1 Overview of Gout

What is gout?

Gout, also known as gout, is a disease caused by a disorder of purine metabolism in the kidneys, causing the kidneys to be unable to filter uric acid from the blood. Uric acid is usually harmless and is formed in the body, then excreted through urine and feces. In people with gout, the amount of uric acid in the blood accumulates over time. When this concentration is too high, small crystals of uric acid are formed. These crystals gather in the joints and cause inflammation, swelling and pain for the patient.

Gout is characterized by recurrent acute arthritis attacks, the patient often has sudden pain in the middle of the night and red swelling of the joints when the acute inflammation flares up, especially the joints in the big toe, but can also affect other joints in the legs (such as knees, ankles, feet) and less commonly in the joints of the hands (hands, wrists, elbows), the spine can also be affected.

Is gout dangerous?

Although gout can cause stress, pain and insomnia, gout is a benign disease and can be controlled with medication and prevented by changing diet.

Based on the severity, gout is divided into 3 stages:

• Stage 1: uric acid levels in the blood have increased but gout symptoms have not yet appeared. Usually, the patient only notices the first symptoms of gout after having kidney stones.
• Stage 2: uric acid levels are now very high, leading to the formation of crystals appearing in the toes (tophi). Tophi often appear slowly, decades after the first gout attack but sometimes earlier. Once they appear, they easily increase in number and mass and can ulcerate. Tophi are often found on the cartilage of the ear rim, then on the elbow, big toe, heel, instep and Achilles tendon.

During this stage, the patient will feel joint pain but the pain will not last long. After a while, the patient will experience other symptoms of gout with increasing intensity and frequency.

• Stage 3: the symptoms of the disease will not disappear and uric acid crystals will attack many joints.

Most people with gout are only in stage 1 or 2, very few people have the disease progress to stage 3 because the symptoms of gout have been properly treated in stage 2.

2 Causes of Gout

The causes of gout include two main causes: primary (most cases) and secondary

Primary:

• 95% of cases occur in men, the common age is 30-60 years old.
• The cause is unknown.
• A diet containing foods high in purines such as liver, kidney, shrimp, crab, egg yolk, mushrooms, etc. is considered to aggravate the disease.

Secondary

Due to genetic disorders (genetic causes): rare.

Due to increased uric acid production or decreased uric acid excretion or both:

• Kidney failure and diseases that reduce uric acid clearance by the glomerulus
• Blood diseases: acute leukemia
• Using diuretics such as furosemide, thiazide, acetazolamide, etc.
• Using cell inhibitors to treat malignant diseases
• Using anti-tuberculosis drugs such as ethambutol, pyrazinamide, etc.

3 Symptoms of Gout

Gout symptoms often occur suddenly and at night. In some cases, gout has no initial signs. Gout symptoms often appear when the patient has had acute or chronic gout.

The main symptoms of the disease include:

• Sudden, severe joint pain, swelling
• Joint pain is worse when touched
• Red, swollen joints
• The area around the joint becomes warm

Most gout symptoms usually last for a few hours to 1–2 days. However, in severe cases, the pain can occur within a few weeks.

If the person with gout does not take gout medication regularly, the symptoms of the disease will be more severe.

• Tophi: This disease is characterized by the accumulation of crystals under the skin. Typically, these lumps will appear around the toes, knees, fingers and ears. If not treated properly, tophi will become larger and larger.
• Joint damage: if gout is not treated properly, the joints can be permanently damaged. This condition increases the risk of damage to bones and other joints.
• Kidney stones: if gout is not treated properly, uric acid crystals can not only accumulate around the joints but also in the kidneys, causing kidney stones.

4 Gout Risk Factors

Gout affects approximately 1 in 200 adults. It can affect anyone, regardless of age or gender. However, men aged 30–50 and postmenopausal women are more likely to develop the disease. It rarely occurs in young people and children.

