gout

and Christiane Fux, medical editor

Sophie Matzik is a freelance writer for the medical team.

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Christiane Fux studied journalism and psychology in Hamburg. The experienced medical editor has been writing magazine articles, news and factual texts on all conceivable health topics since 2001. In addition to her work for, Christiane Fux is also active in prose. Her first crime novel was published in 2012, and she also writes, designs and publishes her own crime plays.

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Gout is a metabolic disorder that mainly causes painful inflammation in the joints. The cause is too much uric acid in the blood, which is deposited in crystal form in the synovium. However, the uric acid level can be controlled through a consistent change in diet and other lifestyle factors. Read here what else you can do if you suffer from gout and find out all about gout.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. M10

Gout: quick reference

Causes: Mostly hereditary, sometimes acquired predisposition to elevated uric acid levels. When combined with an unfavorable lifestyle, gout attacks occur.
Diet: Reduce purine-rich foods (meat, offal, certain types of fish), severely restrict fructose-rich drinks, alcohol, especially beer
Typical symptoms: painful, sometimes swollen, reddened joints. The big toe is particularly often affected in gout. Later also movement restrictions deformations.
Diagnostics: increased uric acid level, in later stages joint damage, kidney damage
Therapy: lifestyle changes, uric acid lowering drugs, physiotherapy, removal of nodular uric acid deposits, correction of deformed joints

This is how gout develops

In gout, the level of uric acid in the blood is too high. Either because too much of it is being produced or because the kidneys are not getting enough of it. Tiny uric acid crystals form, which are particularly deposited in the joints. If the values are particularly high, there is a risk of an acute attack of gout with pain, redness and swelling.

Uric acid is produced when purines are broken down. Purines are breakdown products that form when the body breaks down diseased cells. But they are also ingested with food, especially meat and offal, but also some types of vegetables.

Uric acid as a trigger

Uric acid is produced by the breakdown of purines. These are either absorbed through purine-rich foods or arise from the breakdown of diseased cells.

Primary gout - congenital disorder

Most gout patients suffer from a congenital metabolic disorder. Doctors then speak of "primary hyperuricemia" or "primary gout". In most cases, the kidneys do not excrete enough uric acid.

In rare cases, the body produces so much uric acid that the kidneys are overwhelmed. The cause is a genetic defect, the so-called Lesch-Nyhan syndrome. It occurs predominantly in boys.

Secondary gout-acquired disorder

In what is known as secondary gout, other diseases cause the excess uric acid. In leukemia, for example, the body's own cells perish en masse. This releases large amounts of purines that accumulate in the blood.

Other diseases that cause an increased production of uric acid,

are

some tumor diseases
Anemia
certain drugs (cytostatics)
Radiation as part of cancer therapy

Conversely, the uric acid level also rises if not enough uric acid is excreted. This is in kidney, humans cannot synthesize n-3 and n-6 fatty acids de novo, and therefore food intake affects their abundance in blood and tissues; Upper middle panel: circulating blood contains pools of n-3 and n-6 fatty acids, including red blood cells, which act as proxies for tissue fatty acids, and immune cells, which can infiltrate inflamed tissue and are direct precursors to nociceptive oxylipins found on nerve endings works; Upper right panel: n-3 illnesses the case or with untreated or inadequately controlled diabetes.kalo

Affluence disease gout

Gout is considered a disease of affluence. It is more common in industrialized countries than in poorer countries. The factors that favor gout include obesity, a diet high in meat, fructose and alcohol, and a sedentary lifestyle.

Trigger for an acute gout attack

An acute gout attack occurs when the uric acid level exceeds a certain level. The main triggers are:

excessive consumption of foods rich in purine, such as meat and offal.
excessive consumption of foods rich in fructose, such as sweetened fruit juices.
Too much alcohol: Alcohol also increases uric acid levels. This is especially true for beer, which is also particularly rich in purine
strict diets: In order to gain energy, the body breaks down muscles on strict diets. Plenty of purines are released in the process.
Physical overexertion: This creates lactic acid in the body, which is excreted by the kidneys and thus blocks the breakdown of uric acid.
diuretics or laxatives: they thicken the blood with excessive or very long use. This increases the uric acid concentration.

How long does a gout attack last?

A gout attack can last for days and even weeks. Then the symptoms slowly subside. However, the duration of the gout attack can be significantly shortened through quick, targeted treatment.

