Gout: The Devil is Biting My Toe

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 1- Approximate time required: 60 min. 

Educational Goal:

 To give a basic overview of gout, Gouty Arthritis and Hyperuricemeia

Educational Objectives:

1. Give the definition of gout and Hyperuricemia

2. Enumerate the causes, contributing factors, signs and symptoms, and triggers for gout.

3. List who is at risk for getting gout

4. Explain treatment therapies and Adult Foster Care issues with gout


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   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.


Gout: The Devil is Biting My Toe


     “Gout is a disease in which a defect in uric acid metabolism causes excess of the acid and its salts (urates) to accumulate in the bloodstream and the joints. It results in attacks of acute gouty arthritis and chronic destruction of the joints… The excess of urates also damages the kidneys, in which stones may form.”

The Bantam Medical Dictionary  Revised Ed 1990


     Dictionaries give such wonderfully precise descriptions of mankind’s diseases. Unfortunately, they are incapable of describing just how painful those diseases are. Gout can lead to one of the most painful afflictions a person can experience. Attacks can last from several hours to several weeks. Fortunately, Gout is not very common, but its occurrences are increasing. Because of this increase and the severity in which patients suffer, I have written this article to prepare the Adult Foster Care Provider to recognize and understand what is going on.    


History of Gout


     Gout is one of the oldest described maladies of mankind, with writings about it dating back as far back as ancient Egypt.  The accounts describes patients suffering horribly with fever, chills and excruciating, burning pain, like hundreds of hot sharp needles poking under the skin. Attacks most often occurred in the big toe above the ball of the foot (first metatarsophalangeal joint).The attacks would last for weeks. Over time the gout attacks became more frequent, eventually leading to kidney disease, heart disease and disabling arthritis.

    In the past Doctors could not do much for the patient. Most victims of Gout were unaware they even had a disease it until they suffered a very painful acute attack of arthritis in a joint. Because the causes where unknown, it was popularly believed to be the result of a gluttonous lifestyle. The pain painful attack was seen as a punishment for extravagant excesses.  One cartoon from the 1700’s depicted a gout attack as the devil biting the foot of its victim. It was not until the 1960s that Doctors had medications to treat the condition.

     Today, after much research, we know what gout is, what causes it, who’s at risk and how to manage the disease. With proper diagnosis and care, modern medicine has reduced the severity of the disease to simply a somewhat painful inconvenience.


What is Gout?


     Gout is a condition of having too much uric acid in the body. Under the right conditions (concentration, temperature, etc.), uric acid collects into hard needle-like crystals. The crystals tend to collect in the body’s cartilage, especially in the joints.  When the crystals become large enough, they act as needles, doing quite a bit of damage to the surrounding tissues.  Tissue damage causes localized inflammation and swelling. Very quickly the affected area can become so painfully inflamed that the patient can’t even stand the weight of a bed sheet on the joint.  Uric acid crystals can also collect in other areas of the body in hard lumps called tophi (frequently in the middle outer edge of the ear). They can also collect in the kidneys, causing damage and contributing to the development of kidney stones.

     Gout is a progressive disease that, if left uncontrolled, will advance to worsening conditions. The progression is described in 4 stages.

1. Asymptomatic Hyperuricemia. At this stage, uric acid concentrations are higher than normal though not enough to form large amounts of crystals. Usually the blood concentration is less than 6.8 mg/dl. There are many people who naturally never progress beyond this stage.

2. Acute Gouty Attacks. When higher concentrations of uric acid occur, crystals start to form and are deposited in the joints or tendons. Lower temperatures make the crystals form faster, such as seen in the feet and ear lobes. It also explains why a majority of attacks start at night, when the average body temperature tends to be lower.  Gravity seems to be a factor in where the crystals collect, with the vast majority happening in the lower extremities and in the fingers.  Up to 90% of flare-ups happen in the big toe. Each episode can last from 3 to 14 days.  Often the initial incident is the first and only indication that the patient has the disease.

3. Intercritical Period. This is the period between episodes. Crystals may still be present but not in high enough concentrations to cause inflammation. It could last from days to years, depending on how well the patient manages their condition.

4. Chronic Gout.  At this stage the patient has persistent, uncontrolled Hyperuricema.  Active untreated or non-responsive gouty arthritis, manifesting itself as frequent flare-ups.  Typically, multiple joints are affected. Uric acid crystals have persisted long enough to start collecting in tophi. Tissue damage and inflammation has continued long enough that the damage is starting to become permanent. Because effective treatments are readily available, the patient appears to be unwilling or unable to control their disease, creating the need for more aggressive management by outside caregivers.


What Causes Gout?


     Uric acid is produced in the body by the breakdown of proteins that we eat. It also results from the normal breakdown and turnover of our cells. As uric acid is washed away in the blood stream it combines with other chemicals to become urate (uric acid salts). Normally urates are removed from the body, mainly in the urine. Some people can’t eliminate all the urates that their body produces. Concentrations start to build up in the blood, causing Hyperuricema.

