tag:theconversation.com,2011:/us/topics/gout-29640/articlesgout – The Conversation2021-02-05T03:50:52Ztag:theconversation.com,2011:article/1517592021-02-05T03:50:52Z2021-02-05T03:50:52Z‘The disease of kings?’ 1 in 20 Australians get gout — here’s how to manage it<figure><img src="https://images.theconversation.com/files/375207/original/file-20201215-21-ygqadc.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C952%2C703&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">"The Gout", by James Gillray.</span> <span class="attribution"><span class="source">Wikimedia Commons</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>I awoke one morning late last year to find a bright red bauble at the foot of my bed. It wouldn’t have looked amiss adorning a Christmas tree. But it felt ready to explode. It was my big toe, and this was my first encounter with gout.</p>
<h2>In good company</h2>
<p>With <a href="https://pubmed.ncbi.nlm.nih.gov/29393108/">a history</a> spanning more than 4,500 years, gout is among our earliest recorded diseases. Hippocrates, traditionally regarded as the father of medicine, called it “<a href="https://arthritis-research.biomedcentral.com/articles/10.1186/ar1906">the unwalkable disease</a>”, because it was very painful for people with gout to walk.</p>
<p>Many famous historical figures <a href="https://goutandyou.com/gout-and-famous-people/">suffered with gout</a>, including Christopher Columbus, Henry VIII, <a href="https://en.wikisource.org/wiki/Dialogue_Between_Franklin_and_the_Gout#:%7E:text=No%2C%20not%20your%20enemy.,the%20one%20nor%20the%20other.">Benjamin Franklin</a> and Beethoven. It became known as “the disease of kings”.</p>
<p>This moniker also reflects the fact gout has historically been <a href="https://pubmed.ncbi.nlm.nih.gov/16820040/">associated with</a> indulging in rich food and excessive alcohol. Scientific evidence today suggests this may have something to do with it, though the common belief drinking <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1002/art.1780180704">port specifically causes gout</a> is unfounded.</p>
<p>Today, no longer just a disease of kings, the prevalence of gout is increasing <a href="https://www.nature.com/articles/nrrheum.2015.91">around the world</a>. Almost <a href="https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/gout/contents/what-is-gout">one in 20 Australians</a> have had at least one attack of gout.</p>
<p>And some <a href="https://pubmed.ncbi.nlm.nih.gov/21169857/">stigma</a> still clings to the condition. Often gout is seen as being self-inflicted, a mark of overindulgence. But living with gout has <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1756-185X.13979">far-reaching implications</a>, hampering a person’s ability to participate in everyday life.</p>
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Read more:
<a href="https://theconversation.com/got-gout-heres-what-to-eat-and-avoid-50239">Got gout? Here's what to eat and avoid</a>
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<h2>What is gout?</h2>
<p>Gout is <a href="https://pubmed.ncbi.nlm.nih.gov/29393108/">the most common form</a> of inflammatory arthritis. It’s caused by sodium urate crystals forming in the joints. While the big toe is particularly susceptible, gout can also affect the ankles, knees, elbows, wrists and fingers.</p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/25422986/">Urate</a>, or uric acid, is an end-product of the breakdown of biochemicals called purines, which are both components of your DNA and absorbed into the body through the foods you eat. Urate levels reflect how much is made in the liver and how much is flushed out when you go to the toilet. </p>
<p>If your urate levels become too high, the urate turns into crystals. When urate crystals form in the <a href="https://www.arthritis-health.com/types/joint-anatomy/how-do-synovial-joints-work">fluid</a> cushioning a joint, the body’s defence forces see them as foreign invaders. Inflammation and debilitating pain follow.</p>
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<img alt="A main, appearing in pain, clutches his inflamed foot." src="https://images.theconversation.com/files/382148/original/file-20210203-21-lbq8xf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/382148/original/file-20210203-21-lbq8xf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/382148/original/file-20210203-21-lbq8xf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/382148/original/file-20210203-21-lbq8xf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/382148/original/file-20210203-21-lbq8xf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/382148/original/file-20210203-21-lbq8xf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/382148/original/file-20210203-21-lbq8xf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Gout can be incredibly painful.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<h2>What causes gout?</h2>
