Gout: An old-fashioned disease still prevalent today
Frank Booth, RGN (retired)
Introduction
As early as the 4th Century BC, Hippocrates wrote about gout and how it affected "old men". By the 17th/19th Century gout was being linked with rich living and was the target of laughter, ridicule and characterisation [1]. To those who have/had it you can be reassured that it is anything but funny.
Today, gout is a little spoken about condition. It is a chronic metabolic disorder with acute flare-ups. It is painful and disabling. Around 10% of patients find that it affects more than one joint. If one joint only is involved it is likely to be the big toe. It is difficult to predict when an attack will occur - symptoms develop rapidly over a few hours and usually last for 3 to 10 days [2].
Just over half of all people with gout (62%) experience a repeat attack within a year. You may experience symptoms every few weeks, months or years, but it is impossible to predict when the condition will recur [2]. The Gout Society suggest that as many as 1: 40 of the population in the UK are susceptible to gout.
Gout is a type of arthritis where crystals of sodium urate form inside and around joints. Although some people may experience just a few attacks in their lifetime, the vast majority of people with gout experience attacks that increase in frequency over time. New joints will often start to be affected [2].
Symptoms & Causes
Symptoms often develop at night, although they can occur at any time. Other symptoms include:
- tender joint – patient is unable to bear anything touching it
- inflammation in and around the affected joint
- red, shiny skin over the affected joint
- peeling, itchy and flaky skin over the affected joint as the inflammation subsides
Causes
Gout is caused by a build-up of uric acid in the blood. Uric acid (UA), a waste product excreted by the kidneys, forms when the body breaks down purine chemicals in the cells. Over-production and/or under-secretion of uric acid causes a build up, and tiny crystals of sodium urate form in and around joints. These hard, needle-shaped crystals build up slowly over several years. Eventually, when there is a high concentration of crystals in your joints, the crystals may cause two problems:
- some may spill over from the joint cartilage and inflame the soft lining of the joint (synovium), causing the pain and inflammation of an acute attack of gout
- some pack together to form hard, slowly expanding lumps of crystals (tophi), which can cause progressive damage to the joint cartilage and nearby bone; this eventually leads to irreversible joint damage, which causes pain and stiffness when the joint is being used
Our general health can be a contributing factor as can our diet, obesity, crash dieting severe illnesses, certain operations and a variety of drugs.
Diagnosing gout
What will your patient tell you? Almost certainly the first indications will be pain in and around a joint, this may spread and the pain can become extreme stopping your patient from standing or walking.
They are likely to be emotionally distressed
Your organisation is likely to have their own policies relating to all aspects of gout which should be referred to.
- male typical uric acid levels are: 3.4 < 7.2 mg/dL (200/430 mmol/L)
- female typical uric acid levels are: 2.4 < 6.1 mg/dL (140/360 mmol/L)
You may see very few clients with gout, but for those you do it is important to understand their needs. Here I must declare an interest, I have gout - my serum uric acid was considerably in excess of 300mmol/L. I am being generous when I tell you that I have never experienced a level of pain and immobility so quickly and so dramatically. Therefore as a recent sufferer, I offer here some personal thoughts.
Gout was never a thought in my mind, so image the stress I suffered when almost totally out of the blue I experienced extreme pain in my right ankle. I first thought that I may have broken my ankle or torn a ligament, gout was not a first thought. I now had such pain that I felt compelled to seek medical advicem but had to wait two weeks to see my GP!
I have multiple pathology; a heart attack some years ago, unstable Type 2 Diabetes, and renal failure that is progressive (stage 4 and occasionally dipping into Stage 5), a terminal condition. In the main, those who care for me at hospital and GP's Services know that I like things to be very 'black and white' with no fluffy bits! Just tell me the truth. I am grateful that I have a heart failure nurse and a GP team that can communicate with each other, and as I am not the easiest patient on their books, I'm sure they co-operate with each other very well on my behalf.
After my diagnosis of gout, my GP and I realise that the normal treatment, non-steroidal anti-inflammatory drugs (NSAIDs), cannot be given as I have reactions to them and they are contra-indicated in people with heart failure. I was prescribed Co-codamol. After the first episode everything settled within about 2 weeks, and in itself was not particularly disabling.
The second episode a few months later was very different in its severity and disabling effects were extreme. On this occasion, only 2 days into the attack I had a routine appointment with the Heart Failure Nurse, who having seen the levels of disability and pain first hand, talked with the GP and all agreed that the benefits of treatment outweighed the risk to my heart failure. So, I was prescribed Colchicine; the usual dose is between 1 and 4 tablets in 24 hours. The course is just 12 tablets. It took a further 2 days to have any benefit, but after that, both ankles improved. Colchicine does have side effects, mostly gastric, and has many contraindications and warnings. I was fortunate not to suffer any.
Secondary Levels of Treatment
Having high levels of UA does not mean that you will develop gout. While gout can develop where blood UA levels reach 6mg/DSL - 357 mmol/L, some individuals can have a UA as high as 565 mmol/L and still have no symptoms.
Colchicine can be a drug to continue with, but there are others that the GP may consider either referral to others or simply prescribe a secondary level of drug treatments. Colchicine can be continued as a short or long term solution either alone or in conjunction with Allopurinol as it may take some months for the Allopurinol some months to become effective. Neither Allopurinol or Colchine are painkillers (analgesics) in their own rights but reduce the ability to stop urate crystals to infiltrate joints.
Cortico-steroids like prednisolone can also be used but as with all steroids they will need to be used with caution. Febuxostat acts in a similar way to the other drugs in reducing the UA, but as its metabolised via the liver it is kinder on the kidneys. Sadly, it is still also contra-indicated for use for people with heart failure.
Fluids are important to keep the kidneys flushed. If an attack is suspected, keep clothing loose and the skin area cool, as this may reduce the pain.
Conclusion
Consider how a patient with heart failure acts to stress and physical activities. When one struggles to walk, especially stairs this puts unreasonable strain on to the heart so by managing both the risk and management of gout as an acute or chronic inflammatory condition you will be directly assisting the heart to maintain its normal function.
Heart Failure is debilitating in its own right and anything added to this that especially adds pain is never going to be helpful.
Your compassion and understanding will be vital to maintain success and compliance by and for/with your patients.
Help
http://http:www.ukgoutsociety.org/ for general information or the booklet in Gout.
http://http:www. arthritisresearch.uk.org
Datapharm: http://http:www.datapharm.org.uk particularly useful if you are interested in pharmacology.
EMC: Electronic Medicines Compendium. http://http:www.medicines.org.uk/emc/medicines/4565
MHRA: Medicines and Healthcare Products Healthcare Products Agency. http://http:www.medicines.org.uk/medicines-guidelines/pages/sectorshow.
It's not hard to give high quality nursing care. As a nurse in training or fully qualified we learn about "conditions" and how to manage them. Sometimes even with this quality knowledge we forget the really important facts that the person being treated is simply that, a person! A human with feelings and emotions, desires and fears. When you come to treat this person always consider that there is likely to be more than meets the eye.