Gout: treatment

Gout treatment is designed to reduce excess uric acid in the blood to healthy levels. Doctors recommend 5.5 to 6.4 milligrams per 100 milliliters of blood as the upper limit.

Gout: "Have your uric acid level tested!"

Three questions for

Prof. Dr. med. Christoph Bamberger,
Internist and endocrinologist
1
Gout or osteoarthritis - how does the patient notice the difference?

Prof. Dr. med. Christoph Bamberger
That's not that easy. Gout typically affects the smaller joints, usually the toes. Osteoarthritis often affects the hips, knees, or the joints between the vertebral bodies. With gout, the pain occurs, but then disappears for a long time. With osteoarthritis, on the other hand, the pain is predictable, i.e. it occurs daily at certain times or with certain movements.
2
What is the best way to prevent an attack?

Prof. Dr. med. Christoph Bamberger
Avoid the typical triggers: hearty meat meals, offal, full plates with shrimp. In addition, large amounts of alcohol can typically trigger a gout attack. Most of the time, these gout triggers are even enjoyed together. Also, drink plenty of water to flush out the uric acid.
3
Do you have to take medication for life with gout?

Prof. Dr. med. Christoph Bamberger
Those who adapt their lifestyle and thus can keep their uric acid level below 7 mg / dl have hardly any gout problems. Those who fail to do this, or who have a high level due to genetic reasons, have to take medication. But they are very well tolerated. In general, everyone should keep an eye on their uric acid levels. Too much uric acid damages the organs long before gout symptoms appear.
Prof. Dr. med. Christoph Bamberger,
Internist and endocrinologist
In 2006, the hormone expert founded the Medical Prevention Center Hamburg (MPCH), now Conradia Medical Prevention, of which he is the director to this day.

Gout: what you can do by yourself

A lot can be achieved by changing your lifestyle, especially by adopting an appropriate diet. If this is not sufficient for gout therapy, medication can also lower the uric acid level.

Diet for gout

Those affected can do a lot to lower the uric acid level themselves. The change in diet plays a decisive role in this:

Purine-rich foods only in small portions: Purines are found in the genome of all living cells, among other things. When it is broken down, uric acid is produced. This applies to your own overaged cells as well as to food. Foods rich in purine include meat (especially offal), sausage, seafood, and certain types of fish. If you are predisposed to gout, overeating can lead to an acute attack of gout.

As little alcohol as possible: Excessive alcohol consumption is particularly problematic in gout. Its breakdown products are excreted through the kidneys and compete with uric acid. Alcohol slows down the breakdown of uric acid and increases its level. Even if you only consume alcohol once more, it can provoke a gout attack. Beer is particularly critical. In addition to alcohol, it also contains a lot of purine.

Be careful with fructose: fructose is not only found in fruits. It is also used to sweeten juices, yoghurts and other foods. The breakdown of fructose in the body increases the production of purines. At the same time, like alcohol, sugar inhibits the excretion of uric acid through the kidneys.

Save fat: Too much fat also inhibits the excretion of uric acid. Gout patients should therefore eat as few fatty foods as possible. If possible, you should not cover more than 30 percent of your daily calorie intake with fat. This limit is reached quickly because fat has the highest energy density of all nutrients.

Pay particular attention to hidden food fats, for example in sausage products or finished products.

If you would like to know more about the best diet for gout, read the text Gout - Nutrition here.

What else you can do yourself

Reduce excess weight: If you have a body mass index of over 25, you should lose body weight. If you weigh less, your uric acid level will automatically decrease. But watch out: weight loss should be slow and controlled. Strict fasting can trigger an acute attack of gout!

Drink a lot: Nutritionists recommend drinking at least two liters a day, preferably mineral water or unsweetened tea. The fluid in the body helps to keep the uric acid concentration low and supports the kidney's filter function. In this way, uric acid is also flushed out and the uric acid level drops.

Move, but don't overdo it: Movement has a positive effect on the gout joints. The function improves and inflammation symptoms subside faster. However, you shouldn't overwork yourself with gout - the resulting lactic acid slows down the breakdown of uric acid via the kidneys.

However, gout cannot be cured with medication either. As soon as the drugs are stopped, their influence on the uric acid level is lost and it rises again.

The use of uric acid lowering drugs is recommended, for example, in the following cases:

uric acid levels over nine milligrams per deciliter of blood serum
with family history of gout and increased uric acid level
in joint gout
in the presence of kidney stones
in chronic gout

Uric acid reduction drugs

Uric acid can be reduced in two ways: Either by excreting more of it, or by reducing its production. Both classes of uric acid lowering drugs are usually prescribed at the beginning of gout treatment. For long-term gout treatment, active ingredients that block production are mainly used.

