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Gout

​Gout: What is it

Gout is a form of arthritis or joint inflammation where sudden pain, redness, warmth and swelling of a joint occurs, due to uric acid from the blood crystallising within the joint. The condition is called ‘Niao Suan’ by traditional Chinese physicians, a term many patients are familiar with.

Symptoms of Gout

An attack often occurs suddenly with the maximum intensity of pain reached within a few hours such that the sufferer may have difficulty even walking. This rapid development of pain is a feature that differentiates it from other forms of arthritis. Similarly, after some days, the pain and swelling subsides, hastened by medication, and things return to normal.

This is unlike other forms of arthritis where pain is present constantly.

The most commonly affected joints are those of the big toe, as well as forefoot, knee, ankle and elbow joints. The shoulders, hips and spine are rarely affected.

Causes of Gout

Uric acid, or urate, is a breakdown of the product purine, a component of DNA found in all cells. Urate is poorly soluble. When the body produces too much uric acid or the kidneys cannot clear enough of it, or if there is over-ingestion of high purine foods, blood uric acid levels rise. This leads to urate deposits of needle-shaped urate crystals in the joint space. These cause intense irritation producing the symptoms of gout.

Risk Factors of Gout

Obesity. Excessive food intake and a large body type increases the body’s production of uric acid.

Excessive Alcohol. Alcohol, especially beer contains high uric acid. A typical scenario of gout is a man after an alcoholic binge, waking up in the middle of the night with excruciating pain in the big toe, ankle or knee.

Food. Food with a high purine content include red meat, beans, nuts, seeds, pulses and their products (e.g. soybean products), certain rich fish like sardines and anchovy, salmon, organ meats like intestines and offal (‘kway chap’) and certain vegetables like spinach and broccoli.

However, moderation in consumption of foods, weight reduction and overall healthy eating is advised rather than total abstinence from such a long list of food items some of which also offer positive health benefits. Food accounts for only 30 percent of uric acid in our blood so even if none of the above are consumed, there may still be gouty attacks requiring medications.

High purine content food is a risk factor for gout according to SGH.

Kidney disease. Someone with impaired kidney function will have difficulty clearing excess uric acid in their urine and are more prone to gout.

Age & Gender. Men are at higher risk. The typical patient is often a middleaged obese man. Women are at lower risk until after menopause. The risk of developing gout also increases with age. Many elderly get attacks of gout for the first time in their senior years.

Family history. There is a higher risk of developing gout if a family member already has gout.

Diagnosis of Gout

Doctors diagnose gout when symptoms affecting a joint are sudden and severe with a swollen and hot joint. There is often a previous experience of a similar event, and a return to normal after the ‘attack’.

Gout is also the likely diagnosis when the ‘typical’ joints are affected, especially the big toe, which can turn red.

A high blood uric acid level with these symptoms suggests the diagnosis of gout. However, a high uric acid without gout symptoms does not mean a diagnosis of gout. Patients need not be treated based on a high blood uric acid level alone if they do not have attacks of joint pain.

Joint aspiration is a procedure where a needle and syringe is used to suction out a sample of fluid from the affected joint. This is sometimes done in specialist clinics both to confirm diagnosis and relieve pain by removing excess fluid from a badly swollen joint. The presence of urate crystals in this joint fluid seen under a microscope definitively confirms a diagnosis of gout.

Medications

Pain relief. Drugs which can rapidly reduce pain and swelling are needed in an acute attack. These include non-steroidal anti-inflammatory drugs (NSAIDs), steroids and colchicine.

Preventing future attacks
Drugs. Pain relief of the current attack is not enough if the sufferer has recurrent attacks. This is because the joint will become damaged with repeated attacks leading to chronic pain and disability from a worn-out cartilage.

Drugs that reduce blood uric acid levels can prevent future attacks. A drug called allopurinol is able to decrease the production of uric acid. The drug probenecid increases the amount of uric acid passed out in the urine.

A small percentage of people will get a rash with allopurinol. When this occurs, the drug must be stopped as the rash can involve the whole body which can be dangerous. If you are given allopurinol, your doctor will warn you about the possibility of this condition called allopurinol hypersensitivity syndrome.

Low purine diet. Food with high purine content should be reduced.

Drink enough water. It is also important to drink more water (at least 2 litres a day) unless instructed by a doctor not to do so.

Prevent future gout attack by drinking enough water according to SGH

Avoid alcohol. The consumption of alcoholic beverages should be avoided, especially beer.

Reduce weight and lead a healthy lifestyle. Weight reduction is also important. For the typical middleaged sufferer, gout is often the manifestation of an unbalanced diet, over-nutrition and lack of exercise. An overall healthy lifestyle, exercise, avoidance of alcohol, dietary modification and weight reduction goes a long way in gout control rather than simply strict abstinence of one or two food items.

Gout and its association with other lifestyle diseases

Gout often occurs together with other diseases due to lifestyle imbalance such as high blood pressure, diabetes and high cholesterol. If you have gout it is important to screen for these diseases as well.

Please consult your Family Doctor if you have any concerns about your health.

Specialist services available at the following SingHealth institution:

Singapore General Hospital
Tel: 6321 4377