The team used anonymized data from 62,574 patients with gout treated in the National Health Service in the United Kingdom. Of these, 10,475 experienced heart attack or stroke after the diagnosis of gout, while others of similar age, sex, and duration of gout did not experience such events. The research showed that gout patients who suffered from a heart attack or stroke were twice as likely to have had a gout flare in the 60 days prior to the event, and one-and-a-half times more likely to have a gout flare in the 61-120 days prior. The results of the study, led by Professor Abhishek in the School of Medicine at the University of Nottingham, were published in the Aug. 2, 2022, issue of JAMA.

Treating and Curing Gout

Treating gout is all about reducing/managing uric acid and treating pain during flare-ups. “It’s important for people living with gout to know that effective medications are available to help them get rid of gout in almost all cases,” explains Dr. Xie. “One group of medications reverses the basic problem causing gout and prevents future attacks, but these medications act slowly and might even make gout attacks worse initially. Another group of medications relieves the pain and swelling of a gout attack right away, but these medications don’t do anything to prevent future attacks. A primary care doctor or rheumatologist can advise on the best use of these medications so that the journey to a gout-free life can be as smooth as possible.”

Treatment to cure can initially be challenging. And gout symptoms can be treated without trying to cure the disease. Unfortunately, for many people gout attacks become more frequent and severe through time.

According to medical experts, gout tends to be undermanaged and undertreated. But painful gout flare-ups and potential long-term joint damage is avoidable with proper treatment. All medications have benefits and potential side effects. To learn which medications may work for you, talk with your health-care provider. For more information about curing gout and treatment options, view Dr. Xie’s excellent video at https://tinyurl.com/UCLAGout.

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