What is Gout

Gout is a form of inflammatory Arthritis characterised by recurrent attacks of a red, tender, hot and swollen joint,^[1] caused by monosodium urate monohydrate^[2] crystals deposition. Pain typically comes on rapidly, reaching maximal intensity in less than 12 hours.^[3] The joint at the base of the big toe is affected in about half of all cases.^[4]/^[5] It may also result in tophi, kidney stones, or kidney damage.^[6] Gout is a dramatic example of a type of Arthritis called crystal arthritis, sometimes called microcrystalline Arthritis because the crystals are very small. The crystals form in the joint space. As the body tries to remove the crystals, a painful inflammation occurs^[7].

Gout is due to persistently elevated levels of uric acid^[8] in the blood^[9] caused by a combination of diet, other health problems, and genetic factors.^[10] At high levels, the uric acid crystallises, and the crystals deposit in joints, tendons, and surrounding tissues resulting in a painful attack of Gout. Gout occurs more commonly in those who regularly drink beer or sugar-sweetened beverages, eat foods high in purines (such as liver, shellfish, sardines or anchovies), or are overweight. Diagnosis of Gout may be confirmed by the presence of crystals in the joint fluid or in a deposit outside the joint. Blood uric acid levels may be normal during an attack.^[11]

Picture Credit: “Gout: the disease of kings” by DanCentury is licensed under CC BY-SA 2.0.

Treatment with a nonsteroidal anti-inflammatory drug  (NSAID), glucocorticoids or colchicine improves symptoms.^[12] Once the acute attack subsides, uric acid levels can be lowered via lifestyle changes. For sufferers with frequent attacks, Allopurinol or probenecid provides long-term prevention.[13] Taking vitamin C and eating a diet high in low-fat dairy products may be preventive.^[14]

Attacks of Gout usually develop very quickly. The first attack often occurs at night. You may go to bed feeling fine but then wake up in the middle of the night with excruciating joint pain.^[15]

There are two different types of Gout:

• Primary Gout – when you have it, and there is no single cause.
• Secondary Gout – when you have it, and it is caused by something else.

Strangely, some people have too much uric acid in their blood but show no symptoms of Gout. This is called asymptomatic hyperuricemia. Gout is the most common type of  inflammatory Arthritis and:

• it is more common in men (about three times more than in women).
• it is more likely to occur as you get older.

Gout occurs in people who have high levels of uric acid, also known as Urate, in their blood. Urate is created every day when our bodies break down purines – these are chemicals naturally produced in our body but are also present in certain foods.  We all have Urate in our blood: this is normal and healthy.

But if levels are too high, it may cause Gout. Usually, about 75% of the Urate in our bodies comes from the breakdown of purines, while only about 25% comes from food and drink. As urate levels build up, your body removes any extra through your kidneys and in your urine. If your body makes too much Urate, or your kidneys are unable to get rid of enough of it, then levels start to rise. If urate levels stay too high, urate crystals can slowly form. They mainly occur in and around firm joint tissues, such as the cartilage. But crystals can also appear under your skin and may even occur in your internal organs, such as the kidneys^[16].

Who does Gout affect?
Gout affects about 1% to 2% of adults in the developed world at some point in their lives^[17] and has become more common in recent decades^[18], believed to be due to increasing risk factors in the population (such as, for example), metabolic syndrome, a longer life expectancy, and changes in diet.^[19]

Gout affects older males most commonly and was historically known as “the disease of kings” or “rich man’s disease”.^[20]  It has been recognised as a painful condition at least since the time of the ancient Egyptians^[21].

A painful great toe due to Gout is often called podagra^[22] Patients will have pain, swelling, and redness at the base of the great toe during gout “attacks.” Patients may have difficulty walking on the affected foot due to the intense pain. A diet high in red meat, seafood, and/or alcohol increases blood uric acid levels and thus increases the risk of Gout. Therefore, a patient’s history may reveal recent consumption of these substances.

Are Gout and Pseudogout the same?^[23]
Gout and Pseudogout are types of Arthritis, and they’re both caused by the accumulation of crystals in the joints. While calcium pyrophosphate crystals cause Pseudogout, Gout is caused by urate (uric acid) crystals. Pseudogout is also known as calcium pyrophosphate deposition (CPPD) disease.