<p>A high level of urate in the blood is the <a href="https://pubmed.ncbi.nlm.nih.gov/31558729/">greatest risk factor for gout</a>. But what causes high levels of urate? While we don’t know exactly, several factors certainly contribute.</p>
<p>A <a href="https://pubmed.ncbi.nlm.nih.gov/28844079/">tangled web</a> links urate, gout and other metabolic diseases, including type 2 diabetes and high blood pressure. <a href="https://pubmed.ncbi.nlm.nih.gov/33231639/">Being overweight</a> is a common factor. </p>
<p>Gout can run in families, with <a href="https://pubmed.ncbi.nlm.nih.gov/28566086/">genetics</a> playing a key role in determining urate levels. For example, genetic differences can impair <a href="https://pubmed.ncbi.nlm.nih.gov/32488095/">urate excretion</a>, thereby increasing blood urate levels.</p>
<p>Gout is also more common in males — almost 80% of people with gout are male. One reason for this is the female sex hormone oestrogen <a href="https://pubmed.ncbi.nlm.nih.gov/30415758/">lowers urate levels</a>, and is therefore protective against gout in pre-menopausal women.</p>
<p>And gout is more common <a href="https://pubmed.ncbi.nlm.nih.gov/32541923/">the older you get</a>. It affects 0.2% of Australian men in their 20s, increasing to <a href="https://pubmed.ncbi.nlm.nih.gov/26233513/">11% over the age of 85</a>.</p>
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Read more:
<a href="https://theconversation.com/arthritis-isnt-just-a-condition-affecting-older-people-it-likely-starts-much-earlier-67698">Arthritis isn't just a condition affecting older people, it likely starts much earlier</a>
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<h2>Management and prevention</h2>
<p>You should ice and raise the affected joint and minimise contact with it — even a light bedsheet can cause excruciating pain.</p>
<p>Attacks of gout can last for days or weeks. If you think you have gout, you should see your doctor. </p>
<p>Anti-inflammatory drugs can ease gout attacks. Your doctor might prescribe <a href="https://pubmed.ncbi.nlm.nih.gov/29359661/">colchicine</a>, or you can get <a href="https://www.healthdirect.gov.au/ibuprofen">ibuprofen</a> over the counter. </p>
<p>It’s <a href="https://pubmed.ncbi.nlm.nih.gov/32776706/">easy to stop exercising</a>, but <a href="https://www.healthgrades.com/right-care/gout/exercise-is-important-when-you-have-gout">swimming and cycling</a> are two ways you can comfortably continue moving during a gout flare.</p>
<p>Many people who have one gout attack will go on to have more. In one study, <a href="https://pubmed.ncbi.nlm.nih.gov/16267879/">70% of people</a> who had an attack of gout went on to have another within a year.</p>
<p>If you suffer two or more attacks, management of <a href="https://pubmed.ncbi.nlm.nih.gov/28549177/">chronic gout</a> involves taking a urate-lowering therapy such as <a href="https://rheumatology.org.au/patients/documents/Allopurinol_2016_002.pdf">allopurinol</a> or <a href="https://arthritisaustralia.com.au/medication-search/febuxostat/">febuxostat</a>.</p>
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<img alt="Two hands clinking beers." src="https://images.theconversation.com/files/382640/original/file-20210204-18-v168bl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/382640/original/file-20210204-18-v168bl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/382640/original/file-20210204-18-v168bl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/382640/original/file-20210204-18-v168bl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/382640/original/file-20210204-18-v168bl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/382640/original/file-20210204-18-v168bl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/382640/original/file-20210204-18-v168bl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Beer is often singled out as it’s relatively purine-rich. But it’s a good idea to cut back on all types of alcohol.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>If you’ve had gout once and want to prevent it coming back, it’s worth thinking about <a href="https://pubmed.ncbi.nlm.nih.gov/23024028/">lifestyle changes</a>. As with <a href="https://theconversation.com/losing-weight-is-hard-but-its-not-any-harder-if-you-have-type-2-diabetes-86773">other metabolic diseases</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/31468681/">losing weight</a> helps.</p>
<p>You might also consider minimising consumption of <a href="https://www.jstage.jst.go.jp/article/bpb/37/5/37_b13-00967/_pdf/-char/en">purine-rich foods</a>, which include meat, seafood and yeast products, like Vegemite.</p>
<p>But as with any diet, sticking to a low-purine diet can be challenging. Evidence for particular <a href="https://theconversation.com/got-gout-heres-what-to-eat-and-avoid-50239">foods to favour or avoid for gout</a> is <a href="https://pubmed.ncbi.nlm.nih.gov/30213692/">weak</a>, and overall, <a href="https://pubmed.ncbi.nlm.nih.gov/30305269/">diet contributes very little</a> to variation in urate levels. </p>
