Brief overview
- Causes: Increased uric acid levels, either congenital or acquired e.g. through disease or diet, other environmental factors such as an unfavorable lifestyle.
- Symptoms: Painful, swollen, reddened joints, arthritis symptoms such as fever, fatigue, feeling of weakness, nausea, vomiting; later, restricted movement and deformation of the joints, complaints due to kidney stones (e.g., pain in the kidneys, blood in the urine, painful urination), nodules under the skin at joints
- Therapy: Change of diet and lifestyle, uric acid-lowering and pain-relieving medication, physical therapy as well as physiotherapy, surgery in case of joint damage or for the removal of nodular uric acid deposits; homeopathy if necessary, home remedies as accompanying measures if necessary.
- Diagnostics: Medical history, physical examinations, blood, X-ray and ultrasound examinations, kidney function tests.
What is gout?
Doctors call gout a metabolic disease associated with an increased uric acid concentration in the blood (hyperuricemia). In a healthy person, it is between three and six milligrams per 100 milliliters of blood serum. From a value of about 6.5 milligrams per 100 milliliters of blood serum, physicians speak of hyperuricemia.
In the case of gout, which like osteoarthritis is a rheumatic disease, there is usually an inflammatory reaction in the joints. Doctors refer to this as arthritis urica. Most often, the base joint of the big toe is affected. In some cases, the joints of the midfoot and the ankle joints are inflamed. The same applies to the knees and the joints of the arms and hands (elbows, wrist as well as finger joints). Less frequently, it affects large joints such as the hip or shoulder.
Depending on the cause of the high uric acid level in the blood, doctors distinguish between a congenital and an acquired form of gout, i.e. a disease that is due to environmental conditions or lifestyle, for example.
Primary gout – congenital disorder
Most gout patients suffer from a congenital metabolic disorder that is inherited and associated with impaired uric acid secretion (excretion) by the kidneys. Doctors refer to this as “primary hyperuricemia” or “primary gout”.
In rare cases, however, the body also produces so much uric acid that the kidneys are overwhelmed. The cause is a genetic defect, which is divided into two clinical pictures:
- Lesch-Nyhan syndrome (occurs predominantly in boys)
- Kelley-Seegmiller syndrome
In these disorders, the activity of an enzyme important for the recycling of purines is almost completely or partially reduced. As a result, the purines are increasingly broken down to uric acid.
Secondary gout – acquired disorder
Other conditions that cause increased production of uric acid include:
- Other tumor diseases
- Anaemia (anemia)
- Chemotherapeutic drugs (cytostatics)
- Radiation as part of cancer therapy
In kidney disease or in untreated or inadequately controlled diabetes mellitus, uric acid levels rise because not enough uric acid is excreted.
How gout develops
In the case of gout, elevated uric acid levels in the blood play a major role, along with other environmental factors. Due to genetics or disease, the body either produces too much uric acid or the kidneys do not excrete enough of it in the urine. As a result, tiny uric acid crystals form, which are deposited in the joints in particular. Very high uric acid levels threaten an acute attack of gout with pain, redness and swelling.
Uric acid is formed when purines are broken down. Purines, in turn, are breakdown products of certain components of genetic material – nucleic acids – and are formed when the body breaks down cells. They are also ingested with food; they are found particularly in meat and offal and in some vegetables.
Triggers for an acute gout attack
An acute gout attack occurs when uric acid levels exceed a certain level. The main triggers are:
- Excessive consumption of purine-rich foods such as meat and offal.
- Excessive consumption of fructose-rich foods such as sweetened fruit juices
- Too much alcohol; beer is particularly rich in purine
- Strict dieting: body breaks down muscle, releasing copious amounts of purines
- Physical overexertion; the kidneys primarily excrete the lactic acid produced, while uric acid breakdown is blocked
- Diuretics or laxatives; when used excessively or for a very long time, the blood thickens and uric acid concentration increases
What are the symptoms of gout?
The most typical symptom in gout is severe pain in the joints. They initially occur in attacks. If gout remains untreated, the symptoms gradually worsen and gout becomes chronic.
When which symptoms become noticeable depends on the stage of the disease.
Gout symptoms in stage I: hyperuricemia
The first clinical signs of gout are then kidney gravel (smallest kidney stones) and kidney stones, which are not yet associated with noticeable symptoms at this stage.
