• Dr. Jennifer Nicole Falk

What Is Causing Your Gout Attacks?


Gout is the accumulation of urate crystals in joints, which occurs either by overproduction or, more commonly, underexcretion of uric acid (1). It only affects about 4% of adults in America, but it can become debilitating, as well as a life-long problem for those afflicted by it (3). The big toe joint is the most commonly affected joint but the knees, ankles, and finger joints can also common sites for gout to occur.


SYMPTOMS/STAGES

The symptoms associated with gout can vary depending on the stage. As such, it is important to obtain a thorough history from the person, in addition to performing a comprehensive exam & work-up, in order to make an accurate diagnosis.


Asymptomatic:

Before the first acute attack, the person may not have symptoms, but their uric acid level is elevated (3).

Acute:

With acute attacks, the affected joint can become red, hot, swollen, and painful. Pain may be present with movement of the joint or pressure placed over the area. With the big toe joint, the person may note that the toe hurts even with the bedsheet over the foot. The person may report the symptoms happened after a night of drinking alcohol or after eating certain high-purines foods, such as red meats, which could have triggered the attack.


Intercritical:

This is the time period between acute gouty attacks. The person may not be symptomatic, but underlying inflammation and joint destruction could still be occurring (3).


Chronic:

Long-term gout can result in joint destruction and severe arthritis, as well as gouty tophi (a collection of urate crystals). Gouty tophi are usually whitish in color and have the appearance of cottage cheese. Their presence can cause added pressure around the areas, as well as lead to joint arthritis (1).


WORK-UP

Clinical:

With acute attacks, the joint will often be warm, swollen, and red. Pain is reproducible with palpation to the area. In chronic gout cases, the area may not be red or swollen. Instead, gouty tophi may just be palpable around the joint and signs of arthritis may be found. Pain may or may not be present.


Imaging:

X-rays can be helpful to better examine the joint, evaluating for signs of arthritis, infection, and other osseous abnormalities. Sometimes the gouty tophi can be seen by increased density within the soft tissues around the joint.


Labs:

If gout is suspected, a series of labs are often run to check kidney function, the uric acid level, as well as inflammatory and infectious markers. Depending on the stage of gout at the time of testing, though, not all lab markers may not be accurate.


Aspiration:

The best way to diagnose gout it to aspirate the joint and perform a synovial fluid analysis, examining for urate crystals.


PODAGRA (GOUT OF THE BIG TOE JOINT) DIFFERENTIAL DIAGNOSES

Because several foot pathologies can present with a red, hot, painful, and swollen big toe joint, it is important to rule-out other potential causes of these symptoms, especially infectious ones.


Bunion

A bunion develops when the first metatarsal bone moves away from the smaller metatarsal bones and the big toe moves towards the second toe, thus creating a bump around the big toe joint. Unlike hallux limitus, where the bony bump is along the top of the big toe joint, with a bunion, the bony bump is along the inside of the foot. Therefore, intighter shoes the bunion can become irritated, causing pain and redness.


To learn more about bunions, click here.


Hallux limitus (aka arthritis of the big toe joint)

Limited motion of the big toe joint (1st metatarsal-phalangeal joint), also known as hallux limitus, is a progressivedisorder that starts with flattening of the 1st metatarsal head, minimal cartilage damage, and small bone spurring andends with a stiff, painful joint (aka hallux rigidus).


Although a hallux limitus and gout differ, in chronic stages of gout, one may can develop arthritis inthe big toe joint. Therefore, you could have both gout and arthritis of the big toe joint.


Septic joint

Infection of the joint is rare, but can occur, especially if there is an open wound or sore around the area.

Like the other differential diagnoses of a painful big toe joint, the area may be red, warm, swollen, and painful; however, in the presence of an infection, there may also be abnormal drainage (e.g. yellow) if an open wound exists. If the infection gets into your bloodstream, it can also make you feel ill (i.e. nauseated, vomiting, fevers, chills). Therefore, it is crucial to seek help immediately if you feel you may have a joint infection.


Check out my blog “Such a Pain in the Big Toe” to learn more about the different pain syndromes that occur around the big toe joint.


GOUT TREATMENT & PREVENTION

Medications:

Medications for gout can be broken down into two categories: 1) Those that treat acute gouty attacks, and 2) Those that help prevent attacks. For acute attacks, NSAIDs (specifically, Indocin), Colchicine, and Corticosteroids are most commonly used (1). An injection of steroid into the joint can often give some temporary pain relief. For more long-term management and the prevention of recurrent attacks, hyperuricemic therapy can be initiated, which may include Probenecid, Sulfinpyrazone, or Allopurinol (1).

Diet:

Uric acid is either produced by the body or obtained from a person's diet, which frequently contains purines (4). Therefore, people with gout are often encouraged to eat a low-purine diet. This often means avoiding (or limiting the amount consumed of) red meat, fish, and beer, and eating more fruits, vegetables, eggs, and low-fat dairy (2).


To learn more about what foods are safe to eat on a low-purine diet and the ones you should avoid/limit, check out this PDF by the Palo Alto Medical Foundation and read this evidence-based article on Healthline. Before changing your diet, it is recommended that you consult your healthcare professional, or nutritionist.



DISCLAIMER: The above information is meant for educational purposes only and should not be construed as medical advice. Please consult the doctor, or your own healthcare professional, should you have questions or concerns related to your health.


References:

1. Pittman, J.R. (1999). Diagnosis and Management of Gout. Am Fam Physician 59(7):1799-1806.Retrieved from https://www.aafp.org/afp/1999/0401/p1799.html

2. Raman, R. (2017). Best Diet for Gout: What to Eat, What to Avoid. Healthline, Retrieved from https://www.healthline.com/nutrition/best-diet-for-gout

3. What is Gout? Arthritis Foundation. Retrieved on November 14, 2018 from https://www.arthritis.org/about-arthritis/types/gout/what-is-gout.php

4. What Role Does Diet Play in Gout Management? Arthritis Foundation. Retrieved on November 16, 2018 from https://www.arthritis.org/about-arthritis/types/gout/articles/purine-foods-gout-attack.php


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