Uricosurics - increased uric acid excretion

Uricosurics cause more uric acid to be excreted. Benzbromaron, for example, belongs to this group. Gout treatment with Uricosurika begins in small doses, as larger doses could provoke a gout attack. It is important that the patient drink more than two liters per day.

Uricostatics - reduced uric acid formation

Uricostatics contain the active ingredient allopurinol. It inhibits an enzyme that is necessary for the last step in uric acid formation. As a result, the uric acid precursors are increasingly found in the blood. However, these are more soluble in water and are therefore more easily excreted than the uric acid itself. Treatment with uricostatic drugs can even dissolve existing deposits of uric acid crystals. So-called gouty tophi and kidney stones ideally regress.

What to do if you have a gout attack

Drugs for long-term gout therapy are unsuitable for an acute gout attack.The main aim here is to relieve symptoms such as pain as quickly as possible. Anti-inflammatory pain relievers are particularly effective in treating gout.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are the first drug of choice in acute gout treatment. They do not contain cortisone. Gout patients are primarily prescribed indomethacin and diclofenac. As a rule, the symptoms improve within a few hours.

Cortisone therapy: If NSAIDs are not enough, cortisol-containing glucocorticoids are used, for example prednisolone. If larger joints like the knee are affected by gout, the doctor can inject cortisone directly into them. For smaller joints, cortisone is given in tablet form. The cortisone preparations must not be taken for more than a few days.

If kidney function is impaired, cortisone is used immediately. Therapy for gout attacks with non-steroidal anti-inflammatory drugs is then not possible.

Colchicine: In the past, gout was often treated with colchicine. Today it is rarely prescribed because of its side effects such as diarrhea, nausea and vomiting. It should not be used during pregnancy. Men who want to father a child in the near future should also refrain from doing so.

No self-treatment with painkillers!

Self-treatment with over-the-counter pain relievers is risky. Acetylsalicylic acid, for example, can significantly increase uric acid levels. It can cause an acute attack even in a symptom-free gout patient. A gout treatment should never be done on your own, but always in consultation with a doctor.

Therapy also when there are no symptoms

In order to avoid secondary diseases, consistent therapy for gout is crucial. The German Society for Rheumatology recommends uric acid lowering therapy for at least five years. If tophi has already formed, treatment should continue for five years after it has dissolved.

Operations for gout

If individual joints are already severely damaged, there is the option of replacing them with artificial joints. Such an intervention is carried out on an inpatient basis. A stay of a few days in the hospital is necessary after the operation.

This is followed by movement and occupational therapy so that the patients learn to deal with the new joint. A new joint can cause severe pain at the beginning. As a rule, however, this procedure is less painful than continuing to live with the broken joint.

Gouty tophi can also be removed surgically. The small, nodular thickenings of the skin are mainly formed above the joints and on the ear cartilage. Although they are harmless, patients often perceive them as a cosmetic problem. Local anesthesia is all that is required for surgical removal. In individual cases, small scars can form in the areas where the tophi have been removed. As a rule, however, they can be completely removed.

Physical gout treatment

Physical gout therapy aims to lessen existing symptoms and reduce pain. In addition, it should prevent joint damage and misalignments in the case of long-standing gout.

Heat and cold treatments can reduce gout pain in the joints.
Muscle relaxation techniques reduce pain.
Physiotherapy strengthens the muscles and relieves the joints.
Through physiotherapy and occupational therapy, movement restrictions and misalignments of the joints can be prevented or corrected.

Gout: homeopathy

Many sufferers swear by homeopathic remedies when asked what helps against gout? However, the effectiveness of homeopathic medicines has not yet been proven. Anyone who is convinced of these can, however, use them in conjunction with the therapy. However, you should not do without a lifestyle change or, if necessary, conventional medicine. Homeopathic gout remedies are:

Bryonia: is especially recommended for acute pain and for general relaxation of the state of mind.
Colchicum: is used for nausea and general malaise.
Ledum: used when applying cold to relieve pain.
Lycopodium: is also used for acute pain and a restless general condition.
Belladonna: is said to be effective against severe pain and fever.

Gout: home remedies

In the event of a gout attack, the following home remedies can be a useful addition:

Protect the joints: Put the affected joint still. Do not strain it again until you have no more complaints. Bed rest may even be required.

