Ashlee Williams, MD (Host): Have you ever woken up with a joint that's suddenly so painful you can barely move it? Gout attacks come on quickly, causing pain, swelling, and tenderness, often in the big toe or another joint. But what causes gout, and what can you do to feel better?

Welcome to the Healthier You podcast. I'm Dr. Ashlee Williams. And today, I'm talking with Dr. Sonia Nair, a board-certified rheumatologist here at Kaiser Permanente, about how to manage the pain and inflammation during a gout flare, and what can you do to prevent them in the future.

Dr. Nair, thanks so much for being here today.

Sonia Nair, MD: Thank you so much for having me.

Host: Yes, I'm really excited to talk about this. I have so many patients coming in with swollen joints. Let's just start with the basics. We always like to start with the basics. What exactly is gout, and what causes a gout attack?

Sonia Nair, MD: Well, gout is one of the most common inflammatory arthritises. It affects about 4% of the population. So, we're all going to encounter it some way or the other. Gout is caused by sudden elevation of the uric acid and that produces a gout attack.

The uric acid is produced by a breakdown in the body of purines. These purines originate from amino acids, which we have in every part of our body. So, we produce these purines by the foods we eat, of course, because of them getting broken down, but our body and all the growth and breakdown in our body which occurs also produces these purines. So, they're all over. It's hard to keep them away.

certain foods, of course, have more purines. Comorbidities or other medical problems which a patient may have will cause the patient to have more purine buildup, and so a high uric acid. So, lots of different factors play a role in causing a gout attack.

The attack itself comes on very suddenly. Oftentimes, we hear of patients waking up in the middle of the night where even a bed sheet touching their toe, if that's the joint affected, can cause severe pain. So, they can be miserable with pain, being caught off guard and not being able to move for the next two, three days at the minimum. So especially if it affects weight-bearing joints like the knee, the ankle, the big toe, which are very, very common sites for gout. You have the patient having such severe pain that they can't work, they can't move around, you know, they completely get stopped. They get stalled. So, that is how the pain would be. So, you have no signals, nothing to tell you that this is going to come. And so, it's very debilitating, extremely painful.

Host: Yeah, it sounds like the pain kind of just comes out of nowhere and it can be pretty severe. I mean, a sheet touching your toe or the impacted joint sounds pretty severe. So, let's say you are having this gout flare. What can you do to manage the pain and inflammation?

Sonia Nair, MD: Right. So once you have an attack, most patients have learned a lesson for life, so they know what it is, right? But the first time you have it, it's hard to slow it down, to stop it because you don't know what's going on. So because the joint is not just painful, it's swollen, it's inflamed, it's best to not move around when you have the attack.

Generally if, say, the knee is swollen, the leg, the thigh, all of these areas get swollen. So, there's a lot of fluid buildup. So, trying to elevate the leg if that's the joint affected is going to help offload it a little bit. Of course, no moving around. And why do we say this? Because the swelling is so severe if you move around. You know, we're so used to pushing ourselves and saying, "I'm going to walk off this pain," and that actually is going to be the worst thing you do to yourself because you can then injure yourself even more, like break ligaments, break other soft tissue structures which hold the joint together. So, you don't want to move around. You want to elevate, you want to offload. If possible, ice it, but I don't think that's going to make a huge difference. You will have to grab some medicine. And painkillers like ibuprofen, naproxen, if there's no contraindication to using it for you, those would be very helpful, especially for the first attack. Tylenol unfortunately will not help. It doesn't play any role in gout.

But then, if you start having more attacks, then your physician most likely is going to prescribe a medication called colchicine, which also helps reduce the inflammation. And then, sometimes when the attack is just too severe, none of these medicines work, then we have to go with steroids, like a short steroid course.

So, you know, we're starting from a milder form, and then much more severe forms where you really have to treat it quickly enough so that the pain and swelling resolves quickly.

Host: Okay. So, we reviewed a few of the medications that could help. Let's talk about diet. Are there any foods that one should avoid to prevent a gout flare or attack?

Sonia Nair, MD: Yeah. I'm so, so glad, Ashley. First of all, you do these podcasts, and I'm so glad we can talk about diet, because I often like to tell patients, "Let's start with what you can eat," because most patients come in with a list of everything on it, and they're still supposed to live and enjoy life, and that makes them not have anything available to eat which is safe for gout.

So, there are myths out there for gout, and the diet related to gout. And so, I like to be specific here. There are certain foods which really cause the gout attacks to be much more severe. They also contribute to the gout attacks not coming under control even though you're on chronic medications.

So, red meats like lamb, beef, pork, venison if you're a hunter, shellfish, shrimp, these have very, very high purine levels. And so, the body doesn't have to work hard to produce uric acid from these purines in these foods. And so, a gout attack comes on very quickly. Alcohol, a lot of people think beer is the culprit, but really it's any alcohol because all alcohol does the same, it increases the purine levels. And so, whether it's beer or whiskey or wine, all of them can contribute. So, we're talking about excessive alcohol use, especially overnight. So, we often find this scenario where folks have been eating burgers and enjoying beers over football weekend, and that is very common. We see most of our emergency rooms have a few patients coming in with a gout attack because it was all consumed at the same time within a 24-hour period. So, the mixing of all these foods also plays a role, foods and alcohol.

In terms of other foods, vegetables don't play any role in causing a gout attack, so I like to say you are safe with all the vegetables you want to eat, whether it's spinach or broccoli because the myths say you can't eat this vegetable or you can eat that one. So really, enjoy all the vegetables you want, all the dairy you want, all the beans that you like, and all of those are safe.

In terms of animal proteins, fish, all kinds of fish, chicken, turkey, all of that is fair game, so you can enjoy that. Organ meats like chicken livers, those again cause the purine levels to go up very fast. And so, we do not want to eat those meats, those forms of protein, like organ meats.

Host: I love when you gave a list of things that we shouldn't be eating. You also gave a list of things that we could eat. So, that's very helpful. Thank you. Can you talk a little bit about if you have a gout attack or flare, are there ways to prevent it from coming back in the future?

Sonia Nair, MD: Yeah. So, you know, like everything else which is chronic, some things start slow and maybe don't occur anymore because maybe we make some lifestyle changes. So if you have that one solitary gout attack because of that overindulgence in a football game, and it doesn't happen again, that's great.

Oftentimes what happens though is after the first attack, maybe one starts seeing a frequency of attacks. So, you start having attacks maybe once in six months, twice a year, thrice a year, four times a year, and it keeps getting more often. We're human. And we are in severe pain. And though that seven-day period. We remember the attack. Most of us after the attack is over, it can spontaneously resolve, especially with these over-the-counter medicines. We forget about the gout attack.

So really, we must bring it up to our primary care physician, if we've had one or have started having multiple. Generally, we say three to four lifetime attacks, if you had any of those, then we really need to be cognizant of the fact that this is not going to go away. So allow your primary care physician to do testing. And most likely your physician is going to check your uric acid level.

We want to check it about two weeks after the attack. Because if we do it right at the time of the attack, oftentimes the uric acid is much lower than what it's supposed to be. So to get a true value, we check it two weeks after the attack. So once we have an idea of the uric acid, depending on the levels, we would decide whether you need chronic treatment. And the chronic treatment is basically a medication which will reduce your uric acid.

Why is it the case? It's like, you know, the patient who's developed gout, again, multiple reasons, but one simple reason is we just don't have enough of the enzyme to break down the uric acid in our body. So, we need a medication which is going to do the same for us and reduce the acid level. You may have heard about medications like allopurinol, Uloric or febuxostat. These medicines do a great job in reducing the uric acid. So, that's what we would use for chronic treatment if needed. That would be by prescription, of course.

Host: So, you talked a little bit about when someone should reach out to their primary care doctor. When should someone see a specialist like yourself, like a rheumatologist? And does gout, like a gout flare or gout attack, does it ever cause permanent changes to the joint?

Sonia Nair, MD: Yeah. I mean, you bring up such great points because, a lot of times my patients, misunderstand and they think it's just an attack. I just have to get through it for a week and I'm good. Well, unfortunately, if you have multiple such attacks happening over and over again, even with a happy interval, you know, where there's no pain, the gout crystal, the urate crystal as we call it, is just such a potent trigger of inflammation that it completely causes a whole lot of chemicals to be released in the joint where there's an attack, and those chemicals start eating into the joint.

