Gout Can Be Difficult to Recognize

Published by Contra Costa Times

Posted on Wed, Mar. 07, 2007

By Dr. Stephen Daniels

"It's my knee, doc," said Henry, a patient I've known for years. "It's been hurting for a few days. Getting worse. I must have dropped something on it without noticing."

Henry works as a maintenance man for an apartment building. Constantly busy, he's not one to complain about minor aches and pains.

His left knee is red, swollen, hot and tender to the touch.

Henry takes medicine for high blood pressure and high cholesterol. He enjoys his beer after work, but quit smoking a few years ago.

We had previously discussed the risks of his beer drinking, but he claims it's his only solace since his wife died and his kids moved out of state.

I think Henry has gout, which should be diagnosed by removing joint fluid with a needle and examining it under a microscope. In recurrent attacks, the symptoms and joint appearance are often so typical of gout, that the doctor makes the diagnosis based solely on the patient's story and the physical examination.

Gout usually affects a single joint, especially the big toe, ankle or knee. Usually the person wakes up with a severely swollen, painful joint and has no recollection of an injury.

Curiously, many patients report injuring themselves, but when told they may have gout, admit to not recalling an injury, but reporting it to explain their painful joint.

Gout (or "gouch" as one elderly patient called it) usually affects one joint at a time, but can be extremely painful. It can recur frequently, or very seldom.

Gout is caused by excess uric acid in the blood, which leads to painful urate (from uric acid) crystals in the affected joint(s). These crystals are like fine pieces of broken glass within the joint, causing extreme irritation and inflammation.

Lifestyle choices, diseases, medications and genetics can increase a persons risk of a gouty attack: excessive alcohol consumption, excess body weight, high blood pressure, thiazide diuretics (medicines commonly taken for high blood pressure), low-dose aspirin (to prevent a stroke or heart attack), a positive family history of gout, men over 50, and women after menopause.

Certain foods that are high in purines, which are made into uric acid, may increase the likelihood of a gouty attack: meat, fish, shellfish, asparagus and mushrooms.

There are medicines both to treat and to prevent gout. The most common treatment for a sudden gouty attack are medicines such as Advil or Aleve, or the stronger doses available by prescription in Motrin and naprosyn, or a similar drug called indocin.

In severe cases, a doctor may prescribe a five-to-seven day course of prednisone, or inject cortisone directly into the joint, both of which can relieve symptoms rapidly. Colchicine can also be very effective both to treat and prevent gout.

Medicines such as allopurinol and probenecid can be taken to lower uric acid levels in the blood, and therefore to prevent gouty attacks. Allopurinol may make the joint more painful if given during a painful gouty attack. So, allopurinol should not be used to treat gout when it is painful, but only to prevent it from reoccurring.

Recognizing gout early can bring dramatic and rapid relief. Don't put off consulting your doctor about a suddenly swollen, red, warm, painful joint.

Daniels practices family medicine at the Pittsburg and Concord health centers associated with Contra Costa Health Services.