You never forget your first gout attack. The severe pain, swelling and redness hits hard and fast. The initial attack often strikes your big toe's large joint, but later ones might affect the foot or ankle. Other hot spots include the knees, hands and wrists.
First-line treatment is quite effective and includes anti-inflammatory medications, ice therapy and rest. A combination of diet and lifestyle changes and prescription drugs — an approach called urate-lowering therapy, or ULT — is typically recommended if attacks recur or become more severe.
The American College of Rheumatology (ACR) has found that despite guidelines regarding ULT published in 2012, appropriate use of this treatment has not increased. One reason may have been the prior lack of strong evidence for the guidelines. And, even when ULT was prescribed, many people did not carry it out.
This spurred the ACR to release updated guidelines with new supporting studies that emphasized these strategies. "While many of these recommendations are not necessarily new, it's good that they were reinforced, as more people need to follow them," says Dr. Robert Shmerling, senior faculty editor at Harvard Health Publishing and former clinical chief of rheumatology at Harvard-affiliated Beth Israel Deaconess Medical Center.
Uric acid and joints
Gout is the most common type of inflammatory arthritis. It's caused by the crystallization of uric acid within the joints.
Your body naturally produces uric acid, which is a waste product of cells. Uric acid is dissolved in your blood and passes through your kidneys into your urine. However, if your body makes too much uric acid or expels too little, uric acid blood levels can build up. This can lead to urate crystals forming in a joint, tendon, and the surrounding tissue. The result: sudden, painful inflammation. While a gout attack can occur at any time, it is most likely to strike at night.
Age is a risk factor for gout. "There is a direct relationship between advancing age and gout," says Dr. Shmerling.
For sudden episodes of gout symptoms, the new guidelines continue to push remedies that have shown to help reduce inflammation caused by urate crystals.
Medication. In some cases, an over-the-counter nonsteroidal anti-inflammatory drug like ibuprofen (Advil, Motrin IB) or naproxen (Aleve) is enough to control the symptoms. But most people need a prescription dose of an anti-inflammatory drug, corticosteroid pills (prednisone), or the drug colchicine (Mitigare, Colcrys). A corticosteroid can also be injected into your joint to help control pain.
Ice. Wrap a cold pack in a thin towel and apply it to the joint for 20 to 30 minutes several times a day.
Rest. Rest the joint on a pillow and try not to move it until the pain subsides.
Flare-ups can last anywhere from several days to a week or longer. While self-care often soothes symptoms, you should see your doctor to confirm a diagnosis and discuss how to prevent future attacks.
"The best way to stop recurring and severe attacks is to lower blood uric acid levels to less than 6 milligrams per deciliter [mg/dL]," says Dr. Shmerling.
This is where ULT comes into play. The new guidelines strongly emphasize that ULT be used primarily for people who have two or more gout flare-ups per year and those who have joint damage caused by gout. ULT should continue even when flare-ups subside.
Here's a look at each component of the approach.
Diet and lifestyle. Changes that can help lower uric acid levels include the following:
- Reduce or even eliminate your intake of meat and shellfish, both of which can raise uric acid levels.
- Cut back on alcohol and foods or drinks made with high-fructose corn syrup, like soft drinks.
- Drink plenty of water every day. Dehydration increases uric acid levels.
- Manage your weight, as gout is linked with excess weight and obesity.
Medication. Diet alone seldom lowers uric acid levels enough, so a prescription drug is usually needed. It can take several weeks to a few months for the drug to take effect. The most common ones include xanthine oxidase inhibitors like allopurinol (Aloprim, Lopurin, Zyloprim) and febuxostat (Uloric). People diagnosed with cardiovascular disease or who have had a recent heart attack should switch from febuxostat to another drug, according to the guidelines.
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