Do I need to seek treatment if I have gout?

Gout is caused by a buildup of uric acid crystals in the joints. These crystals trigger inflammation, leading to sudden, severe pain, often in the big toe. These episodes are known as gout flare-ups.

When should you consider urate-lowering therapy? The ACR recommends it for patients experiencing:

• Two or more gout flare-ups per year
• Tophaceous gout (the formation of tophi, which are visible deposits of uric acid crystals under the skin)
• Radiographic evidence of joint damage caused by gout

Even with just a second flare-up, even if not within a single year, discuss urate-lowering therapy with your doctor. For a first flare-up, especially if you have a high serum urate level (9 mg/dL or higher), kidney stones (urolithiasis), or stage 3 or greater chronic kidney disease, talk to your doctor about the potential benefits of starting urate-lowering therapy.

Importantly, urate-lowering therapy isn't generally recommended for people with asymptomatic hyperuricemia (high uric acid levels without any gout symptoms).

Urate-Lowering Therapies: Managing Uric Acid Levels

The primary goal of gout management is to lower uric acid levels in the blood, preventing crystal formation and future flare-ups. Allopurinol is a commonly prescribed medication for this purpose.

• Starting Allopurinol: A low dose of allopurinol can usually be initiated even during a gout flare-up, provided it is started with appropriate anti-inflammatory therapy to prevent any worsening of the flare.

• Pegloticase (Krystexxa): This intravenous medication rapidly breaks down uric acid. However, due to its high cost and potential adverse effects, it's generally reserved for patients with severe gout who haven't responded to other treatments. This includes patients with tophi or frequent flare-ups (more than one per year) despite being on maximally tolerated doses of other urate-lowering therapies.

Lifestyle Modifications and Concurrent Medications

While medication is often necessary, lifestyle changes and careful consideration of other medications can also play a significant role in gout management.

• Hypertension Medications: If you have both hypertension and gout, discuss with your doctor the possibility of switching from hydrochlorothiazide (a diuretic that can raise uric acid levels) to losartan, an alternative blood pressure medication that can help lower uric acid.

• Aspirin: Low-dose aspirin should generally be continued if medically indicated, even though it can slightly increase uric acid levels. The benefits of aspirin for cardiovascular health usually outweigh the potential risks.

• Cholesterol Medications: While fenofibrate (a cholesterol-lowering medication) can reduce uric acid levels, changing your cholesterol medication solely for gout management is generally not recommended.

• Diet and Lifestyle:

  • Alcohol, Purines, and High-Fructose Corn Syrup: Limiting consumption of these substances may help lower uric acid levels, but the evidence is somewhat limited.
  • Vitamin C: Supplementation with vitamin C has not been shown to effectively reduce uric acid levels or prevent gout flare-ups.
  • Weight Loss: Losing weight can significantly reduce the frequency of gout flare-ups.
  • The Importance of a Balanced Approach: While dietary changes can be helpful, it's important to avoid feeling blamed or overly restricted. Focus on a balanced and sustainable eating plan, and remember that medication is often necessary to effectively manage gout.