Cool joints: In addition, pain in the affected joints can be relieved with cooling compresses. All you need is a towel soaked in cold water. Alternatively, you can cool sore joints with curd compresses. Quark keeps the cold longer than a wet towel.

Ice packets, on the other hand, are too cold and can quickly damage the skin. Cooling should not take longer than ten minutes at a time, but several times a day.

Warming the joints: Conversely, warmth can also relieve pain, for example by bathing in warm water. This relaxes muscles and joints and reduces pain. As a bath additive, hay flowers or chamomile flowers are recommended as home remedies for gout attacks.

Drink tea: Drinking tea is good for gout. It washes the uric acid out of the body. Special teas such as tea made from flax seeds, birch leaves or as an infusion with a clove of garlic are often recommended. However, the basis of the effect of tea is that it is diuretic.

Gout: symptoms

The most common symptoms of gout are severe pain in the joints. At first they appear like seizures. If gout is left untreated, the symptoms gradually worsen and the gout becomes chronic.

Gout symptoms by stage

Symptoms appear over the course of years or even decades. How they make themselves felt depends on the stage of the disease.

Stage I gout symptoms: hyperuricemia

In the first stage, only the uric acid level is increased. In a healthy person, it is three to six milligrams per 100 milliliters of blood serum. From a value of 6.5 milligrams per 100 milliliters of blood serum, doctors speak of hyperuricemia.

A slightly elevated uric acid level can last for several years without causing symptoms. The first signs of gout are kidney gravel, kidney stones or an acute attack of gout (stage II). The higher the uric acid level, the greater the risk of a gout attack.

Stage II gout symptoms: Acute gout

If the uric acid level exceeds a certain value, an acute attack of gout occurs. Symptoms are severe pain in individual joints.

Most commonly the metatarsophalangeal joint of the big toe is affected, as well as other joints in the legs and feet. Hands and arms are less common. If left untreated, a gout attack lasts a few hours to a few days. After that, the symptoms slowly subside.

Joints prone to gout

Uric acid crystals build up in the joints and cause the symptoms. The metatarsophalangeal joint of the big toe is particularly prone to gout. But the knee joint as well as shoulder and finger joints are often affected.

In more severe cases, additional symptoms of inflammation appear. The affected joints will then be red, swollen, and warmer than usual. In addition, they are usually extremely sensitive to touch. The skin over the joint may itch or peel. Doctors refer to this as uric arthritis.

Other possible symptoms in stage II:

fever
headache
Heart pounding
Nausea and vomiting
Feeling of weakness and restricted performance

The first attack of gout usually comes at night. If left untreated, the attack can last for days and up to two weeks. Then the gout symptoms slowly subside. Treated in good time, the duration of the gout attack can be shortened.

With repeated attacks of gout, the mobility of the affected joints becomes increasingly poor. It is more difficult for the patient to walk and grasp.

Stage III gout symptoms: intercritical phase

Doctors refer to the period between two gout attacks as the intercritical phase. If left untreated, the symptoms of gout will recur at irregular intervals. During the intercritical phase, the patients are initially symptom-free, but their uric acid level is still increased.

Stage IV Gout Symptoms: Chronic Gout

If the gout progresses, symptoms such as pain and restricted mobility also occur between the attacks: the gout becomes chronic.

Joint gout: With a chronic course, more and more uric acid crystals are deposited in the joints. They are then permanently red and swollen and painful even at rest. Eventually, joint changes occur that deform the joint and limit its range of motion. Such changes cannot be reversed with medication.

Soft tissue gout: The uric acid crystals are also deposited in other body tissues. Under the skin, for example on the ear cartilage, or above the affected joints, small, hard tissue nodules with white spots, so-called joint phi, sometimes form. Soft tissue gout is particularly common in the fingers and feet. The internal organs are also affected, especially the kidneys.

Kidney gout: uric acid crystals also collect in the kidneys. At first they form tiny stones, the so-called kidney gravel. If this clumps together, larger kidney stones develop. They can seriously affect kidney function. If they clog the drainage system of the kidney, the urine backs up in the kidney. The organ can then become inflamed and eventually fail. In 40 percent of cases with gout, the kidneys are impaired before the first attack occurs.

