Gout: prevention, diagnosis and when to see a doctor

Gout is one of the few forms of arthritis that can be effectively controlled if the diagnosis is made in time and it is treated correctly. At the same time, it is often confused with a sports injury, and treatment is limited to painkillers during an attack. The editorial team explains how to prevent attacks, how the diagnosis is made and when a doctor is needed.

How to recognize a gout attack

A typical attack develops quickly, often at night or in the morning: over a few hours the joint becomes sharply painful, swollen, hot, and the skin over it turns red. The pain is so severe that even the touch of a blanket is unbearable.

Most often the first metatarsophalangeal joint is affected, but the ankle joint, the midfoot, the knee, the elbow or the fingers can also suffer. Without treatment an attack usually subsides on its own within a week or two.

For an athlete the insidiousness lies in the fact that an attack often happens after competitions, a party or a period of dehydration, and the person links the pain with an injury. The absence of a clear injury mechanism and the sudden onset should raise suspicion.

Without control of urate levels, attacks become more frequent over time, affect more joints, and tophi - nodular deposits of crystals - can form in the tissues. Destruction of joints and formation of kidney stones are also possible.

Diagnosis: tests and imaging

The 'gold standard' of diagnosis is the detection of monosodium urate crystals in the synovial fluid under a polarizing microscope. Joint aspiration also helps rule out septic arthritis, which can have similar manifestations and is an emergency condition.

The level of uric acid in the blood is important but has limitations: during an acute attack it may be normal. Therefore the test should be repeated a few weeks after the inflammation subsides. In athletes it is important to give blood not after an exhausting workout and against a background of normal hydration.

Ultrasound can reveal the characteristic 'double contour sign' on the cartilage and tophi. Dual-energy CT (DECT) makes it possible to visualize urate deposits. The ACR/EULAR 2015 classification criteria take into account the clinical picture, laboratory data and imaging.

The doctor also assesses concomitant conditions: kidney function (creatinine, estimated GFR), glucose, lipid profile, blood pressure. Gout is closely linked with cardiometabolic risks, and their examination is part of the standard.

Prevention: lifestyle

The EULAR and ACR guidelines stress that lifestyle changes are an important addition but for most people with frequent attacks are insufficient without drug therapy. However, for preventing the first attack and reducing the frequency of flare-ups they are important.

The main steps are reducing the amount of alcohol (especially beer), sugary drinks with sugar and fructose, large portions of red meat and offal. Low-fat dairy products in observational studies are associated with a lower risk.

• stable hydration, without 'making weight' through dehydration;
• a minimum of beer and sugary drinks;
• moderate portions of meat, enough dairy products;
• gradual weight loss in case of excess;
• control of blood pressure, glucose, kidney function.

For athletes hydration is of key importance: adequate fluid intake during and after training, avoiding sharp dehydration before weigh-ins and prolonged fasting. Gradual weight loss in case of obesity lowers urate levels.

Popular supplements such as cherry juice or vitamin C have limited and contradictory data. They do not replace treatment, and relying on them as the main method of prevention is unwise.

Drug treatment: principles

An acute attack is treated with anti-inflammatory agents: colchicine, NSAIDs or glucocorticoids. The choice depends on concomitant conditions, kidney function and interaction with other drugs, so it is made by a doctor. The earlier treatment is started, the faster the attack subsides.

Urate-lowering therapy (allopurinol, febuxostat, uricosuric agents) is indicated for recurrent attacks, tophi, joint damage or kidney stones. The goal is to steadily keep the uric acid level below 6 mg/dL, and in severe disease below 5 mg/dL, according to EULAR recommendations.

Treatment is started with low doses and gradually increased under the control of tests, while simultaneously prescribing prophylaxis of flare-ups for the first months. It is precisely the incorrect start of therapy that is a common reason why patients believe that 'allopurinol makes gout worse'.

Urate-lowering drugs are usually taken for a long time. Stopping them on one's own leads to the return of attacks. For athletes these drugs are not prohibited by WADA, but any therapy should be declared to the team doctor.

When to see a doctor

Any first episode of sudden severe pain and swelling of a joint without an obvious injury is a reason to see a doctor. Even if the pain subsides, it is important to confirm the diagnosis, because further tactics depend on it.

Care is needed immediately if an inflamed joint is accompanied by fever, chills, general weakness - this can be septic arthritis, which destroys a joint within a few days. You should also see a doctor urgently if the attack does not subside or several joints are affected at once.

1. fever together with joint swelling;
2. the first attack in your life;
3. recurrent attacks or nodules under the skin;
4. renal colic or worsening kidney function.

A scheduled visit to a rheumatologist is worthwhile if attacks recur, nodules have appeared under the skin, there have been renal colics or the uric acid level is persistently elevated against a family history.

It is also important for athletes to coordinate the use of NSAIDs with a doctor, especially in combination with dehydration: such a combination increases the risk of kidney damage.

Editorial conclusions

Gout is well diagnosed and effectively controlled, but it requires a systematic approach. The basis of diagnosis is joint aspiration, urate levels and modern imaging, and the basis of treatment is anti-inflammatory therapy of attacks and urate-lowering therapy to the target level.

For athletes the main prevention is stable hydration, limiting alcohol and sugary drinks, and a sensible choice of protein sources.

Sudden pain in the foot should not be written off as an injury: a timely diagnosis protects against frequent attacks, tophi and joint damage.

We also advise reading our articles on the causes of gout in athletes, on kidney function tests and on the optimal drinking regimen during training.

References

1. Richette P, Doherty M, Pascual E, et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis. 2017;76(1):29–42.
2. FitzGerald JD, Dalbeth N, Mikuls T, et al. 2020 American College of Rheumatology guideline for the management of gout. Arthritis Care Res (Hoboken). 2020;72(6):744–760.
3. Neogi T, Jansen TL, Dalbeth N, et al. 2015 Gout classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis. 2015;74(10):1789–1798.
4. Dalbeth N, Merriman TR, Stamp LK. Gout. Lancet. 2016;388(10055):2039–2052.
5. Choi HK, Atkinson K, Karlson EW, Willett W, Curhan G. Purine-rich foods, dairy and protein intake, and the risk of gout in men. N Engl J Med. 2004;350(11):1093–1103.
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