     About 90 % of those with Hyperuricema are not able to eliminate urates fast enough. Less than 10% have a problem with abnormally overproducing urates. Genetics seems to be the key factor in who develops this condition. Those afflicted have problems producing enough of the enzyme Uricase, which breaks down uric acid. There are other causes that can also be factors, such as kidney diseases, renal insufficiencies and some medications.

The primary drug classes that can cause gout are Aspirin, Niacin, Cyclosporine and the Thiazides, like Hydrochlorothiazide (HTCZ), which is used as a diuretic (water pill).   It is also worthy to note that 75% of gout cases are accompanied by Metabolic Syndrome (Prediabetes), which causes abdominal obesity, hypertension, insulin resistance and abnormal lipid levels.

     Not everyone who has Hyperuricema develops the painful symptoms of Gouty Arthritis. Diet can play a key role. Even with excretion problems, if you reduce the foods that lead to urates to a low enough levels, the body will be able to keep up. More about diet later.


Who’s at Risk for Developing Gout?


     Even though no one knows exactly how many people have Hyperuricema and are at risk for attacks, one study showed that in the 1990’s 8 million people received gout therapy. Each year that number increases. Scientist agree that this increase is probably due to living longer, obesity, diet choices and alcohol consumption.

      Age is a risk factor.  As a person get older the risks increase. In the same article mentioned above, it was shown that those aged 65 to 74 had a prevalence of 31 per 1000. In ages 75 and older gout prevalence increased to 41 per 1000.

     Gender is a risk factor. Males are 9 times more likely to develop gout. In women, the risk increases after menopause, narrowing the gender gap to 1 woman for every 3 men.

     If your parents had gout you have a 20% chance of developing it yourself.

    British people are 5 times more likely to develop gout.

    American blacks (but not African blacks) are more likely to have problems with gout than other ethnic racial groups.

    Lifestyle and diet choices increase the risk of gout. Especially alcoholic beverages (particularly beer), purine rich meats (red meat, internal organs meats, shellfish and oily fish), and high fructose corn syrup drinks. 


Signs and Symptoms of Gout


     How can a person tell if they’re having a Gouty Arthritis attack and not some other condition? That’s a good question. Early recognition of the signs and symptoms of Gouty Arthritis can lead to faster therapy applications.

      As mentioned earlier, the majority of attacks happen at the base of the big toe. The first incident rarely happens to more than one joint (85 – 90% of cases). Other area of flares are (in occurrence order) insteps, ankles, heels, knees, wrists, fingers, and elbows. Occurrence will most likely happen at night. Flare sights will have swelling that is very painful. The skin will be warm, red or purple in color, and, later on, possibly itchy and peeling. Infections and gout are the only things that cause peeling as the inflammation subsides. The site will become extremely sensitive to touch. In some case fevers can accompany flares. The attack will usually take 2-4 hours to develop. Flares can last for days or weeks and will eventually resolve themselves with or without medication.

     Many conditions mimic gout. Only a doctor finding uric crystals from samples of the flare area can tell for sure that it’s gout and not something else. Other conditions that look similar to it are Rheumatoid Arthritis (which usually involves several joints at once) and Psuedogout. Psuedogout is cause by calcium based crystals and usually happens in the knees, wrist and shoulder. If you are concerned, just ask the Doctor to sample for urate crystals.


What Can Trigger Attacks?


     Once an attack of Gouty Arthritis has occurred the patient is at increased risk for future attacks. Whenever the conditions are right, crystals can form again. Binge eating and drinking can cause a sudden increase in urates. Dietary causes account for about 12% of gout cases. Other triggers are gout-causing medication use, renal failure, frequent dehydration, fevers, weight gain, surgeries, lead poisoning  and injury to the joint.

One more curious note, gout attacks tend to happen more often in the spring.      


How is Gout Treated?


     There are two aspects to gout therapy:  1. Acute attack relief, and 2. Preventing the attacks from reoccurring.


1. Acute attack relief

     The goals of therapy are the reduction of the inflammation and pain relief.  First line medications are:

Non-steroidal Anti-inflammatory agents (NSAIDs) work by disrupting the chemical pathway of inflammation. Pain relief follows inflammation reduction. In the past, Indomethacin was the preferred agent, but ibuprofen and naproxen have similar effectiveness. NSAIDs have a number of side effect issues, but in the short run they can be dealt with. For example, a stomach acid blocker or antacids can relieve GI problems.

Colchine (Colcrys) is a medicine that decreases uric acid deposition and helps stop the inflammation process. It causes dose-limiting GI problems and is usually prescribed as, “Take 1 tablet every hour until attack resolves or diarrhea occurs.”

Corticosteroids are synthetic versions of our body’s own anti-inflammatory hormones. Commonly used versions are Prednisone (Deltasone) and Methylprednisolone (Medrol). They are powerful medications, but they have multiple serious side effects. They are usually used only when NSAIDs and Colchine are not advisable.

