Questions and Answers About Gout.

This fact sheet contains general information about gout. It describes what gout is and how it develops. It also explains how gout is diagnosed and treated. At the end is a list of key words to help you understand the terms used in this fact sheet. If you have further questions after reading this fact sheet, you may wish to discuss them with your doctor.

* What Is Gout?

* What Causes Gout?

* Who Is Likely To Develop Gout?

* How Is Gout Diagnosed?

* How Is Gout Treated?

* What Can People With Gout Do To Stay Healthy?

* What Research Is Being Conducted To Help People With Gout?

* Where Can People Find More Information About Gout?

* Acknowledgments

* Key Words

What Is Gout?

Gout is one of the most painful rheumatic diseases. It results from deposits of needle-like crystals of uric acid in the connective tissue, joint spaces, or both. These deposits lead to inflammatory arthritis, which causes swelling, redness, heat, pain, and stiffness in the joints. Arthritis is a term that is often used to refer to the more than 100 different rheumatic diseases that affect the joints, muscles, and bones, and may also affect other connective tissues. Gout accounts for about 5 percent of all cases of arthritis. Pseudogout, also a crystal-induced arthritis, is a condition with similar symptoms that results from deposits of calcium pyrophosphate dihydrate crystals in the joints. It is sometimes called calcium pyrophosphate deposition disease, crystal deposition disease, or chondrocalcinosis.

Uric acid is a substance that results from the breakdown of purines or waste products in the body. Normally, uric acid is dissolved in the blood and passes through the kidneys into the urine, where it is eliminated. If the body increases its production of uric acid or if the kidneys do not eliminate enough uric acid from the body, levels build up (a condition called hyperuricemia). Hyperuricemia may also result when a person eats too many high-purine foods, such as liver, dried beans and peas, anchovies, and gravies. Hyperuricemia is not a disease and by itself is not dangerous. However, if excess uric acid crystals form as a result of hyperuricemia, gout can develop. The excess crystals build up in the joint spaces, causing inflammation. Deposits of uric acid, called tophi, can appear as lumps under the skin around the joints and at the rim of the ear. In addition, uric acid crystals can also collect in the kidneys and cause kidney stones.

For many people, gout initially affects the joints in the big toe, a condition called podagra. Sometime during the course of the disease, gout will affect the big toe in about 75 percent of patients. Gout can also affect the instep, ankles, heels, knees, wrists, fingers, and elbows. The disease can progress through four stages:

* Asymptomatic (without symptoms) hyperuricemia--In this stage, a person has elevated levels of uric acid in the blood but no other symptoms. The tendency to develop gout, however, is present. A person in this stage does not usually require treatment.

* Acute gout, or acute gouty arthritis--In this stage, hyperuricemia has caused the deposit of uric acid crystals in joint spaces. This leads to a sudden onset of intense pain and swelling in the joints, which may also be warm and very tender. An acute attack commonly occurs at night and can be triggered by stressful events, alcohol or drugs, or another acute illness. Early attacks usually subside within 3 to 10 days, even without treatment, and the next attack may not occur for months or even years. Over time, however, attacks can last longer and occur more frequently.

* Interval or intercritical gout--This is the period between acute attacks. In this stage, a person does not have any symptoms and has normal joint function.

* Chronic tophaceous gout--This is the most disabling stage of gout and usually develops over a long period, such as 10 years. In this stage, the disease has caused permanent damage to the affected joints and sometimes to the kidneys. With proper treatment, most people with gout do not progress to this advanced stage.

What Causes Gout?

A number of risk factors are related to the development of hyperuricemia and gout:

* Genetics may play a role in determining a person's risk, since 6 to 18 percent of people with gout have a family history of the disease.

* Being overweight increases the risk of developing hyperuricemia and gout because excessive food intake increases the body's production of uric acid.

* Excessive use of alcohol can lead to hyperuricemia because it interferes with the removal of uric acid from the body.

* Eating too many foods that are rich in purines can cause or aggravate gout.

* An enzyme defect that interferes with the way the body breaks down purines causes gout in a small number of people.

* Exposure to lead in the environment can cause gout.

Some people are at risk for high levels of uric acid in body fluids because of certain medicines they take or other conditions they may have. For example, the following types of medicines can lead to hyperuricemia because they reduce the body's ability to remove uric acid:

* Diuretics, which decrease the amount of uric acid passed in the urine. Many people take diuretics for hypertension, edema, or cardiovascular disease.

* Salicylates, or medicines made from salicylic acid, such as aspirin.

* The vitamin niacin, also called nicotinic acid.

* Cyclosporine, a medicine used to control the body' s rejection of transplanted organs.