Gout symptoms in stage II: Acute gout
If the uric acid level exceeds a certain value, an acute gout attack occurs. Symptoms include severe pain in individual joints.
If left untreated, a gout attack lasts from a few hours to a few days. After that, the symptoms slowly subside.
In more severe cases, additional symptoms of inflammation occur. The affected joints are then reddened, swollen and warmer than usual. They are also usually extremely sensitive to touch. The skin over the joint often itches or peels.
Other possible symptoms in stage II:
- Fever
- Headache
- Palpitations
- Nausea and vomiting
- Feeling of weakness and reduced performance
With repeated attacks of gout, the mobility of the affected joints increasingly decreases. Walking and reaching become increasingly difficult for those affected.
Gout symptoms in stage III: Intercritical phase
Gout symptoms in stage IV: Chronic gout
If gout progresses, symptoms such as pain and limited mobility occur between attacks: Gout becomes chronic.
Joint gout: The joints are permanently red and swollen and hurt even at rest. Eventually, joint changes occur, deforming the joint and limiting its mobility.
Soft tissue gout: The uric acid crystals are also deposited in other body tissues. Under the skin, for example on the cartilage of the ear or above the affected joints, small hard tissue nodules with white spots sometimes form, known as articulophi. Soft tissue gout particularly frequently affects fingers and feet. The internal organs are also affected, especially the kidneys.
Kidney gout: Uric acid crystals also collect in the kidneys. They initially form tiny stones called kidney gravel. If this clumps together, larger kidney stones form. These can severely impair kidney function. If larger kidney stones block the drainage system of the kidney (renal pelvis and ureter), the urine backs up into the kidney.
In 40 percent of cases, the kidney is even affected by gout before the first attack occurs.
How can gout be treated?
If a gout attack occurs or if symptoms have been present for some time, the family doctor is usually the first point of contact. He usually makes the diagnosis and takes care of the therapy. If complications arise or the therapy does not work, your family doctor will probably refer you to a gout specialist. These are usually internists (specialists in internal medicine) or rheumatologists, who take care of the often damaged joints, muscles and tendons, especially in chronic gout.
Gout treatment is primarily concerned with reducing the excess of uric acid in the blood to a healthy level. Therapy is basically always necessary for gout, as it does not go away on its own. However, after an initial attack of gout, it is not mandatory to treat with medication. In addition to the standard therapies, there are a number of other things that can help against gout or alleviate the symptoms.
Become active against gout yourself
Changing the diet for gout
Those affected have a number of ways to help lower uric acid levels themselves. A change in diet plays a decisive role in this:
Purine-rich foods only in small portions: Purines are present in varying amounts in some foods. Purine-rich foods include meat (especially offal), sausage, seafood and certain types of fish. Therefore, lavish eating sometimes results in an acute gout attack if you have a predisposition to gout. It is recommended to consume these foods in smaller quantities.
As little alcohol as possible: Excessive alcohol consumption is particularly problematic in gout. The kidneys excrete its breakdown products. In the process, they compete with uric acid. In this way, alcohol slows down the breakdown of uric acid and causes its levels to rise. In the worst case, even small amounts of alcohol can provoke a gout attack in people at risk. Beer is particularly critical. In addition to alcohol, it also contains a lot of purine.
Save fat: Too much fat also inhibits the excretion of uric acid. Experts therefore recommend eating as little high-fat food as possible – do not cover more than 30 percent of your daily calorie intake with fat. However, this limit is quickly reached, because fat has the highest energy density of all nutrients.
Pay particular attention to hidden dietary fats, for example in sausages or convenience foods.
If you would like to know in more detail how best to eat for gout, read the text Gout – Nutrition.
Other tips against gout
Reduce excess weight: If your body mass index is over 25, doctors recommend that you lose weight. If you weigh less, your uric acid level will automatically drop. But be careful: Lose weight slowly and in a controlled manner. Rigorous fasting carries the risk of triggering an acute attack of gout!
Move, but do not overdo it: Exercise has a positive effect on gouty joints. The function improves and inflammation symptoms subside more quickly. However, do not overexert yourself – excessive exercise produces more lactic acid, which slows down the breakdown of uric acid via the kidneys. Regular walks, on the other hand, are recommended.