Cold Packs can be used to reduce inflammation, but some practitioners avoid their use because the reduced temperatures can lead to more urate crystals being formed. Aspirin should also be avoided because it too can cause crystals to form  


2. Prevent future attacks (Prophylaxis)

     The goals of therapy are to reduce or eliminate future flares and avoid permanent damage to the joints and kidneys.


Diet and lifestyle modification.

     Diet and lifestyle modifications alone can reduce or eliminate future gout flares and are considered a first-line therapy.

    A diet rich in dairy products with a supplement of at least 500 mg of Vitamin C daily has been shown to reduce gout flares.

   Uric acid production can be managed by reducing the consumption of purine-rich meats and alcohol. Purine-rich vegetables do not seem to increase gout attacks, so they are of no concern, except for high fructose corn syrup.

   Proper hydration promotes the flushing out of metabolic wastes, including uric acid.

   Weight loss can also prevent reoccurring gout attacks. Unfortunately, there are certain weight loss techniques that can actually increase uric acid production and would be counterproductive. Very low caloric diets promote the breakdown of body tissue, leading to more metabolic uric acid production. Low carbohydrate diets rely heavily on proteins for caloric intake, thus increasing the amount of dietary uric acid. A diet alternative would be a calorie reduced, moderate aerobic exercise regime of more than 45 minutes at a time (avoid heavy exercise, which breaks down tissue, increasing metabolic uric acid).


Pharmaceutical Prophylaxis

When diet and exercise are not enough and when it’s economically feasible, gout-preventing meds can be taken. But first the risk versus reward of gout-causing meds like aspirin and niacin should be reevaluated.

Common medications that reduce the risk of gout flares are:

Allopurinol - Effective for both overproducers and underexcreters. It comes as a generic and has been a first-line med for 50 years.

Febuxostat (Uloric) - A newer drug in the same drug class. It has no generic and provides a valuable alternative to allopurinol.

Probenecid - Used for correcting defective underexcretion and comes as a generic. Probenecid requires proper hydration to avoid kidney stone formation. 

Colchine (Colcrys) - can also be used for long-term prevention at lower doses.

Pegloticase (Krystexxa) - An injected medication given every two weeks. Its use is reserved for cases that do not respond to other gout medications.


Adult Foster Care Issues


     The most common reason for gout therapy failure is patient noncompliance – both with lifestyle and diet changes, and with pharmaceutical regime adherence. You, the caregiver, are in an excellent position of being able to properly follow through with all the needed therapies. By doing so, you will be making a major positive impact on the quality of life of your resident. Avoiding even one attack is worth the effort

     If you have a gout sufferer under your care you must have a plan of action in place before a gouty flare occurs. Have your plan written into the patient’s file. Make sure that all substitute caregivers know where to find your plan of action.  

The plan of action should include when to call the doctor, when to call emergency services, contingency plans for nighttime attacks, standing doctor’s orders when an attack happens (for example, the use of cold packs and/or discontinuing certain meds if the attack is prolonged). You will have to request those orders when the patient moves in. You might even have to suggest the standing orders if the doctor is unfamiliar with care homes.




     Unlike times in the past the prognosis for Arthritic Gout suffers is quite good. If a patient suffers from a Gouty Arthritis attack, the condition can be relieved quickly. The chances of further attacks can be diminished significantly by adherence to the appropriate prophylaxis therapies. The Adult Foster Care Provider can help the patient and assist with the necessary life changes that are required by therapy.      


Other Sources for Help


American College of Rheumatology

1800 Century Place Suite 250

Atlanta Ga. 30345



Arthritis Foundation

1330 West Peachtree Street

Atlanta Ga. 30345




1.  Michael L Snaith, ABC of Rheumatology: GOUT, HYPERURICAEMIA, AND CRYSTAL ARTHRITIS. BMJ 310 : 521 (Published 25 February 1995)

2.  R D Sturrock  Gout,  Easy to misdiagnose.  BMJ 320 : 132 (Published 15 January 2000)

3.  Dixie-Ann Sawin, Breaking the Chain of Gout: Pharmacist strategies to improve outcomes in gout and Hyperuricemia. U.S. Pharmacist-part 2 of 2 (Published February 2010)

4.  Gout. Wikipedia The Free Encyclopedia.


5.  Gout and Hyperuricemia. Medicinenet.com. 


6.  Gout- Topic Overview WebMD.


7.  Carol Eustice, What is Gouty Arthritis. About.com. http://arthritis.about.com/od/gout/g/goutdefinition.htm

8.  Gout. Medline Plus.


9.  William C. Hiel Jr., Gout. EMedicineHealth.


10. Anthony di Fabio, Gouty Arthritis. Arthritis Trust of American. (published 1997) http://www.arthritistrust.org/Articles/Gouty%20Arthritis.pdf

11. Colchicine.  RXList the Internet Drug Index.  http://www.rxlist.com/colchicine-drug.htm


Gout:  The Devil is Biting My Toe

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