What is a good treatment for gout?

What is gout? Gout has been called the "disease of kings" and is famous in historical documents going back thousands of years (to the time of Egyptian Pharoahs).  

Gout occurs when the body produces too much Uric Acid.  The body produces Uric Acid when its digesting foods that contain high amounts of purine (including Red Wine, Red Meat, and other delicious foods that are expensive and highly desirable).  Therefore wealthy people with indulgent diets are at greatest risk for Gout (hence "disease of kings") because they are consuming a lot of Uric Acid (or more specifically a lot of purine, which is converted into uric acid by our body). However, some people, even with a good diet, develop gout due to a genetic predisposition  (their body is bad at clearing uric acid, so its easy for it to build up in the body even when you dont eat a lot).  

So what happens when your body contains too much uric acid?  Uric acid can precipitate out of the fluid in your body and become sharp crystals. Its similar to the formation of salt crystals as sea water evaporates (or sugar crystals, think rock candy).  The problem is that crystals are sharp and painful when they collect inside your joints (it usually happens in the big toe, or the fingers).  The crystals cause significant inflammation.

What is the treatment? The best treatment for a flair up is stuff that reduces inflammation.  So strong antiinflammatories (like indomethacin, called NSAIDS) or steroids (prednisone) are both effective.  A recent study that gave people either steroid or NSAIDS showed that both work very well, although neither is clearly superior.  Some studies also show that a short course of NSAIDS has a lower risk of severe complications (although NSAIDS also have complications, such as stomach pain or ulceration, which can occur in as many as 10% of people).

How do doctors know its gout? Gout can be diagnosed by taking fluid out of the inflamed joint and looking for crystals.  If you see the crystals, then its definitely gout.  But you can have gout without seeing crystals (this test is actually not very reliable).  Also, you can look at levels of Uric Acid in the body (remember gout is caused by Uric Acid), however, levels can be normal 33% of people with gout (therefore this test alone isnt enough for diagnoses).  Other doctors believe that gout can be diagnosed simply by examining the inflamed joint.   This is still an area of controversy. 

References

1) Man CY et al. Comparison of oral prednisolone/paracetamol and oral indomethacin/paracetamol combination therapy in the treatment of acute goutlike arthritis: a double-blind, randomized, controlled trial. Ann Emerg Med. 2007; 49:670-7. see full article. 

2) Janssens HJ et al. A diagnostic rule for acute gouty arthritis in primary care without joint fluid analysis. Arch Intern Med. 2010; 170:1120-6. see full article. 

3) Kienhorst LB et al. The validation of a diagnostic rule for gout without joint fluid analysis: a prospective study. Rheumatology (Oxford). 2015; 54:609-14. see full article.

4) Richette P, Bardin T. Gout. Lancet. 2010; 375:318-28. see full article.

5) Rainer TH et al. Oral Prednisolone in the Treatment of Acute Gout: A pragmatic, Multicenter, Double-Blind, Randomized Trial. Ann Intern Med. 2016 Apr 5; 164(7): 464-71. full article. 

6) Hasselbacher P. Variation in synovial fluid analysis by hospital laboratories. Arthritis Rheum. 1987;30(6):637-42. full article.