<p>So rather than purely focusing on purine-rich foods, <a href="https://pubmed.ncbi.nlm.nih.gov/33082244/">consuming less in total</a> can better control urate levels while improving your overall health. Limiting <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3991555/">alcohol</a> is also a good idea.</p>
<h2>Epilogue</h2>
<p>With a red bauble stuck on the end of your foot, you learn to appreciate how important your big toe is for mobility.</p>
<p>Eventually, I managed to drop my <a href="https://pubmed.ncbi.nlm.nih.gov/32835125/">COVID kilos</a>, by watching portion sizes, not going back for seconds, replacing unhealthy snacks with fruit, and cutting back on alcohol.</p>
<p>And with that, I’m hoping my first encounter with gout might be my last. Although keeping off the kilos will require constant vigilance, the memory of that painful red bauble should be a powerful motivator.</p>
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Read more:
<a href="https://theconversation.com/not-feeling-motivated-to-tackle-those-sneaky-covid-kilos-try-these-4-healthy-eating-tips-instead-152316">Not feeling motivated to tackle those sneaky COVID kilos? Try these 4 healthy eating tips instead</a>
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<img src="https://counter.theconversation.com/content/151759/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>If you’ve ever had a bout of gout, you’ll know it’s truly awful. Here’s what causes it, and what you can do about it.Andrew Brown, Professor, School of Biotechnology and Biomolecular Sciences, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/676982017-01-25T19:53:56Z2017-01-25T19:53:56ZArthritis isn’t just a condition affecting older people, it likely starts much earlier<figure><img src="https://images.theconversation.com/files/149195/original/image-20161208-31405-1d8emw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">No-one wakes up at 65 with arthritis. It's a condition that starts earlier in life and perhaps goes unnoticed until it worsens later in life. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p><em>This article is part of our series on <a href="https://theconversation.com/au/topics/older-peoples-health-33308">older people’s health</a>. It looks at the changes and processes that occur in our body as we age, the conditions we’re more likely to suffer from and what we can do to prevent them.</em></p>
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<p>Arthritis is an umbrella term for over 100 conditions affecting the joints. All result in pain and often severely limit the activities a person can do. There are many different types of arthritis, each with a different cause.</p>
<p>Arthritis is a major cause of disability in Australia and world-wide. It also presents a significant cost to the community. In Australia, arthritis <a href="http://www.move.org.au/Research/PDFs/PLS/APWS-PLS.aspx">costs $55.8 billion per year</a>. </p>
<p>Most people think of arthritis as a disease of the elderly. While this is where it’s most commonly seen, it’s not where it starts. No-one wakes up with arthritis at 65. The different types of arthritis have different causes, but most of these start much earlier in life with mild symptoms that often go unnoticed. It’s usually only as the condition worsens over time that symptoms are noticed, and this is usually in older age.</p>
<p>Two of the most common types of arthritis are osteoarthritis and gout.</p>
<h2>Osteoarthritis</h2>
<p>Osteoarthritis is common as people age, and most frequently affects the hands, neck, back, knees and hips. Many people get osteoarthritis due to a familial tendency to develop it. Clearly we can’t change this.</p>
<p>We describe osteoarthritis as a disease of ageing, but it often begins many decades before a person has joint problems. In the past it was thought osteoarthritis was due to “wear and tear” of the joints and was thus inevitable. We now know this is not the case and there are a number of causes of osteoarthritis, with obesity being one of the most common contributing factors.</p>
<p>Osteoarthritis is more common in women than men, and is exacerbated by age. Over the age of 60 years, <a href="http://www.aihw.gov.au/osteoarthritis/who-gets-osteoarthritis/">more than 30% of people</a> have osteoarthritis.</p>
<p>It was previously thought that obesity affects joints because of the extra load the person carries, but this wouldn’t explain osteoarthritis in the hands. We now know obesity also causes inflammation in the joints as well as the extra loading. Obesity affects joints across all of the life span, so damage is already present in middle age, but becomes worse over time.</p>