Medication for uric acid reduction
Gout cannot be cured with medication. As soon as you stop taking the drugs, their effect on uric acid levels is lost and they rise again.
Doctors therefore recommend taking uric acid reducers in the following cases, for example:
- In the case of uric acid levels above nine milligrams per deciliter of blood serum
- In the case of a family history of gout and elevated uric acid levels
- In the presence of joint gout
- In the presence of kidney stones
- In chronic gout
There are two categories of medications for treating high uric acid levels: Either they promote uric acid excretion or they inhibit its production.
Uricosurics – increased uric acid excretion
Uricosurics cause the body to excrete more uric acid. Benzbromarone, for example, belongs to this group. Gout treatment with uricosurics begins in small doses, since larger doses carry the risk of a gout attack. It is important that patients drink more than two liters per day.
Uricostats – reduced uric acid formation
Uricostats contain the active ingredient allopurinol. It inhibits an enzyme that is necessary for the last step of uric acid formation. As a result, there is an increased amount of uric acid precursors in the blood. However, these are more soluble in water, which means that the body excretes them more easily than the uric acid itself. Treatment with uricostatics even dissolves deposits of uric acid crystals that have already formed. So-called gout tophi and kidney stones thus regress in the ideal case.
What to do in case of an acute gout attack?
Medications for long-term gout therapy are unsuitable for an acute gout attack. The main thing here is to relieve symptoms such as pain as quickly as possible. Anti-inflammatory painkillers offer particularly effective help for gout.
Cortisone therapy: If NSAIDs are not sufficient, doctors use glucocorticoids containing cortisol, for example prednisolone. If larger joints such as the knee are affected by gout, the doctor sometimes injects the cortisone directly into the joint. For smaller joints, cortisone is given in tablet form. However, you must not take the cortisone preparations for more than a few days.
If kidney function is impaired, the doctor usually treats with cortisone immediately. Gout attack therapy with non-steroidal anti-inflammatory drugs is then not possible.
Colchicine: In the past, gout was often treated with colchicine. Today, doctors rarely prescribe it because of its side effects, such as diarrhea, nausea, and vomiting. It should not be taken during pregnancy. It is also unsuitable for men who want to father a child in the near future.
No self-treatment with painkillers!
Ointments containing diclofenac as an active ingredient, for example, are generally safe and can be used as an adjunct to local application for painful joints. But here, too, it is advisable to consult the attending physician before use.
Therapy even when there are no symptoms
In order to avoid secondary diseases, consistent treatment of gout is crucial. The German Society for Rheumatology recommends uric acid-lowering therapy over at least five years. If tophi have already formed, treatment is indicated for another five years after their resolution.
Surgery for gout
If individual joints are already severely damaged by gout, there is the option of replacing them with artificial joints. Such an operation is performed as an inpatient. After the operation, a stay of several days in the hospital is necessary.
This is followed by movement and occupational therapy so that the affected person can learn to deal with the new joint. A new joint sometimes causes severe pain at the beginning. As a rule, however, this operation is ultimately less painful than continuing to live with the broken joint.
Physical gout treatment
Physical gout therapy aims to reduce existing symptoms and decrease pain. It is also designed to prevent joint damage and misalignment in cases of prolonged gout.
- Heat and cold treatments, as well as ultrasound and electrotherapy, help reduce gout pain in the joints.
- Muscle relaxation procedures reduce pain.
- Physical therapy strengthens muscles, relieving pressure on joints.
- Physiotherapy and occupational therapy prevent or correct restricted movement and misalignments of the joints.
Homeopathy for gout
Many sufferers swear by homeopathic remedies when asked “What helps against gout?”. However, the effectiveness of homeopathic medicines has not yet been proven. For those who are convinced of them, they are an option to accompany therapy. A change of life-style, or if necessary, orthodox medicines are nevertheless recommended as main components of a gout therapy. Homeopathic gout remedies are:
- Bryonia: Recommended especially for acute pain and for general relaxation of the state of mind.
- Ledum: Supplementary for successful, pain-relieving cold applications
- Lycopodium: For acute pain and a restless general condition
- Belladonna: Against severe pain and fever
The concept of homeopathy and its specific efficacy are controversial and not clearly supported by studies.
