Gout
Gout is a type of arthritis, which was historically known as the 'disease of kings' due to its association with rich foods and alcohol. Gout is common today among New Zealanders, particularly in Maori and Pacific Island people, and men are more at risk than women.
Symptoms of gout
An acute attack of gout causes sudden intense swelling, redness and warmth in a joint, most commonly the big toe, although it can occur in the ball of the foot, instep, ankle, knee, wrist, tip of the elbow or fingers. Gout is considered the most painful of all types of arthritis, with the person unable to weight-bear or wear shoes if the gout is present in the foot. In addition to localised pain, a person with gout may also have a mild fever or feel unwell.
Causes of gout
The most common reason gout occurs is due to high uric acid levels (hyperuricaemia) in the blood, but not everyone who develops gout will have hyperuricaemia.
Common causes of hyperuricaemia include: dietary factors such as purine-rich foods (meat, organ-meat, e.g., kidneys, liver, brains), seafood (e.g., herring, mussels, sardines, and scallops), some types of alcohol (especially beer); genetic conditions; certain medicines (for example aspirin and most diuretics); some medical conditions; and chemotherapy and radiation treatment (see Treatment Tips for more on associated foods/alcohol).
Uric acid accumulates in joint
Gout occurs when uric acid accumulates in a joint and saturates out to form tiny needle-shaped crystals. The body mounts an inflammatory response to the crystals in that joint, leading to gout symptoms of inflammation and pain. Most early gout attacks resolve after seven to 10 days, but the severe pain usually makes people seek treatment earlier.
The length of time between attacks can vary widely, with some people only ever having one attack. For most people, a second attack of gout will occur within a year. If a person’s uric acid level remains high (greater than 0.36mmol/L) despite them being symptom-free, there can be on-going joint inflammation which results in joint damage and tophi formation.
Tophi formation over time
Years of unresolved gout can lead to chronic (long term) ‘tophaceous’ gout. Tophi are firm, white, translucent nodules that can occur around the joints or on the outer ear, and arise from urate crystal deposits. They usually take at least five to 10 years after the initial gout attack to develop. As well as causing joint destruction, tophi are disfiguring and also cause physical problems. Although effective treatment can lead to the regression of tophi, they are far more difficult to manage once they have developed.
Risk factors for gout
The following factors increase the likelihood of developing gout:
High uric acid levels in the blood (hyperuricaemia)
Male
Maori and Pacific ethnicity
Family history of gout
Chronic renal (kidney) impairment
High blood pressure (hypertension)
Obesity
Diuretic use (‘water’ pills - ask your doctor if you can cut down or change to a different medication if you get gout)
Coronary heart disease
High intake of meat, purine-rich food and alcohol, particularly beer
Use of cancer-treating medicines.
See Your Pharmacist or Medical Professional
Everyone with gout (or suspected gout) should be assessed by a doctor. You may also need certain types of treatment which can only be prescribed by a doctor.
Your pharmacist can advise on the type of pain relief most suitable for you, and give advice on the condition, until you can see your doctor.
It is important to get professional advice on pain relief for gout, as some people cannot take certain pain medications (e.g., NSAIDs) due to other medical conditions, or other medicines they may be taking.
Treatment Tips
If you are prone to high uric acid levels, or have had a gout attack, try the following measures:
Reduce meat intake (especially wild game, organ and red meats) and seafood (especially anchovies, herring, shellfish, sardines, and some larger saltwater fish)
Reduce alcohol intake (especially beer, lager, port, and fortified wines)
Avoid a high fructose intake (e.g., fruit, honey, corn syrup)
Avoid overeating or starving, and maintain a healthy bodyweight
Drink at least five glasses of non-alcoholic fluids each day
See your doctor as early as possible if another gout attack occurs
Take any medications prescribed by your doctor for gout and continue taking them for as long as advised
Rest and try to keep weight off the painful joint
Try using ice or a heat pack on the joint (stop if the pain worsens).
Treatment Options
Pharmacy products can be used to treat the pain and swelling associated with gout.
Usually NSAIDs (non-steroidal anti-inflammatory drugs) are recommended for gout, though not everyone can take these.
Prescription medicines available through your doctor can help prevent gout attacks and lower your chances of developing long-term complications such as tophi and kidney problems.
Any medicine used to treat acute attacks should be taken at the first sign of an attack, at an effective dose.
In most people the pain and inflammation can be controlled within 12-24 hours and treatment stopped after a few days.
ACUTE GOUT
Non-steroidal anti-inflammatory drugs (NSAIDs)
[PHARMACY ONLY]
e.g., diclofenac, naproxen
Take regularly until severe pain reduces, then decrease dosage (ask your pharmacist if unsure of dosage).
NSAIDs are not suitable for everyone. Check with your pharmacist before taking NSAIDs if you:
Have a history of stomach problems, such as ulcers or indigestion
Have asthma – some people with asthma find their condition is made worse by these types of medicines
Have kidney problems or a heart condition
Take other medications
Have an allergy to NSAIDs
Are pregnant or breastfeeding
Are elderly – you may be at more risk of side effects
Are dehydrated.
Sometimes NSAIDs can cause side effects. If you develop indigestion, or unusual or increased bleeding or bruising, stop taking them and talk to your pharmacist.
Corticosteroids
[PRESCRIPTION ONLY]
Oral corticosteroids e.g., prednisone
Intra-articular corticosteroids, e.g., methylprednisilone, triamcinolone
These medicines are an alternative if you cannot take NSAIDs (available on prescription from your doctor)
Intra-articular corticosteroids (injected into the joint) may be considered if gout is localised to single joints.
Other treatments
[PRESCRIPTION ONLY]
e.g., colchicine
May be used as an alternative treatment, or in addition to NSAID treatment
Can also be used as a preventive treatment.
PREVENTION of GOUT
[PRESCRIPTION ONLY]
e.g., allopurinol
First-choice drug treatment for lowering uric acid levels (but may not be suitable for some people due to existing conditions)
Best started at a low dose at least two weeks after an acute gout attack
1-2% of people develop a rash (more common in patients with kidney impairment)
If a person has been taking allopurinol regularly at the time of an acute attack, it should be continued.
[PRESCRIPTION ONLY]
e.g., probenecid
May be used in combination with allopurinol in certain people (i.e., with persistent hyperuricaemia)
Not to be used if the person has a history of kidney stones
Good fluid intake (8 glasses of water per day) is important
If a person has been taking probenecid regularly at the time of an acute attack, it should be continued.
More Information
Availability of medicines
GENERAL SALE available through pharmacies and possibly other retail outlets.
PHARMACY ONLY available for sale through pharmacies only.
PHARMACIST ONLY may only be sold by a pharmacist.
PRESCRIPTION ONLY available only with a prescription from your doctor or other health professional.
Consumer Medicine Information on some medicines is available at the government website www.medsafe.govt.nz