<p>Hormones and injuries to joints also play a part in osteoarthritis. Many women develop hand osteoarthritis at menopause.</p>
<p>Maintaining a healthy weight, avoiding injuries to joints and regular exercise in order to strengthen muscles around the joints, are all important for the prevention of osteoarthritis. </p>
<p>Muscle strengthening exercises are very effective for reducing pain in osteoarthritis. Anti-inflammatory creams <a href="https://www.oarsi.org/sites/default/files/docs/2014/non_surgical_treatment_of_knee_oa_march_2014.pdf">have been shown to improve joint pain</a>. Medications such as paracetamol and anti-inflammatory tablets should only be used in the short term, and with advice from a doctor.</p>
<h2>Gout</h2>
<p>Gout is a very different type of arthritis. It results from a build-up of uric acid in the body. Uric acid is normally produced in the body, but some people don’t process uric acid effectively, so it builds up. Under some circumstances, such as changes in the diet, medications such as diuretics or excess intake of alcohol, this build-up can be <a href="http://www.move.org.au/Conditions-and-Symptoms/Gout">deposited in the joints</a>. This causes arthritis, experienced as a very painful, swollen joint.</p>
<p>Gout is more common in men than women, although women catch up after menopause. As with osteoarthritis, it tends to run in families. Gout becomes more common as we age because uric acid is able to accumulate with time. This is mainly because the kidneys cannot eliminate it as well as they used to, often as a result of other conditions such as diabetes or high blood pressure that over years may effect the kidneys. Some commonly used medications such as diuretics (or “water tablets”) can make this worse.</p>
<p>Diet is important for preventing gout. Alcohol needs to be taken in moderation, especially beer, both to prevent development of gout and to reduce the number of episodes. There are some types of food such as offal (liver, kidney) and shell fish that may result in an increased production of uric acid in the body and precipitate gout. One new risk factor for gout is a high intake of fructose, a sweetener commonly used in many soft drinks. Obesity can also make gout worse, so needs to be prevented as part of gout treatment.</p>
<p>Many people will also need medications to keep their gout in check. Gout can readily be treated with medications such as anti-inflammatories or colchicine. If gout occurs repeatedly, medication can also be prescribed to prevent this.</p>
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<p><em>Read other articles in the series <a href="https://theconversation.com/au/topics/older-peoples-health-33308">here</a>.</em></p><img src="https://counter.theconversation.com/content/67698/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Flavia Cicuttini receives funding from NHMRC, MOVE Australia, Australian Arthritis Foundation, Monash University, The Alfred Foundation, Medibank Health Research Fund
Member of the RMA
</span></em></p>Most people think of arthritis as a disease of the elderly. While this is where it’s most commonly seen, it’s not where it starts.Flavia Cicuttini, Head, Musculoskeletal Unit DEPM, and Head Rheumatology Unit, Alfred Hospital, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/630302016-07-26T20:52:34Z2016-07-26T20:52:34ZMyths about gout are hampering its treatment<figure><img src="https://images.theconversation.com/files/131986/original/image-20160726-7037-rg1g6z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The prevalence of gout is increasing worldwide. It has become the most common cause of inflammatory arthritis in men, and its prevalence in postmenopausal women continues to rise. This increase is due to changes in diet and lifestyle, increased use of certain diuretics and increasing obesity.</p>
<p>Developed countries have a higher burden of gout than developing countries. But in the developing world – and particularly in Africa – where countries have experienced a rapid epidemiological transition and increases in non-communicable chronic diseases such as obesity, there is an increasing risk.</p>
<p>Gout is a form of <a href="http://www.niams.nih.gov/health_info/gout/gout_ff.asp">arthritis</a> that happens when too little uric acid is excreted from the body and then forms crystals in and around joints in the body. Uric acid forms when proteins called purines break down in the body. Although essential for a normal metabolism, excess uric acid is excreted from the body mainly via the kidneys into urine. </p>
<p>Many patients with gout struggle to control the disease. The crystals cause acute attacks of pain, heat, redness and swelling in these joints, which can be painful and debilitating. Over time, chronic gout occurs when lumps or “tophi” develop on the elbows, earlobes, fingers, knees, ankles and toes. Eventually the joints become deformed.</p>