Gout: examinations and diagnosis

If you suspect gout, your family doctor or a doctor specializing in internal medicine, i.e. an internist, are the right people to contact. In an anamnesis interview, he records your medical history and asks you about your complaints. He will then ask various questions, such as:

Have you ever had similar complaints in the past?
Do you have relatives with similar complaints?
What is your diet like?
Do you drink alcohol?
Are the symptoms persistent or intermittent?

Physical examination

After taking the medical history, a physical exam will take place. The doctor feels the joints, the abdomen and the lower abdominal organs in order to localize tenderness or pain. Under certain circumstances, he may discover nodular tissue changes over the joints (so-called gout toophia), which are typical for gout.

With movement tests, the doctor can determine movement restrictions in the joints. In particular, an attack of gout in the foot must also be differentiated from other injuries such as sports injuries or ankle twisting.

Uric acid level

A blood test can, among other things, determine an increased uric acid level. In a healthy person, uric acid levels are between three and six milligrams per 100 milliliters of blood serum. From values of over 6.5 milligrams per 100 milliliters of blood serum one speaks of hyperuricemia.

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.

Markers of inflammation in the blood

Certain markers of inflammation in the blood provide additional evidence of gout. This includes

increased value of the C-reactive protein (CRP value)
increased number of white blood cells (leukocytes)
increased blood cell sink rate (ESR)

To confirm the gout diagnosis, a sample of the synovial fluid is also examined. If uric acid crystals can be detected here, it is very likely gout.

X-ray and ultrasound examinations

With the help of X-rays, the doctor can determine what damage the gout has caused to the joints. In addition, an ultrasound is sometimes performed. An X-ray examination with contrast agents can clarify whether the kidneys have been damaged by the disease.

Kidney function test

A kidney function test can be used to determine whether and, if so, to what extent the kidney's performance is impaired.

Gout: disease course and prognosis

Most cases of gout first appear between the ages of 40 and 60. About two percent of the adult population in developed countries suffer from gout. Men are affected much more often than women.

The predisposition to increased uric acid levels is usually innate and therefore incurable. With consistent therapy, however, the uric acid level can often be permanently reduced. The risk of an acute gout attack is not averted, but it is significantly reduced.

Prognosis for an acute attack of gout

If the uric acid level exceeds a certain value, an acute attack of gout occurs. If left untreated, it lasts from a few hours to a few days. After that, the symptoms slowly subside. After a gout attack, it may take some time (even months to years) before the next gout attack occurs. The duration of the gout attacks and the time between them vary greatly from person to person.

Gout: Long-Term Forecast

The course of the disease and prognosis therefore depend on how pronounced the predisposition is for a high uric acid level and how consistently a patient takes his uric acid-lowering medication, or how well he implements a uric acid-lowering lifestyle. This includes, above all, a diet that is low in purine, fructose and alcohol.

No break in therapy

There can be long periods of time between two attacks of gout during which the patient has no symptoms. It is also important to continue the therapy in these “intercritical phases”. If it is interrupted, the symptom-free sections are shortened. Symptoms such as pain and restricted mobility then increasingly appear in the time between two gout attacks.

Permanent joint changes

Damage to the joints that has occurred once does not go away again. They can cause permanent pain or loss of mobility. In severe cases, the joints can also deform. Pronounced joint damage caused by gout is called uric arthritis.

Kidney damage and kidney stones

A long time untreated gout can also cause various secondary diseases, especially of the kidneys. Kidney stones are a common complication of gout. They block the drainage channels of the kidney and the urine builds up. This is usually followed by an inflammatory reaction. This and the progressive accumulation of uric acids can cause the kidneys to fail at some point. Doctors speak of a gout kidney. In order to prevent such damage, the treatment of gout should be carried out consistently as early as possible and also in the long term.

Chronic gout

Chronic gout develops relatively rarely these days. The patients suffer from constant pain. In contrast to an acute gout attack, they do not subside. Chronic gout develops primarily when hyperuricemia has persisted for a long time and is not treated. As a rule, chronic gout is more likely to affect older people than younger people.

Additional information

Books

Sven-David Müller: Gout traffic light, Trias, April 27, 2016

Edeltraut Hund-Wissner: Delicious food for gout: Over 130 recipes: Finally low uric acid levels Trias, October 21, 2015

Guidelines

DGRh guideline: Long version of the S2e guideline on gouty arthritis (specialist doctor), evidence-based guideline of the German Society for Rheumatology (DGRh), 08/2016

DEGAM guideline: Frequent gout attacks and chronic gout in primary care, 09/2013