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.

What is gout?

Gout is a form of inflammatory arthritis that results from an excess of uric acid in the blood.

Uric acid is a chemical that is created in the body when it digests and breaks down certain substances in food called purines. Gout is genetically inherited and affects men more than women by a ratio of about 3 to 1.

Gout statistics and facts

• 8.3 million people in the United States have gout (6.1 million men and 2.2 million women).*
• Among people who have gout attacks, 90% have kidneys that don’t remove enough uric acid from their urine while 10% make too much uric acid in their system.
• 90% of gout attacks start in a single joint. Most often, it is the “bunion joint” of the big toe.
• 90% of gout patients have one or more of the following conditions (comorbidities), which make it more difficult to manage gout: kidney dysfunction, coronary heart disease, obesity, high cholesterol and/or triglycerides, diabetes mellitus.**

*Prevalence of gout and hyperuricemia in the US general population: the National Health and Nutrition Examination Survey 2007-2008. Zhu Y, Pandya BJ, Choi HK. Arthritis Rheum. 2011.
**Comorbidities of gout and hyperuricemia in the US general population: the National Health and Nutrition Examination Survey 2007-2008. Zhu Y, Pandya BJ, Choi HK. Am J Med. 2012.

What are the symptoms of gout?

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.

What causes gout?

Gout is caused by disordered metabolism of purines. In people with gout, an excess of purines causes uric acid to crystallize in the joints, causing inflammation and pain.

You get purines mostly from food, and they are essential for the body to work properly. Excess purines are normally eliminated in the urine. But sometimes, an excess can lead high levels of urate (a breakdown product of purines) in the blood. This is called hyperuricemia, and it can leave needle-like urate crystals inside your joints.

A similar condition, known as pseudogout has similar symptoms. In both conditions, white blood cells surround chemical crystals, which leads to inflammation. In pseudogout, the associated crystals are formed from calcium pyrophosphate dihydrate, rather than from uric acid, as in gout. Pseudogout requires different treatment.

Gout risk factors

Men get gout more than women by about three to one. Having one or more of the following conditions puts someone at a higher risk for gout.

• kidney dysfunction
• heart disease
• obesity
• high cholesterol
• high triglycerides
• diabetes

How is gout diagnosed?

Diagnosis of gout usually involves:

• a physical exam of the joints
• X-rays of affected joints
• extraction synovial fluid of an affected joint to look for crystals of uric acid

A definitive diagnosis of gout requires that six of the following 12 markers must be present:

1. a tophus (urate crystal deposits in the joints or body)
2. an episode of arthritis in a single joint
3. a history of more than one such episode of arthritis
4. redness of the skin around a joint (erythema)
5. swollen or painful big toe joint (the metatarsophalangeal or MTP joint)
6. inflammation of the big toe joint on one foot only
7. inflammation of one or more midfoot joints on one foot only
8. rapid joint swelling that reaches a maximum level within a 24-hour period
9. elevated levels of uric acid in the blood
10. an X-ray showing uneven (asymmetric) swelling in a joint
11. an X-ray showing joint cysts or bone erosions without any indication of prior inflammation
12. joint inflammation where the joint fluid tests negative for infection

Gout treatments

Changes in diet to avoid foods high in purines reduce the inflammation and pain in mild cases. Your doctor may also prescribe NSAIDs (to alleviate pain and swelling).

For more severe gout, other medications are needed to lower the uric acid. These may include one or more of the following:

• allopurinol (Zyloprim)
• colchicine (Colcrys)
• febuxostat (Uloric)
• lesinurad (Zurampic)
• pegloticase (Krystexxa)

Most people who suffer from gout attacks must take medication throughout their lifetime.

If your doctor has prescribed colchicine to prevent gout attacks, the attacks will return if you stop the drug. If you are given allopurinol to reduce the uric acid in the blood (to reduce gout attacks) or to reduce the uric acid in the urine (to reduce the risk of uric-acid-related kidney stones), the risk returns if you stop the drug.

Whether or not you take medication for your gout, it is important to limit your intake of foods high in purines. For the first six months after starting allopurinol for gout, your diet is especially important in helping to prevent attacks.

Further reading on gout

Find more detailed information about gout in the articles and other content below, or find a doctor at HSS who treats gout.