Pseudogout occurs when calcium pyrophosphate crystals form in the synovial fluid in the joints. Crystals can also deposit in the cartilage, where they can cause damage. The build-up of crystal in the joint fluid results in swollen joints and acute pain.

Another difference between the two conditions is that after Gout flares up, it usually lasts for a few days and then disappears until the next eruption some weeks or months later, whereas Pseudogout can last for several weeks.

Also, Gout often occurs on the big toe, whereas Pseudogout does not.

Researchers don’t fully understand why the crystals form, but the chance of them forming likely increases with age. Crystals form in about half of people over the age of 85, according to the Arthritis Foundation. However, many of these people do not have Pseudogout.

Contributing factors for Pseudogout may include:

• hypothyroidism, or an underactive thyroid
• hyperparathyroidism, or an overactive parathyroid gland
• excess iron in the blood
• hypercalcemia, or too much calcium in the blood
• magnesium deficiency

To help with acute attacks of Pseudogout, your doctor may prescribe NSAIDs to reduce the swelling and relieve the pain. Caution: You may not be able to take NSAIDs if:

• you’re taking blood-thinning medication, such as warfarin (Coumadin)
• you have poor kidney function
• you have a history of stomach ulcers

To help reduce the risk of additional flare-ups of Pseudogout, your doctor may prescribe low doses of colchicine (Colcrys) or NSAIDs.

Gout pain is known to be excruciating and tends to be more severe than pseudogout pain. A Gout attack often strikes in the middle of the night, whereas Pseudogout may flare up at any time of day. If left untreated, Gout attack symptoms will usually go away within a few days or weeks.^[26] An attack of Gout can occur suddenly, often awakening a sufferer in the middle of the night with the sensation that their big toe is on fire.

Gout attacks typically affect only one joint.^[27] In contrast, Pseudogout attacks commonly affect between one and four joints^[28]. In addition, the locations of the flare-ups tend to differ:

• Gout most commonly affects the big toe, instep, heel, ankle, and/or knee^[29]. About 50% of first-time gout attacks in men involve a big toe joint, whilst for women (who are generally significantly less likely to develop Gout), an attack is most likely to affect a knee^[30].
• Pseudogout is most likely to affect the knee, wrist, and/or large knuckles of the hand (the metacarpophalangeal joints). Unlike Gout, Pseudogout rarely affects the big toe^[31], but it may also involve the hip, shoulder, and/or spine^[32].

Other conditions that are similar to Gout^[33]
Apart from Pseudogout, the following conditions are similar to Gout:

Infected joint (septic Arthritis)
A single joint that’s red, hot, and swollen might be Gout — or it might be septic Arthritis. To further add to the confusion, both conditions can cause you to develop a fever and for your white blood cell count to spike. In either instance, your body thinks you have an infection it’s trying to fight off, but in only one of those cases (septic Arthritis) is an infection present. If you do have septic Arthritis, laboratory analysis of fluid taken from the impacted joint should reveal the particular organism that’s causing an infection.

Bacterial skin infection (cellulitis)
You have a fever, chills, and an area of your skin (probably somewhere on a lower leg) that is red, hot, and painful to touch. It could be Gout, or it could be cellulitis, which is a potentially serious infection that occurs when bacteria infiltrate your skin via a cut or crack. Trying to extract fluid to test it is a really bad idea because it could cause the infection to spread further.

Stress fracture
If your doctor suspects that you might have a fractured toe (or any other joint), an X-ray might be in order.

Rheumatoid Arthritis
Rheumatoid Arthritis (RA) and Gout can cause visible nodules, especially in the advanced stages. If you have Gout, the bumps (called tophi) are made of lumps of uric acid crystals. What causes nodules to form in people with RA is unknown, but about 25% of RA patients get them. Here’s a link that may make things clearer: more about rheumatoid nodules and more information about gout tophi.

Psoriatic Arthritis
As with RA, psoriatic arthritis (PsA) sometimes causes swelling around the fingers or toes that can look a lot like Gout tophi. The swelling in PsA is called dactylitis, giving digits a sausage-like appearance. If you have PsA, you might also have skin plaques indicative of psoriasis. Note: while you can have PsA without skin psoriasis, the conditions often go together. Many people with PsA also have pitted fingernails, which is not something that should happen if you have Gout. If you have PsA rather than Gout, your doctor won’t find uric acid crystals in your joint fluid.

The Gout by James Gillray. Published 14^th May 1799.
Public Domain.
File URL: https://upload.wikimedia.org/wikipedia/commons/b/b8/The_gout_james_gillray.jpg

Advice from the NHS^[34] and others
The NHS advise that anyone suffering from a Gout attack should see a GP for treatment to help during the attack and to stop further attacks. A Gout episode usually lasts five to seven days, then gets better. It may not cause lasting damage to your joints if you get treatment immediately.

Gout episodes can vary from person to person. Some people only have an attack every few years, while others may have attacks every few months.
Without medication, attacks tend to happen more frequently, and other joints can become affected.  Having high urate levels and Gout for a long time can lead to other health problems, including^[35]:

• narrowing of the arteries - which can lead to an increased risk of stroke, heart attacks or other heart problems
• osteoarthritis, which occurs when the urate crystals and hard tophi cause joint damage
• an increased risk of developing kidney disease or worsening of the condition if you already have it
• kidney stones
• an increased risk of some cancers, especially prostate cancer
• mental health problems, including depression
• underactive thyroid
• erectile dysfunction

Non-urgent advice
See a GP when you have:

• sudden severe pain in a joint – usually your big toe, but it can be in other joints in your feet, hands, wrists, elbows or knees
• hot, swollen, red skin over the affected joint

Urgent advice
For UK patients, ask for an urgent GP appointment or call 111 if:

• the pain is getting worse
• you also have a very high temperature (you feel hot and shivery), and
• you also feel sick or cannot eat

These symptoms could mean you have an infection inside your joint and need urgent medical help.

What happens at and after your appointment
The GP may ask about your diet and if you drink alcohol. You may be referred to a specialist – called a rheumatologist – who will arrange a blood test and scan. Sometimes a thin needle is used to take a sample of fluid from inside the affected joint, to test it.

The blood test will tell your GP or specialist how much uric acid is present in your blood. Excess uric acid in your blood can lead to crystals forming around your joints, which causes pain.

Treatment to reduce pain and swelling
Attacks of Gout are usually treated with a nonsteroidal anti-inflammatory drug like ibuprofen. If the pain and swelling do not improve, you may be given steroids as tablets or an injection.

Treatment to prevent Gout from coming back
Gout can come back every few months or it may be years. The general situation is that it can come back more often if it’s not treated. If you have frequent attacks or high levels of uric acid in your blood, you may need to take uric acid-lowering medicine. Once prescribed, unless told otherwise by your doctor, it’s important to take uric acid-lowering medicine regularly, even when you no longer have symptoms.

Making lifestyle changes, principally losing weight^[36] and adjusting your diet to exclude certain food and drinks, may mean you can stop or reduce further attacks.

Things to Do and Things to Avoid Doing^[37]

* The NHS weight loss plan can be accessed at: https://www.nhs.uk/better-health/lose-weight/

** A more complete list of foods you should avoid if you suffer from Gout is provided by Cleveland Clinic (at: https://my.clevelandclinic.org/health/treatments/22548-gout-low-purine-diet):

• Sugary drinks and sweets. Standard table sugar is half fructose, which breaks down into uric acid. Any food or drink with high sugar content can trigger Gout.
• High fructose corn syrup. This is a concentrated form of fructose. If you start looking at labels, you’ll find high fructose corn syrup in all kinds of packaged food products that you wouldn’t otherwise expect.
• Alcohol. Even though not all alcoholic drinks are high in purines, alcohol prevents your kidneys from eliminating uric acid, pulling it back into your body, where it continues to accumulate.
• Organ meats. These include liver, tripe sweetbreads, brains and kidneys.
• Game meats. Specialities such as goose, veal and venison are among the reasons why Gout was known in the Middle Ages as the “rich man’s disease.”
• Certain seafood, including herring, sardines, anchovies, scallops, mussels, codfish, tuna, trout and haddock.
• Red meats, including beef, lamb, pork and bacon.
• Turkey. This leaner meat is nonetheless high in purines. Especially avoid processed deli turkey and chicken.
• Gravy and meat sauces.
• Yeast and yeast extract.

Important to note is that people who take medications to deal with water-retention (diuretics) are more likely to develop Gout.

What can trigger a Gout attack
You might get an attack if you:

• have an illness that causes a high temperature
• drink too much alcohol or eat a very large, fatty meal
• get dehydrated
• injure a joint
• take certain medicines

Gout sometimes runs in families. It’s more common in men, especially as they get older. You might have a higher chance of getting Gout if you:

• are overweight
• drink alcohol
• have been through the menopause
• take medicines such as diuretics (water tablets), or medicines for high blood pressure (such as ACE inhibitors)
• have high cholesterol, high blood pressure, kidney problems, osteoarthritis or diabetes
• have had surgery or an injury

Gout Complications
It’s rare to get many attacks (chronic Gout), but if you do, it can damage your joint. Chronic Gout can also cause tiny white lumps, called tophi, to appear under your skin, usually on your ears, fingers or elbows. You can get kidney stones if your uric acid levels are very high, so you’ll need treatment to reduce the levels.

Treatment
Some (but not all) common medications^[38] used to treat Gout are as follows:

*** Colchicine is an anti-inflammatory medicine that works best if taken within the first 24 hours of a Gout attack.

**** The John Hopkins Arthritis Center (US) say that the goal of treatment during an acute gout attack is suppression of inflammation and control of pain. It is important to note that if a patient is not on uric acid-lowering therapy at the time of an acute attack, then this is not the time to initiate such therapy. However, if a patient is already on uric acid-lowering therapy at the time of an acute attack, it should not be discontinued.

Aspirin, certain diuretics for high blood pressure (and other conditions), and drugs for people who had organ transplants can trigger Gout. After a flare-up, talk to your doctor about the medicines you take; if needed, it may be possible to find another option^[41].

Dietary Advice for people living with Gout
The UK Gout Society has detailed dietary advice^[42] for people living with Gout (downloadable in a PDF).

A Gout diet isn’t likely to lower the uric acid concentration in your blood enough to treat your Gout without medication, but it may help decrease the number of attacks and limit their severity. Following a Gout diet, along with limiting calories and getting regular exercise, can also improve your overall health by helping you achieve and maintain a healthy weight^[43].

To avoid flare-ups of Gout, it’s a good idea to ensure your diet is based on low-purine options^[44], such as:

• Low-fat and non-dairy fat products, such as yoghurt and skimmed milk.
• Fresh fruits and vegetables.
• Nuts, peanut butter, and grains.
• Potatoes, rice, and pasta.
• Eggs (but in moderation).
• Meats like fish, chicken, and red meat are fine in moderation (around four to six ounces per day).
• Vegetables: You may see vegetables like spinach and asparagus on the high-purine list, but studies show they don’t raise your risk of Gout or Gout attacks.

Caution: Take care when dieting – when you slim down, it can protect yourself from another flare, but if you lose weight too quickly, you could raise your chances of an attack^[45].

Closing Thoughts

No Cure but Treatment is available
There is no cure for Gout, but it can be controlled quite well with medication. Proper treatment can help you entirely avoid attacks and long-term joint damage.^[46] Worryingly, it is possible to have gout and another form of Arthritis at the same time^[47].

Drinking more Water
One of the easiest and most significant ways to prevent or ease Gout flare-ups is to drink more water^[48]:

• Staying hydrated reduces the amount of uric acid in the body.
• Fluctuations in uric acid cause Gout, and flushing out as much as possible will reduce symptoms.
• Proper hydration helps avoid the formation of kidney stones and maintain a healthy weight, an excess of which can also trigger the onset of Gout.

Why Gout attacks often occur at night
Gout attacks often occur at night, but experts aren’t sure why uric acid crystals tend to collect in joints overnight. It may be one or a combination of reasons, including^[49]:

A painful gout attack occurs when uric acid crystals collect in a joint and trigger an inflammatory response. The body’s temperature drops slightly during sleep, and this temperature drop catalyses the formation of uric acid crystals in the joint. This factor may also help explain why Gout often affects foot and hand joints – extremities that tend to maintain a lower temperature than the rest of the body.

Sleep can induce changes in breathing patterns that influence the production of uric acid in two ways:

• Your breathing slows down during sleep, and the lungs expel less carbon dioxide. Excess carbon dioxide can cause the blood to become slightly more acidic. This condition, called respiratory acidosis, may encourage the formation of uric acid crystals^[50].
• A sleep disorder called sleep apnea causes the body to take in less oxygen. The decrease in oxygen can cause the body to produce more purines, potentially leading to hyperuricemia^[51] and a Gout attack.
• If you have sleep apnea, you may be as much as 50% more likely to have Gout.
• Our bodies produce less cortisone while sleeping. Cortisone suppresses inflammation, so a reduction in cortisone production during the night may be a contributing factor in gouty inflammation.
• A loss of water in both the blood and the joints may play a role in gout attacks in two ways:
• While sleeping, the body loses moisture through breathing and perspiration – as this happens, blood loses some of its water content. As the water content decreases, the concentration of uric acid in the blood increases and leads to or exacerbates hyperuricemia, the precursor to Gout.
• Dehydration can lead to a concentration of uric acid in joint fluid^[52]. When we sleep, joints are at rest, and some of the water in the joints’ fluid is reabsorbed into the body. The uric acid, however, remains in the joint. The high concentration of uric acid in the joint may spur the formation of uric acid crystals.

Best Foods, Gout Supplements, Vitamins and Natural Remedies

• The Arthritis Foundation has put together a list of the best food to eat, which you can access online^[53].
• Google Gout Supplements, Vitamins and Natural Remedies for information available online, and click here for information.
• Folic acid naturally reduces the amount of uric acid that the body produces. It can help to regulate the amount of uric acid already in the body, making Gout flare-ups less painful when they occur. It may also help as a preventative to flare-ups.

Picture Credit/Acknowledgement: https://en.wikipedia.org/wiki/Gout

Gout during Medieval Times

Gout and ‘Podagra’^[54] in medieval Cambridge, England
The International Journal of Paleopathology reported^[55] on a research project to estimate the prevalence rate of gout and explore the social factors that contributed to its development in the various sub-populations in medieval Cambridge. The abstract says:

• One hundred and seventy-seven adult individuals from four medieval cemeteries in and around Cambridge were examined. Lesions were assessed macroscopically and radiographically.
• Gout was identified in 3% of the population. Individuals buried in the friary had the highest prevalence (14%), with low prevalence rates in the Hospital (3%) and town parish cemetery (2%), with no cases in the rural parish cemetery. Gout was more prevalent during the 14^th-15^th centuries than in the previous four.
• The high prevalence rate of gout in the friary is at least partly explained by the consumption of alcohol and purine-rich diets by the friars and the wealthy townsfolk. Medieval medical texts from Cambridge show that gout (known as podagra) was sometimes treated with medications made from the root of the autumn crocus. This root contains colchicine, which is a medicine that is still used to treat gout today.
• This study is one of the first to assess the epidemiology of gout in medieval England and suggests that gout varied with social status.

Cambridge University Library to publish medieval medical cures^[56]
For centuries, gout was known as the disease of kings. The affliction was said to be triggered by a diet rich in meat and wine plus a sedentary lifestyle, and until the 20th century, most gout sufferers were wealthy, if not royalty. King Charles V of Spain suffered from gout, as did Alexander the Great, Charlemagne, and Benjamin Franklin. In a desperate attempt to follow orders, doctors invented some out-of-the-box cures, some of which are summarised below:

• Baking a salted owl and grinding it into powder to treat gout is one of the bizarre suggestions that has been found among thousands of medieval medical remedies.
• If that didn’t work, stuffing a puppy with snail and sage, roasting it over a fire and using the boar’s grease to make a salve is another suggested gout cure.
• Boil a red-haired dog alive in oil until it falls apart, then add worms, hog’s marrow and herbs before applying the mixture to the affected parts.
• Take a frog when neither sun nor moon is shining, cut off its hind legs and wrap them in deer skin (and, presumably, eat the concoction).
• One physician recommended eating a roast kitten to cure gout.
• Another suggested transferring the disease to a tree, preferably an oak or poplar. Founding Father Benjamin Rush suggested heavy bloodletting to cure the disease, while a reverend at the time suggested eating raisins soaked in brandy.
• In the 16^th century, physician Lorenz Fries advised gout sufferers to “roast a fat old goose and stuff with chopped kittens, lard, incense, wax, and flour of rye.” The patient was supposed to eat the kitten-stuffed goose and apply the drippings to the affected joints.
• In the 17^th century, English doctor Nicholas Culpeper suggested a plant-based treatment. Patients were directed to mix up a concoction of horseradish and ground elder (also known as gout-herb).

With the excruciating pain this condition causes, it’s no surprise that medieval patients were willing to try almost anything, including the above, in search of a cure.

The treatments are among 8,000 medical recipes contained in 180 medieval manuscripts. Most are dated to the 14^th or 15^th centuries, although the oldest is from a thousand years ago. The texts are from the University Library, Fitzwilliam Museum collections and a dozen Cambridge colleges. The Cambridge University Library is digitising the manuscripts in a two-year project (called the Curious Cures Project), which will be available online free of charge to the public when complete.

Sources and Further Reading

• https://www.nhs.uk/conditions/gout/
• https://en.wikipedia.org/wiki/Gout
• https://khealth.com/learn/gout/fastest-way-to-treat-gout/
• https://my.clevelandclinic.org/health/diseases/4755-gout
• https://www.healthline.com/health/gout
• https://www.health.harvard.edu/newsletter_article/all-about-gout
• https://www.arthritis.org/diseases/gout
• https://creakyjoints.org/about-arthritis/gout/gout-overview/gout-misdiagnosis/
• https://creakyjoints.org/wp-content/uploads/2021/12/Patient-Guide-to-Gout_2ndEd_120921.pdf
• https://www.webmd.com/arthritis/ss/slideshow-gout
• https://www.medicalnewstoday.com/articles/144827
• https://www.versusarthritis.org/about-arthritis/conditions/gout/
• https://www.mayoclinic.org/diseases-conditions/gout/symptoms-causes/syc-20372897
• https://wikem.org/wiki/Gout_and_pseudogout
• https://www.hopkinsarthritis.org/arthritis-info/gout/clinical-presentation-of-gout/
• https://www.assh.org/handcare/blog/what-is-the-difference-between-gout-and-pseudogout
• https://jfootankleres.biomedcentral.com/articles/10.1186/1757-1146-4-13
• https://footeducation.com/gout-great-toe-podagra/
• https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/conditions/gout
• https://www.arthritis-health.com/blog/4-comparisons-gout-and-pseudogout
• https://orthop.washington.edu/patient-care/articles/arthritis/gout.html
• https://arthritis-research.biomedcentral.com/articles/10.1186/ar1906
• YouTube Video: Gout – causes, symptoms, diagnosis, treatment, pathology: https://youtu.be/bznoU5bke4U
• UK Gout Society Fact Sheets:

Gout and other health problems, at: http://www.ukgoutsociety.org/wp-content/uploads/2020/02/goutsocietyhealthproblemsfinal2020.pdf

Caution: No advice is implied or given in articles published by us. The information contained in this paper is provided for informational purposes only. There is no implied endorsement or promotion of any organisation by the writer. This guide is for general interest only and is compiled from the sources stated but has not been medically reviewed. It should never be used as a substitute for obtaining advice from your Doctor, a consultant Rheumatologist or other qualified clinician/medical practitioner. If you have already been given dietary advice you should not make changes without first talking to your GP, consultant or dietitian. Any medications mentioned in this paper include names for US drugs. The facts are believed to be correct as at the date of publication, but there may be certain errors and omissions for which we cannot be responsible. The hyperlinks were valid at the date of publication.

Gout and treatments, at: http://www.ukgoutsociety.org/wp-content/uploads/2021/03/Final_All_about_gout_and_treatment_2021.pdf

Gout and diet, at: http://www.ukgoutsociety.org/wp-content/uploads/2020/02/goutsociety-allaboutgoutanddiet-2020.pdf

• Video from John Hopkins Rheumatology: what is Gout? An Introduction to Gouty Arthritis: https://youtu.be/12oykWTeaXg
• Video: How to Treat Gout Attacks at Home – WebMD: https://www.webmd.com/arthritis/gout-attacks-at-home
• Video: https://upload.wikimedia.org/wikipedia/commons/transcoded/b/b2/En.Wikipedia-VideoWiki-Gout.webm/En.Wikipedia-VideoWiki-Gout.webm.720p.vp9.webm
• Book: The Intestine Phenomenon: Gut Health and Good Digestion, Nutritional and Lifestyle Factors in Rheumatism, Cancer, Diabetes, Gout and Autoimmune Diseases (Guidebook), by Liam Wade, available at: https://www.amazon.co.uk/Intestine-Phenomenon-Nutritional-Rheumatism-Autoimmune/dp/B095GJ4Y5F/
• Book: What Foods To Eat To Get Rid Of Gout: Verywell Health: Free Gout Cookbook, by Jamar Devalk, available at: https://www.amazon.co.uk/What-Foods-Eat-Get-Gout/dp/B09FS2TJTT/
• