Today is Gout Awareness Day and in partnership with Horizon Therapeutics we present ten “hard questions” commonly asked by our patients with gout about their condition and treatment options. Many of us can find it challenging to give clear and substantial answers to some of the questions asked by our patients with gout. In this blog we will provide some very short answers to these common questions, but we encourage you to download our more comprehensive pocket guide: Handling the Hard Questions: What Our Patients Are Asking Us About Gout which will give you greater details to share with your patients.

1. How did I get gout?

Gout occurs because either a person produces too much uric acid or does not excrete enough uric acid from the kidneys. It does run in families. Gout flares can also occur when a person has too much purine in their diet (e.g. red meat, shellfish, high fructose corn syrup). Consumption of alcohol can also bring on flares. People with kidney disease, men and post-menopausal women are more likely to get gout. Medications such as diuretics, cyclosporine, and low dose aspirin can increase uric acid levels. It is not recommended to stop medications without discussion with the prescribing provider.
Learn more, download the guide.

2. How do you know I have gout and not something else?

When a patient has a hot red swollen joint the rheumatology provider considers several diagnoses including gout (monosodium urate crystals), pseudogout (calcium pyrophosphate crystals), septic arthritis, psoriatic arthritis, rheumatoid arthritis, cellulitis and sarcoid arthropathy. A good history and physical gives the rheumatology provider some clues as to what the cause may be. The rheumatology provider may aspirate fluid from the joint to look for crystals and inflammatory fluid as well as infection. Lab work may be ordered based on history and physical to look for serum uric acid levels and other causes of inflammation. The provider may also order imaging such as x-ray, ultrasound, or CT scan to help differentiate the cause.
Learn more, download the guide.

3. Why is my big toe swollen?

Urate crystals can accumulate in joints and tissue when uric acid levels elevate in the bloodstream. Urate crystals are needle-like and get trapped in the joint. When this occurs white blood cells are activated and surround the affected joint. This in turn causes the hot, red swollen joint. This condition may become chronic and cause joint destruction. Urate crystals can also deposit in the urinary tract and form renal stones.
Learn more, download the guide.

4. Why is it so important that you monitor my uric acid levels?

Elevated levels of uric acid in the bloodstream cause the production urate crystals which cause gout attacks. The goal uric level is less than 6 mg/dL in patients with gout. In patients with tophaceous gout (large deposits of urate crystals in the tissue and joints) The goal uric acid level is lower. When a patient is not at goal they are at higher risk for developing gout flares. Medication may be adjusted or changed according to serum uric acid level and number of flares.
Learn more, download the guide.

5. Is there anything I should change about my diet?

Foods that are rich in purine can trigger gout flares. These include shellfish red meat, organ meat, and foods containing high fructose corn syrup. Alcohol consumption can also trigger gout flares. Staying hydrated is beneficial in decreasing gout flares. It is unlikely that a person with gout can control their disease on diet alone. Even with excellent adherence to a proper diet a person can only lower serum uric acid by about 1 mg/dL.
Learn more, download the guide.

6. What are my options to treat gout?

There are several medications  used to treat gout. For management of acute flares, medications such as NSAIDs, corticosteroids and colchicine are used. The medications are carefully selected by the provider based on other conditions the patient may have.

Patients that have more than two flares in a year are given uric acid lowering agents. These include allopurinol and febuxostat which block the production of uric acid. Probenecid is a uricosuric agent which helps with removing uric acid through the kidneys. Pegloticase is a uric acid specific enzyme that is prescribed for patients who did not have adequate response to other uric acid lowering agents. All of these medications have potential side effects so it is important to discuss the medication with the prescribing provider.
Learn more, download the guide.

7. How long will a typical gout flare last?

Gout flares often start without warning it can last for several days and even weeks. Flares generally last longer the longer the patient has gout. Symptom onset 2 1/2 times is more often at night. Foods high in purine and alcohol may trigger a flare. Flares are also triggered by sudden trauma to the joint, an illness with fever, and after surgery. The initiation of uric acid lowering treatment without the use of a medications such as colchicine, prednisone or an NSAID can cause flare up of gout. It could also be caused by starting on high dose of medication instead of titrating up the dose to a therapeutic level of less than 6 mg/dL.
Learn more, download the guide.

8. Is my gout under control when I am not in an active flare?

Gout is in control when acid levels are less than 6 mg/dL. Just because an acute flare is not present does not mean uric acid is not circulating in the blood and depositing crystals in joints and tissue in the body.  If uric acid levels are higher than goal a person is more likely to have breakthrough flares. This emphasizes the importance to stay on medication as prescribed  and get  blood levels checked as directed by the rheumatology provider.
Learn more, download the guide.

9. Will my gout ever go away?

Unfortunately, gout is not curable. It is a chronic disease and if it goes untreated destroys joints, can cause kidney and heart problems, and will produce pain and swelling which effects quality of life. Fortunately, if gout is properly treated with medication,  proper diet, and exercise patients can lead productive lives relatively pain-free.
Learn more, download the guide.

10. What are the risks if I decide I don’t want to take medication to treat my gout?

Short term effects of not treating gout include joint pain and swelling which effect quality of life. Long term effects of not treating gout include joint damage and erosion, heart disease, and kidney disease.

Many patients have a hard time accepting the diagnosis of a chronic disease such as gout. They may be apprehensive to take medication and think diet alone can control it. Diet can only lower serum uric acid by approximately 1 mg/dL. Diet modifications can help decrease flares once uric acid is at goal of less than 6 mg/dL.
Learn more, download the guide.

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Many patients with gout have questions about their condition and treatment options, particularly following a recent diagnosis. By providing patients with evidence-based answers to common questions, providers can help alleviate patient concerns and emphasize the importance of interventions that can help prevent flares and long-term damage. We hope you find this guide informative and useful not only for your professional development, but also in daily clinical practice.