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	Uric Acid frequently asked Questions and Answers

		What is gout?


		Gout is a type of arthritis (inflammation of the joints) that mostly affects men aged 40 and older. Almost all people with gout have hyperuricaemia (too much uric acid in the blood). However not everyone with hyperuricaemia has gout. Uric acid is a normal waste product from the breakdown of purines. Purines are found in most foods but some foods are much richer in purine content than others. Uric acid is normally dissolved in the blood and excreted through the kidneys.

		Hyperuricaemia is the result of either the body producing too much uric acid or the kidneys not clearing it fast enough. 70% to 95% of hyperuricemia cases are the result of under-excretion of uric acid, rather than uric acid overproduction.

		In people with gout, uric acid changes into crystals which are deposited in joints and other tissues. The crystal deposit in the joint irritates the synovium (joint lining) resulting in inflammation. The joint becomes very painful, swollen, red and hot. This is called an acute attack of gout.

		Who gets gout?


		Gout is one of the most common types of arthritis.

		Gout typically strikes only after 20 to 40 years of persistent hyperuricemia and men tend to have higher uric acid levels than women. For these reasons, men over 40 years old account for about 90% of the population affected by gout. For many men, hyperuricemia begins at puberty and may last a lifetime.

		Rare inherited genetic disorders that cause hyperuricemia can result in gout in children. Among children, the levels of uric acid are the same for both genders.

		Less than 5% of patients with gout are female. The female hormone oestrogen appears to facilitate uric acid excretion by the kidneys (the body's chief mechanism for disposing of uric acid), so levels in women remain essentially stable until menopause, after which they approach male levels. Premenopausal women are thus much less likely than men of the same age to be hyperuricemic, and whereas men usually experience their first attack of gout between the ages of 30 and 50 years old, women are more likely to experience gout between the ages of 50 and 70.

		Hyperuricaemia and gout can be inherited. 10% to 20% of gout patients have a family history of gout, but it is not known if genetics, environmental factors, or both play roles in this association.

		Gout can also occur as a complication of other conditions such as kidney damage. Kidney disorders and kidney damage impair the ability of the kidneys to eliminate waste products, including uric acid that then builds up in the blood. A number of diseases, including leukaemia, lymphoma, and psoriasis, can cause gout. Over exposure to lead can also cause gout.

		The list of drugs that can cause hyperuricemia is extensive. Diuretics ("water pills" used to control hypertension) cause hyperuricemia by decreasing uric acid excretion. Others are pyrazinamide (used to treat tuberculosis) and the immunosuppressive drug cyclosporine (given to transplant recipients to prevent organ rejection). Low doses of aspirin and other salicylates decrease uric acid excretion, whereas high doses have the opposite effect.

		Alcohol use increases uric acid levels in three ways: by providing an additional dietary source of purines (the compounds from which uric acid is formed); by intensifying the body's production of uric acid; and by interfering with the kidneys' ability to excrete uric acid.

		Researchers report a clear link between body weight and uric acid levels and have also discovered that obesity is an especially important risk factor in men.

		Hypertension (high blood pressure) is found in 25% to 50% of patients with gout, but whether it causes hyperuricemia is unknown.

		What are the symptoms of gout?


		Gout is often divided by experts into four symptomatic stages: asymptomatic hyperuricemia, acute gouty arthritis, intercritical gout, and chronic tophaceous gout.

		Gout symptoms can be precipitated by stress, infection, joint injury, weight loss, surgery, certain kinds of drug treatment, overindulgence in alcohol or purine-rich foods, or even something as seemingly inconsequential as a long walk that one was not sufficiently physically fit to undertake.

		An attack often occurs very suddenly with the maximum intensity of pain reached within a few hours. The joint can be extremely painful and is often swollen, warm and inflamed. The very rapid development of joint pain is a feature that differentiates it from most other forms of arthritis.

		The most common joint affected is the first joint of the big toe. Other joints that may be affected are the knee, ankle, foot, hand, wrist and elbow joints. The shoulder, hip joints and the spine are rarely affected.

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What happens if gout is not treated?

Although gout itself is not life-threatening, it is often associated with serious diseases.

Diabetes and obesity are very common in gout patients as well as high blood pressure and kidney disease. Kidney disease, in fact, is more common in gout patients than in people with diabetes.

In the beginning, attacks of gout are few and far between. Each episode lasts for only a few days and in between attacks the person is well and has no symptoms. If the disease is not controlled by medication, attacks may become more frequent and tend to last longer. Repeated attacks can damage the affected joints. Once the joints are damaged, the person may experience stiffness and limitation of motion even after the attack of gout is over. In some patients, uric acid crystal deposits form lumps under the skin. They are often found in or near severely affected joints, in or near the elbows, over the fingers and toes and along the outer edge of the ears. If untreated, they can damage the affected part of the body.

Uric acid crystals can form kidney stones. These stones can cause pain (colic) but more importantly, they can cause kidney damage through repeated infection or obstruction to the flow of urine.

How is gout diagnosed?

Standard diagnostic tools for gout may include a medical history and physical examination, a blood test for hyperuricemia, and urine sample. For a definitive diagnosis of gout, a sample of synovial fluid from the affected joint is required. X-rays can provide helpful information in some cases.

As part of the diagnostic process other disorders that resemble gout symptoms or cause hyperuricemia should be ruled out.

What lifestyle changes can help prevent gout?

A gout attack can be triggered by drinking alcohol, eating too much, extreme dieting, surgery and injury to joints.

Avoid purine-rich foods. Because uric acid levels are only minimally affected by diet, dietary therapy does not play a large role in the prevention of gout. Still, people who have suffered an attack of gout may benefit from reducing their intake of purine-rich foods if they habitually eat unusually large quantities of such foods. These include beer and other alcoholic beverages, anchovies, sardines (in oil), fish roes, herring, yeast, organ meats (e.g., liver, kidneys), legumes (e.g., dried beans, peas, and soybeans), meat extracts, consommé, gravies, mushrooms, spinach, asparagus, cauliflower, and poultry.
Protein restriction. Diets high in protein, particularly animal protein, increase uric acid. Although few studies have been conducted and none of determined the value of reducing protein. One study of gout patients suggested that eating tofu, which is made from soy and is a source of complete protein, may be a better choice than meat.
Maintain healthy weight. A supervised weight-loss program may, however, be a more effective way to reduce uric acid levels if the patient is overweight. Crash dieting, on the other hand, is counterproductive because it can increase uric acid levels and can cause an acute attack.
Maintain fluids and avoid alcohol. Drinking plenty of water and other non-alcoholic beverages helps remove uric acid crystals from the body. Heavy drinking, especially binge drinking of beer or distilled spirits, should be avoided, because alcohol is a source of purines and can also cause overproduction and under-excretion of uric acid.
Avoid joint injury. People with gout should also attempt to identify and avoid activities that cause repetitive joint trauma, such as the wearing of tight shoes.

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