* Levodopa, a medicine used to treat Parkinson's disease.

Who Is Likely To Develop Gout?

Gout occurs in approximately 275 out of every 100,000 people. Men are more likely to develop gout than women, and men aged 40 to 50 are most commonly affected. Women rarely develop gout before menopause. The disease affects men and women differently: Men tend to develop gout at an earlier age than women, and alcohol is more often associated with the development of the disease in men. Gout is rare in children and young adults.

Signs and Symptoms of Gout

* Hyperuricemia

* Presence of uric acid crystals in joint fluid

* More than one attack of acute arthritis

* Arthritis that develops in 1 day

* Attack of arthritis in only one joint, usually the toe, ankle, or knee

* A painful joint that is swollen, red, and warm

How Is Gout Diagnosed?

Gout may be difficult for doctors to diagnose because the symptoms may be vague and often mimic other conditions. Although most people with gout have hyperuricemia at some time during the course of their disease, it may not be present during an acute attack. In addition, hyperuricemia alone does not mean that a person has gout. In fact, most people with hyperuricemia do not develop the disease.

To confirm a diagnosis of gout, doctors typically test the fluid in the joint, called synovial fluid, by using a needle to draw a sample of fluid from a person's inflamed joint. The doctor places some of the fluid on a slide and looks for monosodium urate crystals under a microscope. If the person has gout, the doctor will almost always see crystals. Their absence, however, docs not completely rule out the diagnosis. Doctors may also find it helpful to examine joint or tophi deposits to diagnose gout. A doctor who suspects a joint infection may check for the presence of bacteria.

How Is Gout Treated?

With proper treatment, most people with gout are able to control their symptoms and live normal lives. Gout can be treated with one or a combination of therapies. Treatment goals are to case the pain associated with acute attacks, prevent future attacks, and avoid the formation of new tophi and kidney stones.

The most common treatments for an acute attack of gout are high doses of nonsteroidal anti-inflammatory drugs (NSAID's) and injections of corticosteroid drugs into the affected joint. NSAID's reduce the inflammation caused by deposits of uric acid crystals. The NSAID's most commonly prescribed for gout are indomethacin (Indocin_(1)) and naproxen (Anaprox, Naprosyn), which are taken by mouth (orally) every day. Patients usually begin to improve within a few hours of treatment, and the attack goes away completely within a few days.

When NSAID's do not control symptoms, the doctor may consider using colchicine. This drug is most effective when taken within the first 12 hours of an acute attack. Doctors can give colchicine by mouth (usually every hour until symptoms go away), or they can inject it directly into a vein (intravenously). When taken by mouth, colchicine frequently causes diarrhea.

For some people, the doctor may prescribe either NSAID's or oral colchicine in small daily doses to prevent future attacks. If attacks continue and tophi develop, however, the doctor may prescribe medicine to treat hyperuricemia, most commonly allopurinol (Zyloprim) and probenecid (Benemid).

What Can People With Gout Do To Stay Healthy?

* To help prevent future attacks, take the medicines your doctor prescribes. Carefully follow instructions about how much medicine to take and when to take it. Acute gout is best treated when symptoms first occur.

* Tell your doctor about all the medicines and vitamins you take. He or she can tell you if any of them increase your risk of hyperuricemia.

* Plan followup visits with your doctor to evaluate your progress.

* Maintain a healthy, balanced diet; avoid foods that are high in purines; and drink plenty of fluids, especially water. Fluids help remove uric acid from the body.

* Exercise regularly and maintain a healthy body weight. Lose weight if you are overweight.

What Research Is Being Conducted To Help People With Gout?

Scientists are studying whether other NSAID's are effective in treating gout and are analyzing new compounds to develop safe, effective medicines to treat gout and other rheumatic diseases. For example, researchers are testing to determine whether fish oil supplements reduce the risk of gout. They are also studying the structure of the enzymes that break down purines in the body, in hopes of achieving a better understanding of the enzyme defects that can cause gout.

Where Can People Find More Information About Gout?

* Arthritis Foundation 

1330 West Peachtree Street
Atlanta, GA 30309
404/872-7100
800/283-7800, or call your local chapter (listed in the telephone
directory)
World Wide Web address: http://www.arthritis.org/

This is the main voluntary organization devoted to arthritis. The foundation publishes free pamphlets on many types of arthritis and a monthly magazine for members that provides up-to-date information on arthritis. The foundation also provides physician and clinic referrals.

