Gout

If you’re one of the roughly 9.2 million people diagnosed with gout, take heart—today we know more about how this disease works and have better ways to treat it. That means you can get back to doing the things you love—being active, playing with your kids, going out with friends—and spend less time held up by joint pain.
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What is gout?

Gout is a form of arthritis that occurs when a substance called uric acid builds up in the blood faster than the kidneys can eliminate it. Uric acid is a natural by-product the body makes after it breaks down purines, which are chemicals your body uses as building blocks for DNA and RNA. Purines are produced by the body itself but can also be found in certain foods, including red meat, organ meats, some seafood, high fructose corn syrup and alcohol.

Over time, high uric acid levels may cause the body to store the excess in certain joints, causing crystals to accumulate. When the buildup is great enough, the body actually tries to get rid of the crystals, leading to the release of inflammatory chemicals that cause heat, swelling, redness—and most of all, pain.

While gout is typically associated with the big toe, it can affect any joint, including knees, ankles, wrists or fingers.

What are the symptoms?

Along with elevated uric acid levels, gout is marked by one or more of the following:

• Intensely painful joint or joints that are overly sensitive to touch
• Swelling around the joint that’s red, tender and warm to the touch
• As gout progresses, possible damage to joints and loss of range of motion

Why me?

Researchers are not entirely sure why some people get gout and others don’t, but it’s likely a combination of genetic and environmental factors. In fact, it’s estimated that between 20% and 80% of people with gout have a family history of the disease. Other factors that can increase your risk include:

Birth gender: Men are more likely to develop gout at a younger age, with risk highest between ages 30 and 55—but after menopause, the risk for women increases, too. That’s because estrogen helps prevent uric acid build-up, and estrogen levels drop after menopause. In fact, a third of gout sufferers over age 65 are women.  

Weight: Excess weight, especially around the mid-section, has been associated with increased risk for gout. On the flip side, sudden weight loss triggered by extreme dieting can also cause flares, so if you’re trying to lose weight, it’s best to stick to a gradual loss—think one or two pounds a week.  

Medical conditions: Untreated high blood pressure, diabetes, metabolic syndrome, heart disease and kidney disease can be associated with an increased risk.

Certain medications: Aspirin, blood pressure drugs and other medications can raise uric acid. Ask your doctor if anything you’re taking could trigger an attack; never stop using medication on your own.

How is gout diagnosed?

Your healthcare provider will examine your joints and ask questions about your symptoms. They will also order tests, likely including:

• Blood tests to confirm your uric acid level is too high (although during an attack, your uric acid level can drop) and other blood tests such as your kidney function
• Fluid samples taken from your joints to check for crystal formation and rule out an infection
• X-rays or ultrasounds of certain joints, to check for damage or the presence of a fracture

Having each battled uncontrolled gout for years before finding treatments that worked, Gary Ho and Dave Buttner learned a thing or two about living with the painful inflammatory condition. Read on to see if their tips—from dietary adjustments to increased physical activity—could help you thrive, as well! —by Lindsay Bosslett

“The right treatment changed
everything for me!”
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GARY HO, 53

When Gary Ho was only five years old, he and his family were forced to flee Saigon, making their way to the United States via the last barge to leave Vietnam and spending several months in a refugee camp.

So to say he’s always been a survivor is, well, an understatement—yet nothing could prepare him for the “16 years journeying in the wilderness,” he describes as the time spent when he first showed the signs of gout until the condition was finally diagnosed and treated.

Gary was only 24 in 1994 when he woke up one morning confused to see that his ankle had, for some unknown reason, swollen overnight.

“It was the most painful experience I had ever had; it felt like I had somehow severely sprained or even broken my ankle.”

Gary first called his father, who told his son that the symptoms he was describing sounded like gout—and he would know, because he had the condition.

So Gary went to his general practitioner and explained the situation—only to hear that he was “too young” for gout and must have just injured himself without realizing.

“I actually felt ecstatic,” Gary remembers. “It was such a relief to hear I ‘didn’t’ have gout, so I went home and told my dad I was in the clear. And the pain eventually went away on its own, so it became an ‘out of sight, out of mind’ situation.”

“I was ready to give up”

Unfortunately, the condition didn’t stay away for long, and over the course of the next 16 years, Gary would experience more frequent and severe flares—yet doctors still discounted the diagnosis because of his youth.