Home remedies for gout
In the event of a gout attack, the following home remedies are considered a useful adjunct to gout therapy:
- Rest joints: Immobilize the affected joint. Do not put any weight on it again until you no longer have any complaints. Bed rest may be necessary.
- Cool joints: Cooling compresses relieve pain in the joints. A towel soaked in cold water is sufficient for this. Alternatively, quark compresses are also suitable. Curd keeps the cold longer than a wet towel. Cool packs are too cold and quickly cause skin damage. Do not cool for more than ten minutes at a time, but several times a day.
- Drinking tea: Drinking tea is good against gout. It flushes the uric acid out of the body. Experts often recommend special teas, such as those made from flaxseed, birch leaves or as an infusion with a clove of garlic. However, the basis of the effect of tea is that it is diuretic.
Home remedies have their limits. If the symptoms persist for a long time, do not improve or even get worse, you should always consult a doctor.
How can gout be detected?
If gout is suspected, the family doctor or a doctor of internal medicine, i.e. an internist, are the right people to contact. In an anamnesis interview, he or she will record your medical history and ask you about your symptoms. He will ask you various questions, such as:
- Have you had similar complaints in the past?
- Do you have relatives with similar complaints?
- What is your diet like?
- Do you drink alcohol?
- Do the complaints occur permanently or intermittently?
Physical examination
With movement tests, the doctor determines whether there are already movement restrictions of the joints.
Determination of blood values
Uric acid level: Among other things, an elevated uric acid level can be determined with a blood test. In men, hyperuricemia exists at levels above seven milligrams per 100 milliliters of blood serum and in women at levels above six milligrams per 100 milliliters.
After an acute attack of gout, the concentration of uric acid drops back to normal. Therefore, gout cannot be ruled out with certainty even if the values are normal.
Inflammatory markers in the blood: Certain inflammatory markers in the blood provide further evidence of gout. These include:
- Elevated C-reactive protein (CRP) levels.
- Increased white blood cell (leukocyte) count
- Increased blood cell sedimentation rate (ESR)
To confirm the diagnosis of gout, the doctor also examines a sample of the synovial fluid. If uric acid crystals can be detected here, it is very likely to be gout.
X-ray and ultrasound examinations
An X-ray examination with contrast media is suitable for a closer look at the kidneys and helps to clarify whether the kidney tissue has been damaged by the disease.
Kidney function test
A kidney function test can determine whether and to what extent the performance of the kidneys is impaired.
What is the course of the disease in gout?
An acute attack of gout usually occurs at night or in the early hours of the morning and sometimes lasts from a few days to two weeks. Then the symptoms slowly subside again. The duration of a gout attack can be significantly shortened by rapid, targeted treatment. After a gout attack, some time (even months to years) sometimes passes before the next gout attack occurs. The duration of gout attacks as well as the time periods in between vary individually.
In chronic gout, which is relatively rare today, the symptoms persist permanently. In any case, this requires continuous treatment.
The predisposition to elevated uric acid levels is usually congenital and therefore cannot be cured. However, consistent therapy can often reduce the uric acid level in the long term. This does not eliminate the risk of an acute attack of gout, but it does significantly reduce it.
The course of the disease and prognosis depend very much on how pronounced the predisposition to high uric acid levels is and how consistently a patient takes his uric acid-lowering medication, for example, or how well he implements a uric acid-lowering lifestyle.
Permanent joint changes
Once damage to the joints has occurred, it does not regress, depending on its severity. In severe cases, the joints sometimes become deformed, causing permanent pain or loss of mobility. In such cases, it is important to consult a specialist, such as an orthopedist, at an early stage. Additional orthopedic therapies may be necessary.
Further information
Books
Edeltraut Hund-Wissner: Delicious food for gout: over 130 recipes: low uric acid levels at last. Trias, October 21, 2015
Guidelines
DEGAM guideline: long version to the S2e guideline Gout: Frequent Gout Attacks and Chronic Gout of the German Society of General and Family Medicine (DEGAM), 03/2019: http://www.awmf.org/leitlinien/detail/ll/053-032a.html
Association
German Gout League e.V.: http://www.gichtliga.de/