So with time, you can have what we call erosive disease. So, the joint is not healthy anymore. Let's say the big toe, we have certain specific findings which we see on X-rays where the big toe has been eaten up. And now, weight bearing on that toe, even when you don't have a gout attack, is going to be painful.

So, we're starting with something which is happening infrequently, something which can be treated very, very easily with medications, and ignoring that in future now Even when you don't have an attack, you start having pain. What's worse is some unfortunate individuals, about 5% to 10% of individuals have a form called tophaceous gout, and that's where these crystals kind of clump up in a joint of the soft tissue, outside the joint and they start sitting there and they don't go away. They just sit there all the time.

So as I had mentioned earlier, they will keep releasing chemicals, which will continue to eat up the joint even though there's no gout attack. So when you get to the tophaceous gout, that is where you would have to call your friendly rheumatologist, because those patients need to be treated very aggressively. And fortunately, we have very good treatments available. So, those cases definitely have to be referred to a rheumatologist. One can start with the primary care doctor. But to optimize treatment, I think that's where you would have to get a rheumatologist.

Unfortunately, we've been talking so much about just gout, the diet, but there are some factors which also play a role, like patients who've had very bad kidney disease patients who had transplants, because of the medications they're on, patients with cardiac disease heart failure, where they need diuretics. Diuretics bump up our acid level, don't allow our body to get rid of this acid, so it just keeps building up. So, these kind of patients tend to have very difficult-to-control gout. No matter how much your primary care doctor tries, it may be very tough to get the patient under control in terms of gout attacks.

So, those, I believe, would also be patients best to refer to a rheumatologist. And something which happens very often and we feel so bad because patients don't understand it no matter how often they're told. Why? Because again, we're human, life happens and we get busy. Especially when your doctor has say, started you on a medication like allopurinol, patients tend to stop taking it once the attack is over because this understanding that gout happens lasts for a few days, and then goes away, starts getting ingrained, right? Because we see that it's not every day that I have pain. So one big error, which we see happening all the time is that we stop the allopurinol once the gout attack has resolved, or maybe when my prescription runs out, I stop the allopurinol. And that is really unfortunate because sooner or later you will have a gout attack. Because as we said, your body is not able to break down that acid yourself, so you need the allopurinol as a helper throughout.

Once the decision has been made, unfortunately, that you need allopurinol, it would be like a blood pressure medicine, which you may just need it always in all your life. It's very unfortunate, but at least it keeps you away from pain, away from all this disability which comes from gout attacks.

Host: Yeah, I think that's a great call-out, Dr. Nair, that you should always talk to your doctor, primary care doctor or specialist if you're going to discontinue a medication. I think that is a common misunderstanding, even in chronic conditions. You mentioned hypertension, but diabetes, it's like, "Oh, once my blood pressure or my diabetes is well-controlled, then I can stop the medication," you know, similar to gout. And I think just reinforcing that with our patients that the medication is helping you get to goal and stay there.

Sonia Nair, MD: Yeah. Yeah.

Host: Yeah. Well, thank you so much, Dr. Nair, for helping us understand gout and ways to manage flares and prevent future attacks. Here are the top takeaways:

One, gout is caused by a buildup of uric acid that can form painful crystals in the joint, triggering sudden inflammation.

Two, during an attack, anti-inflammatory medication can help control pain and inflammation; while resting, icing, and elevating the affected joint can provide additional relief. Try to treat the attack as soon as possible.

Three, limiting alcohol, sugary drinks, and foods high in purines while staying hydrated and maintaining a healthy weight may help reduce future attacks.

Four, if you have recurrent gout attacks, medication that lowers uric acid can help prevent future flare-ups and protect your joints.

And five, gout is manageable. But untreated gout can lead to more frequent attacks, crystal buildup, and permanent joint damage.

For more expert insights, visit kp.org/doctor and explore more episodes of Healthier You wherever you get your podcasts. If you found this episode helpful, be sure to subscribe so you don't miss what's next. And leave a comment with topics you'd like for us to cover in future episodes. Thank you. And from all of us here at Kaiser Permanente, be well.