<p>But both gout and tophi can disappear if they are properly treated. Many doctors and patients are, however, unsure of the best treatment. This results in poor patient education, patients taking treatment “on and off” rather than daily as prescribed, doctors using the wrong medicine, or at the wrong dosage (frequently too little) and perhaps not being aware of interactions between drugs, and poorly addressed lifestyle factors.</p>
<h2>Myths and facts about gout</h2>
<p>There are several incorrect common beliefs about gout.</p>
<p>One of the most popular is that gout only affects the big toe. But this is not true. The first gout attack usually occurs in the lower limb (knee, ankle or big toe), but later almost any joint can be affected.</p>
<p>It is also often reported that the underlying problem for most gout sufferers is that their bodies produce too much uric acid. But this is not true. More than 90% of gout sufferers get rid of too little uric acid in their kidneys. This poor renal secretion of uric acid can be the result of kidney problems, high blood pressure, excess alcohol consumption or medication – for example diuretics (water reduction tablets) or drugs used to treat TB infection. In addition, certain genes result in too little uric acid being secreted from the body, and thus increase the risk of gout.</p>
<p>Another common belief is that acidic foods cause gout. But acidic foods such as tomatoes and oranges cannot cause or worsen gout. </p>
<p>Rather, foods high in purines can increase the risk of gout, particularly in someone who is secreting too little uric acid. Some foods have a very high purine content. These include seafoods such as mussels, lobster, sardines and salmon, as well as beer, bacon, liver, sweetbreads, turkey, veal, and high fructose corn syrup. High fructose corn syrup is often found in processed foods such as soft drinks, chips and biscuits, syrups, chutneys and sauces.</p>
<p>There are certain foods that are protective of gout. These include coffee, low-fat dairy products and particularly yoghurt, high doses of vitamin C, cherry or lemon juice, soya and lentils.</p>
<p>Although any type of alcohol inhibits uric acid secretion and should be avoided in patients with gout, beer is a “double hit” because it is rich in guanosine, which adds to the body’s purine load. </p>
<h2>The best treatment</h2>
<p>Patients with gout often have other illnesses. Elevated uric acid and gout are frequently associated with the metabolic syndrome – a cluster of diseases consisting of diabetes, high blood pressure, high cholesterol and obesity, leading to heart attacks and kidney failure. </p>
<p>But that does not mean that everyone with a raised blood-uric acid level needs treatment for gout. Many people with high uric acid levels never develop gout. Even patients who have one attack of gout may not need treatment to reduce the uric acid levels. They should consider a lifestyle change, such as altering their diet, losing weight and drinking more water.</p>
<p>The “gold standard” to diagnose an acute attack of gout is to remove some fluid from the joint with a needle and syringe, and examine this under a microscope for uric acid crystals. If this cannot be done, certain typical symptoms and signs seen together are highly suggestive of gout, and a diagnosis can be made. Joint ultrasound or dual energy CT scan images show gout very well.</p>
<p>Non-steroidal anti-inflammatories are the best treatment for an acute gout attack unless the person has kidney problems or stomach ulcers. Patients who cannot use these anti-inflammatories require corticosteroids, either injected into the joint or taken as tablets (otherwise known as prednisone). </p>
<p>A patient with numerous acute attacks, or tophi, requires drugs called allopurinol that lower the uric acid level in the body. But these prevent attacks of gout rather than treating an attack. </p>
<p>In the first six months of using allopurinol, gout attacks can occur more frequently. Understanding this, and having anti-inflammatories on hand, is important. </p>
<p>It is important that patients do not stop or alter the dosage of medication as it may result in the uric acid level returning to its initial level. They may get “stuck” in this cycle of stop-and-start treatment and the gout will steadily get worse. But with consistent use over time, once the uric acid level drops, acute attacks will stop and tophi will be disappear. This may takes months or years in a patient with many tophi.</p><img src="https://counter.theconversation.com/content/63030/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bridget Hodkinson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Doctors and patients are unsure of the best treatment for gout, leading to poor patient education and compliance, poorly addressed lifestyle factors, and suboptimal use of available drugs.Bridget Hodkinson, Rheumatologist, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.