“By the time 2010 came around, I was at my wits’ end,” Gary recalls. “I’d lost most of my 20s and 30s to this mysterious condition. I would have flares multiple times a year, and each time, the pain was so terrible I would wind up on crutches or needing a wheelchair.”

Desperate, Gary turned to the internet to research his condition, where he concluded that because of his symptoms and family history, he had to have gout. His internet sleuthing also provided a path to getting a proper diagnosis: He needed to find a rheumatologist.

That’s when the fates connected Gary with Christopher Parker, MD, a rheumatologist who specializes in treating gout.

“Right from my initial appointment, the experience was night and day from my previous doctor visits,” Gary recalls. “Dr. Parker spent 10 or 15 minutes just asking me questions and listening to my journey from the last 16 years. He examined me, then said, ‘Gary it’s real simple: You show all the signs of gout. Let’s just take a blood test and find out your uric acid level.’ I couldn’t believe the answer could be so easy.”

And when the results came back, there was no doubt. Gary’s uric acid levels were 10 mg/dL, way higher than the 6 mg/dL or less they should be.

“I don’t live in fear anymore!”

Because Gary’s uric acid levels were so high and had gone untreated for so many years, his condition was considered out-of-control or “refractory gout,” which is the most severe stage marked by increasingly frequent and more painful flares, as well as the presence of tophi—large, visible lumps made from uric acid crystals that form around joints. In fact, Gary had them on his elbow and toe.

Gary was started on an anti-inflammatory to control his pain, and the typical first-line medication for gout: allopurinol, which works by slowing uric acid production in the body. The problem?

“My levels were already so high—allopurinol can take two or three years to bring your uric acid levels down, it’s a slow-and-steady method, and it wasn’t doing enough to get my condition under control.”

Luckily, the fates were with Gary again—his doctor just so happened to be part of a clinical trial at the time for a new gout treatment, one that worked by actively dissolving uric acid crystals and flushing the excess out of the body.

“Dr. Parker explained that this medication was given by infusion and I’d have to go to his office once every two weeks for several months to receive it, but at that point I thought, what do I have to lose? Whatever it takes to get rid of this pain. So I signed up!”

Gary felt the difference after the very first infusion, which dropped his uric acid levels from 10 mg/dL to undetectable. After a few initial weeks dealing with the challenges of his levels suddenly dropping—which can also spark flares—Gary finally woke up one morning and realized his wheelchair days were a thing of the past.

“Looking at the before and after photos from when I got those infusions—they speak a thousand words about how it changed my life. By the sixth month of infusions, my tophi had shrunk away. By the ninth month, I was officially done with treatment and, unbelievably, I have been flare-free since 2010. I still have gout, but it’s managed now. Because of that treatment, I regained the quality of life that I deserve—today I’m married, we have a son, I’m active and able to go to the gym, I can eat what I like and I feel unstoppable. I’m going on 54 and I feel younger than I did at 24. I don’t live in fear anymore!”

“Stay focused on tomorrow!”
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DAVE BUTTNER, 68

Retired Air Force and National Guardsmen Dave Buttner is no stranger to gout.  His first exposure was through his dad, who developed the inflammatory condition as a result of medications he took after a stroke. “It was debilitating,” says Dave, who was 18 at the time. “One of the worst cases I’ve ever seen, he couldn’t even get out of bed without help.”

So when Dave first experienced his own flare in his 30s, the diagnosis didn’t take him by surprise. “Like most people with gout, it started in my big toe,” says the Port Hueneme, CA, resident. “And it just so happened to be the toe I injured when I was a kid—I was chopping wood and accidentally hit it with a sledgehammer. I’ve since learned it’s common for gout to first pop up in a joint that was previously injured.”

The inflammation would come and go for many years before Dave found a doctor who was willing to listen to him—and diagnose and treat him for out-of-control or “refractory” gout.

Here, Dave shares the tips that have helped him learn to thrive despite gout—ask your healthcare team if they could help you, too!

Stay active. Even during a flare, Dave—who typically hops on his bike two to three days a week for five or so miles at a time—makes an effort to stay mobile. “There are times a flare has been so bad I can’t cycle, but I try to at least walk.” Just remember that new or excess activity can trigger or worsen a flare—think "weekend warrior"

Be cautious with your diet. “I do try to limit high purine foods like organ meats—although I’ll admit cutting liver out of my diet didn’t take much sacrifice. I also love beer, which is unfortunately another trigger food, so while I still have an occasional stout or porter, I try to make sure I don’t drink too many.”