Risk factors include:

• A diet high in protein and seafood
• Age and gender: the disease is more common in men and older people
• Drinking a lot of beer over a long period of time
• Obesity
• A family history of gout
• Recent trauma or surgery
• Excessive weight gain
• High blood pressure
• Abnormal kidney function
• Using certain medications that can cause uric acid to build up in the body such as: Aspirin, Diuretics, Chemotherapy drugs, Drugs that can weaken the immune system such as cyclosporine
• Having had diseases such as diabetes, impaired kidney function, heart disease, atherosclerosis, blood vessel blockage, infectious diseases, high blood pressure
• Dehydration

5 Preventing Gout

Living habits that help limit the progression of gout:

• Follow your doctor’s instructions, do not take medication without a prescription or stop taking prescribed medication.
• Re-examine on schedule to monitor the progression of the disease as well as your health status.
• Treat well the diseases that cause secondary gout such as kidney failure, metabolic diseases, …
• Exercise daily
• Maintain a reasonable weight

It is especially necessary to maintain a reasonable diet:

• Avoid eating organs, especially liver, sardines
• Avoid eating seafood and red meat
• Eat less saturated fat and products containing less fat
• Eat more foods rich in fiber such as cucumbers, cassava, tomatoes, …
• Replace refined sugar with natural sugar in vegetables and grains
• Drink plenty of water: drink 2.5-3 liters of water per day
• Reduce the use of alcoholic beverages, especially beer and wine
• Do not drink coffee, tea, carbonated drinks

6 Diagnostic measures for gout

Gout is often difficult to diagnose accurately because the symptoms are similar to other diseases.

Diagnostic measures applied include:

• Medical history
• Clinical examination
• Paraclinical tests:
• Blood test to measure uric acid concentration in the blood
• Joint fluid aspiration to find uric acid crystals
• Joint X-ray
• Joint ultrasound
• Joint CT scan
• Definitive diagnosis

One of the following criteria can be applied:

Bennet and Wood criteria (1968): sensitivity 70%, specificity 82.7%
Finding sodium urate crystals in joint fluid or in tophi.

Or at least 2 of the following:

• History or current at least 2 episodes of painful swelling of a joint with sudden onset, severe pain, and complete resolution within 2 weeks.
• History or current painful swelling of the metatarsophalangeal joint with sudden onset, severe pain, and complete resolution within 2 weeks.
• Presence of tophi
• Previous or current response to colchicine (reduced inflammation, pain within 48 hours).

ILAR and Omeract criteria (2000): sensitivity 70%, specificity 78.8%

Presence of urate crystals in synovial fluid, and/or:

• Characteristic urate crystals found in tophi by chemical or polarized light microscopy, and/or:
• Presence of 6 of the following 12 clinical, laboratory and radiographic features:
• Maximal inflammation within one day
• More than one attack of acute arthritis
• Arthritis in a single joint
• Redness of the joint
• Swelling, pain in the metatarsophalangeal joint I
• Unilateral metatarsophalangeal arthritis I
• Unilateral ankle arthritis
• Visible tophi
• Hyperuricemia (male ≥ 420 mmol/l, female ≥ 360 mmol/l)
• Asymmetric joint pain and swelling
• Subcortical cysts, no bone defect on radiographs
• Negative bacterial culture

7 Treatment measures for gout

Principles of gout treatment

• Treatment of arthritis in acute gout.
• Prevention of gout recurrence, prevention of urate deposition in tissues and prevention of complications through treatment of hyperuricemia syndrome with the goal of controlling blood uric acid below 360 mmol/l (60 mg/l) for gout without tophi and below 320 mmol/l (50 mg/l) for gout with tophi.

Specific treatment

Diet – lifestyle for people with gout:

• Avoid foods high in purines such as animal organs, meat, fish, shrimp, crab, … Can eat eggs, fruit. Eat no more than 150 grams of meat per day.
• Do not drink alcohol, need to lose weight, exercise regularly.
• Drink plenty of water, about 2-4 liters of water per day
• Avoid drugs that increase uric acid in the blood, avoid factors that trigger acute gout attacks such as stress, trauma, etc.

Medical treatment

• Anti-inflammatory drugs: used during acute gout attacks to reduce inflammation
• Uric acid-lowering drugs: used during the chronic phase to prevent recurrence of acute gout attacks

Surgical treatment

Tophi removal surgery is indicated in the following cases:

• Gout with ulcer complications
• Tophi infection
• Large tophi, affecting movement or for aesthetic reasons

During surgery, colchicine should be used to prevent acute gout attacks and combined with uric acid-lowering drugs.