Question

I have been having gout attacks for 30 years and they have recently greatly increased in frequency. My uric acid levels were in the 8's but I have been on allopurinol for about 4 months, and now the level is down to 5.3. But the attacks are still occurring; colchicine helps perhaps 50% of the time. I have also been experiencing pain in other joints, most recently a knee. Is this gout or arthritis, and what can I do to stop the pain?

Answer

All the risk factors for gout are mediated through increases in serum and tissue uric acid crystal levels. The incidence of gout is closely related to the level of serum uric acid, i.e. if it is less than 6 which yours now is, the five year cumulative incidence is 0.5 % for gout. The diagnosis of gout relies on the criteria of the American College of Rheumatology, which suggests that when 6 of the 11 criteria below are present, there is a specificity of 93% in differentiating gout from pseudogout, with an overall sensitivity of 85%. The criteria are: more than one attack of acute arthritis, maximum inflammation develops within one day, oligoarthritis attack, redness observed over joints, first metatarsophalangeal joint (toe middle joint) painful or swollen, unilateral first metatarsophalangeal joint attack, unilateral tarsal (toe) joint attack, tophus (small hard concretion on the joints), hyperuricaemia (high uric acid levels), asymmetrical swelling within a joint on radiography, complete termination of an attack. From the above you may be able to diagnose with reasonable certainty whether you have gout.

Of course this does not stop a second diagnosis of another inflammatory condition also being present. But it seems unlikely that if you have had gouty attacks for so long with a high uric acid level that you would be wrong in saying that you had gout.

Gout can lead to arthritis itself, which can of course present with inflammation of the joints which are no longer related to the uric acid level. The differential diagnosis of the acute attacks is infection or other crystal-associated inflammations of the synovia (the membrane lining a joint cavity). Examination of the fluid aspirated (i.e. drawn out by suction or siphoning) from a joint would demonstrate the type of crystals involved and whether there is any infection. There are a number of less classic attacks which may be associated with other conditions that cause arthritis, such as psoriasis, trauma and exacerbation of osteoarthritis.

To manage the problem, apart from drug therapy, it is important to look at provoking factors. Measures which often help include gradual weight loss (if you are overweight), reduction of any alcohol consumption, avoidance of toxins such as low dose aspirin, a review of any other drug therapy you use which may be precipitating attacks.