Inflammatory arthritis that starts with pain and swelling of the big toe is most likely due to gout. This condition is chronic and progressive, but highly treatable.
Gout is a form of inflammatory arthritis that results from an excess of uric acid in the blood. Among people with gout, 90% have kidneys that don’t adequately remove uric acid from their urine, while 10% have high uric acid levels because they produce too much uric acid.
Uric acid is a chemical that is created in the body when it digests and breaks down proteins. Among the breakdown products of protein are compounds called purines, and these, in turn, get broken down to uric acid.
The key symptom is painful attacks in the joints – often, appearing first in the big toe. Other joints that may be affected include the ankle, foot, knees and, in severe cases, the wrists, elbows and fingers. People with gout may also experience kidney stones and damage to their kidneys.
Gout is caused by an elevated amount of uric acid, either because a person’s kidneys do not adequately remove uric acid from their body, or because their body simply makes too much of it. The overabundant uric acid can then crystallize in the joints, causing inflammation and pain. A condition known as pseudogout has similar symptoms but is caused by a very different type of crystals. In both conditions, white blood cells surround the crystals, which leads to inflammation.
In pseudogout, the associated crystals are formed from calcium pyrophosphate dihydrate, rather than from uric acid, as in gout. The inflammation looks similar in a joint with pseudogout as in gout. However, there are some differences regarding which joints are commonly affected. For example, the big toe, very common in gout, is not so common with pseudogout. The treatment of a flare of gout and pseudogout are treated similarly, but the prevention regimens are very different, since the crystals that cause the problems are different.
The largest determining factor whether you inherit a genetic tendency to get it. Also, men get gout more than women by about three to one, but even more frequently than that before the age range during which women reach the menopause. Women are more likely to contract gout after they reach menopause. Having the following conditions puts someone at a higher risk for gout, as 90% of gout patients have one or more of them: kidney dysfunction, coronary heart disease, obesity, high cholesterol and/or triglycerides, or diabetes.
Making a diagnosis of gout usually involves the doctor interviewing the patient to understand the history of their joint pain, a physical exam, X-rays of affected joints, blood testing (especially for uric acid), and extraction of joint fluid to test for deposits of excess uric acid.
The history of the joint pain will include learning which joints are involved, whether joint swelling is present, whether the painful joints get red, and whether the inflammation happens in one or in many joints at a time. The physical exam of the joints will help determine which joints are affected, whether there is redness, heat or swelling, and whether there are any bumps (such as over the toe or elbow) that might be collections of uric acid crystals. This type of bump is called are called a “tophus” (plural, "tophi"), which is Latin for "stone."
Making a final diagnosis of gout requires putting together the findings from these questions and tests. Gout is often under-diagnosed. For example, a gout flare may be mistaken for an injury, such as an ankle sprain. But it in other instances, it is also over-diagnosed. For example, a hot, red and swollen knee may look like a gout flare, but it could be pseudogout (due to calcium crystals instead of uric acid), or an infection that is unrelated to gout or pseudogout.
All patients with gout, even just one flare, are advised to consider their diet, but most need medication to conquer the disease. Many foods have proteins that, when digested, produce uric acid. But certain foods have been shown in studies to be especially likely to cause gout flares. and should be avoided. For flares of gout, treatments include NSAIDs (to alleviate pain and swelling), oral steroids such as prednisone, colchicine and local steroid injections. For patients with two gout flares in a year, or with other factors that suggest active treatment is needed, medications to lower uric acid are used. These include allopurinol, febuxostat (Uloric), and intravenous pegloticase (Krystexxa).
Vitamin C has been shown to have a small effect at helping the body remove uric acid, but is not recommended for gout treatment since other options are much better and more effective.
The effect of drinking cherry juice has been shown to be small, and the effects of medications such as allopurinol so much more potent (with good safety profile), that it is not felt to be the answer to gout treatment.
Foods known to trigger flares of gout include:
The key message for patients is that gout is a treatable disease and it is very reasonable to expect to be gout-free in the future if you stay with your uric acid-lowering medication. Uric-acid-lowering medication isn’t a “cure” − since you need to keep taking it to reap its benefits – but in the vast majority of cases it can completely control gout. If you stop the uric-acid-lowering medication, the gout can and likely will come back. Uric acid-lowering medications can also markedly reduce the risk of uric-acid-related kidney stones (although they don’t prevent calcium-related stones).
When you first start a uric-acid-lowering medication, this leads to uric acid crystals being removed from the joint lining via the bloodstream. As the crystals are released, they can cause gout flares. These flares early in uric-acid-lowering treatment (such as allopurinol) are not a reason to stop the uric-acid-lowering medication. For the first six months after starting a medication such as allopurinol, low-dose colchicine is often added to help reduce early flares. People are also advised to be especially careful in the first six months after starting allopurinol (or other uric acid-lowering medication). Down the road, the diet won’t be as crucial after many of the crystals have been removed from the joints via the bloodstream.
Find more detailed information about gout in the articles and other content below, or find a doctor at HSS who treats gout.
Get more detail on the mechanisms and treatments of this condition.
Written for clinicians, these articles may also be of interest to some patients.