* National Arthritis and Museuloskeletal and Skin Diseases Information Clearinghouse (NAMSIC)

National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
301/495-4484
TTY: 301/565-2966
Fax: [phone]
NIAMS Fast Facts--For health information that is available by fax
24 hours a day,
call 301/881-2731 from a fax machine telephone.
World Wide Web address: http://www.niih.gov/niams/

This clearinghouse, a public service sponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), provides information about various forms of arthritis and rheumatic diseases. The clearinghouse distributes patient and professional education materials and also refers people to other sources of information.

Acknowledgments

The NIAMS gratefully acknowledges the assistance of John H. Klippel, M.D., NIAMS; N. Lawrence Edwards, M.D., of the University of Florida in Gainesville; and Lawrence Ryan, M.D., of the Medical College of Wisconsin, in the preparation and review of this fact sheet.

Key Words

Arthritis:                Literally means joint inflammation. It is
                          a general term for more than 100
                          conditions known as rheumatic diseases.
                          These diseases affect not only the joints,
                          but also other parts of the body,
                          including important supporting structures,
                          such as muscles, tendons, and ligaments,
                          as well as some internal organs.

Cartilage:                A tough, resilient tissue that covers and
                          cushions the ends of the bones and absorbs
                          shock.

Colchicine:               A medicine used to treat gout. It may be
                          given by mouth (orally) or injected
                          directly into a vein (intravenously).

Connective tissue:        The supporting framework of the body and
                          its internal organs.

Corticosteroids:          Potent-anti-inflammatory hormones that are
                          made naturally in the body or syntheti-
                          cally for use as drugs. The most commonly
                          prescribed corticosteroid is prednisone.

Crystal-induced           An accumulation of crystalline material
arthritis:                in various parts of the body, especially
                          the joints. Gout and pseudogout are
                          examples of crystal- induced arthritis.

Gout:                     A type of arthritis caused by the body's
                          reaction to needle-like crystals that
                          accumulate in joint spaces. This reaction
                          causes inflammation and extreme pain in
                          the affected joint, most commonly the big
                          toe. The crystals are formed from uric
                          acid. Gout is caused by either increased
                          production of uric acid or failure of the
                          body to eliminate uric acid.

Hyperuricemia:            Increased amount of uric acid in the
                          blood.

Inflammation:             A characteristic reaction of tissues to
                          injury or disease. It is marked by four
                          signs: swelling, redness, heat, and
                          pain.

Joint:                    A junction where two bones meet. Most
                          joints are composed of cartilage, joint
                          space, fibrous capsule, synovium, and
                          ligaments.

Joint space:              The volume enclosed within the fibrous
                          capsule.

Ligaments                 Bands of cordlike tissue that connect
                          bone to bone.

Nonsteroidal              A group of drugs, such as aspirin and
anti-inflammatory drugs   aspirin-like drugs, used to
(NSAID's):                reduce the inflammation that causes
                          joint pain, stiffness, and swelling.

Psendogout:               Similar to gout; however, the crystals in
                          the synovial fluid are composed of
                          calcium pyrophosphate dihydrate and not
                          uric acid. As in gout, the crystals in
                          the joint space cause an intense
                          inflammatory reaction in the joint.

Purines:                  Components of all human tissue that break
                          down to form uric acid. Purines are also
                          found in many foods in varying amounts.

Rheumatic diseases:       A general term that refers to more than
                          100 conditions that affect joints,
                          muscles, bones, and other connective
                          tissues.

Synovial fluid:           A substance found around the joints that
                          nourishes and lubricates them.

Tendons:                  Fibrous cords of tissue that connect
                          muscle to bone.

Tophus (plural tophi):    A hard deposit of crystalline uric acid
                          that may appear as a lump just under the
                          skin, particularly around the joints and
                          at the rim of the ear.

Uric acid:                An organic substance that results from
                          the breakdown of purines or waste products
                          in the body. It is dissolved in the blood
                          and passes through the kidneys into the
                          urine, where it is eliminated. Most
                          patients with gout have high levels of
                          uric acid in their blood. If the concen-
                          tration of uric acid in the tissues rises
                          above normal levels, crystals can form in
                          the joints and cause inflammation.

Uric acid crystals:       Caused by high concentrations of uric
                          acid. When uric acid crystals form in the
                          blood, they can collect in connective
                          tissue, joints, and kidneys. Some kidney
                          stones are made of uric acid.

(1) Brand names included in this fact sheet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean that the product is unsatisfactory.

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the National Institutes of Health (NIH), leads the Federal medical research effort in arthritis and musculoskeletal and skin diseases. The NIAMS supports research and research training throughout the United States, as well as on the NIH campus in Bethesda, MD, and disseminates health and research information. The National Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse (NAMSIC) is a public service sponsored by the NIAMS that provides health information and information sources. Additional information can be found on the NIAMS Web site at http://www.nih.gov/niams/.