Do your own research. After a few years of living with gout—and having flares treated with prednisone, which only seemed to help when he was actively taking it—Dave recruited the help of his sister. Since these were still pre-internet days, she accessed the University of Vermont’s medical library to look up the condition, which is when Dave learned about options like allopurinol and colchicine, which, in addition to naproxen, is what he still uses today to control his uric acid levels and treat the inflammation during flares.

Find a doctor who “gets” you. When Dave presented his own research to the doctor who initially diagnosed him, the doctor responded with annoyance. “That’s when I knew I had to find someone who would be open to a conversation with me.”

Drink plenty of water. The Arthritis Foundation recommends people with gout drink at least 8 glasses of nonalcoholic beverages a day, with plain water being best. That’s because water helps the body flush out excess uric system via urination.  “I try to start every day by drinking 20 oz. of water,” Dave adds. “Like anyone else, I’m not perfect and sometimes I don’t get enough the rest of the day, but at least that gives me a good start.”

Try some cherries. A gout-friendly diet isn’t just about restriction, Dave emphasizes. “There are also foods that help the body flush uric acid out rather than producing more of it, one of which is cherries. I almost always either have some on hand or have the juice in my fridge.”

Seek support. An active member of the Arthritis Foundation for more than 14 years, Dave credits the organization for allowing him to connect with others living with gout. “It’s a great resource for anyone out there living with a form of arthritis,” he adds. In fact, since 2009 Dave has been participating in the AF’s California Coast Classic bike tour, which raises money for research. Learn more about the tour, below.

MISSED A DOSE—HELP!

Q: I’ve been prescribed a daily pill to control my gout, but I’m so forgetful! What should I do if I miss taking a pill and are there any other available treatments? 

A: Taking your uric acid-lowering medicine every day is the key to long-term control of gout. But if you miss taking your pill one day, don’t worry—just take the dose you missed as soon as you remember, then take your next dose at the same time you normally would have and continue on.

Daily uric acid-lowering medications work by reducing how much uric acid your body produces—they will slowly lower your levels over a long period of time, and then keep them at a controlled level going forward. However, if you’ve had uncontrolled gout for a while, or your uric acid levels are extremely high when you’re diagnosed, daily medications may not be enough. In that case, you may be prescribed an infusion that will actively dissolve built-up crystals and flush excess uric acid from your body.

—Madelaine Feldman, MD, FACR, The Rheumatology Group, Immediate Past President at Coalition of State Rheumatology Organizations

OKAY TO DRINK BEER?

Q: I’ve recently been diagnosed with gout and my doctor told me I should cut out beer. Does that mean I can never have one ever again? Is all alcohol off-limits?  

A: It is true that beer—and any type of alcohol—contains purines, which are chemicals that create uric acid as a byproduct when your body digests them. But dietary intake, whether from drinks or other high-purine foods such as organ meat, certain seafood or high fructose corn syrup, only accounts for about 1/3 of the uric acid found in the body. For most people, the most important step in controlling gout is to take medication to lower their uric acid below 6 mg/dL and keep it there. Once those levels are achieved, you can typically still have a drink now and then without triggering a flare. However, if your uric acid is not under control, you may need to stop or cut back significantly until it is. 

           —Madelaine Feldman, MD, FACR

CONCERNED ABOUT LUMPS

Q: I’ve had gout for nearly 10 years and I probably flare up three or four times a year. I’ve been managing the condition with diet, but a few months ago I noticed a lump forming on my elbow and some smaller ones on my forearm. I went to the doctor who said they were “tophi” caused by my uncontrolled gout, and that my uric acid levels were too high. But I thought a few flares a year was me controlling it—I don’t understand what this lump is!

A: If you’re having multiple flares a year, that means your gout is not controlled. Over time, if your uric acid level remains too high, deposits of uric acid crystals grow around the joints and can form lumps. These lumps, called tophi, may become disfiguring and crippling. Patients with gout of this severity need to be on medications to control the inflammation and also need to have their levels of uric acid lowered—a low-purine diet may lower your levels by 1 or 2 mg/dL, but that won’t bring you into the goal level of below 6 mg/dL if your starting levels are too high.

Luckily, there are uric acid-lowering medications that can break down deposits, cause the tophi to regress, control the arthritis and eventually eliminate flares completely. You’ll want to talk to your doctor about which medication they recommend and get started as soon as possible to avoid permanent joint damage.  

—Herbert S. B. Baraf, MD, FACP, MACR, Clinical Professor of Medicine, George Washington University, Gout Education Society member, founding member of Arthritis and Rheumatism Associates

WHY AM I FEELING WORSE?

Q: I was recently diagnosed with gout and my rheumatologist put me on a medication to help remove excess uric acid from my body. The only thing is, I think I feel worse since being on it! I thought lowering my uric acid was supposed to stop these flares!

A: There are three things to remember about being on uric acid-lowering medication. First, when treatment is started, it may temporarily increase the risk for additional attacks of gout—that’s because a sudden drop in uric acid, especially if it’s extreme, can trigger a flare. That’s why most patients will be on concurrent medication for at least 6 months—colchicine is most commonly used for this purpose and it helps manage the inflammation and pain associated with the temporarily increased flares.

Second, patients need to be reminded that uric acid-lowering medications should never be stopped during an acute attack, or they can make the attack worse.

Third, starting uric acid-lowering medication is a lifelong commitment. Once levels are lowered to the goal range of below 6 mg/dL, flares will cease as long as you keep taking your daily meds, monitor your levels and consume high-purine foods and drinks in moderation.

—Herbert S. B. Baraf, MD, FACP, MACR

If you have gout, priority No. 1 is talking with your healthcare provider about treatment options. And you may have already discovered what dietary triggers—shellfish, alcohol, red meat—can set you up for a painful flare. But did you know non-food saboteurs can also lead to an attack? Here are the top most overlooked gout triggers; ask your healthcare team if any of them could be adding to your pain.

1. Medication. Certain meds, such as aspirin, diuretics (i.e., “water pills’), opioids and high-dose niacin (typically prescribed for high cholesterol) can increase blood levels of uric acid, the culprit that causes gout. Ask your healthcare professional if anything you’re taking could pose a problem. Note: Never stop taking medication without your doctor’s approval.
2. Dehydration. Not drinking enough water can allow uric acid to concentrate in the blood, triggering an attack. Not only does drinking adequate water help flush uric acid from the bloodstream, it also helps cushion joints and tissues. Aim for 6 to 8 glasses a day.
3. Excess weight. Gout is linked to carrying too much weight, especially around the middle, and if you also have risk factors for metabolic syndrome, such as high blood pressure and high blood sugar. The good news: A study in Rheumatology found that overweight gout sufferers who shed 10-20 pounds doubled the odds of normalizing their uric acid level.
4. Crash diets. Although losing excess weight is helpful for those with gout, extreme dieting or fasting can raise the level of ketones, a chemical produced when fat is broken down for energy, in your body—and ketones compete with uric acid for excretion. So if you’re trying to lose weight, stick to a healthy plan and aim to lose no more than 1-2 pounds a week.
5. Menopause. An increased risk of gout can be an unwelcome consequence of menopause, since estrogen, a hormone that aids in uric acid excretion, falls sharply during this time. Experts believe this protective effect of estrogen is also the reason premenopausal women are less likely to get gout than men.

Therapies that can foil gout pain for good
The most effective way to prevent gout attacks: Take medication to lower your uric acid level—and take it as directed. “Gout is a chronic disease,” notes Brian Mandell, MD, a rheumatologist at the Cleveland Clinic and advisor for The Gout & Uric Acid Education Society. “There are certainly dietary changes you can make and a common-sense lifestyle is advised—but mainly because gout is associated with problems like diabetes and heart disease,” he explains. “For the majority of people, this is a genetic metabolic disease—their kidneys cannot excrete uric acid as efficiently as other people.” And consider this: Only about a third of uric acid comes from our diet; most uric acid is made by our own body as a natural by-product of cell breakdown, so there’s only so much lifestyle changes can accomplish. The upshot: Ask your doctor about medication to keep your uric acid below 6 mg/dL—your target blood level to prevent gout pain.

Uric acid levels still too high? If your current uric acid-lowering therapy isn’t getting you where you need to be, ask your healthcare provider about options for treatment-resistant gout, which may be able to help get your numbers in goal range.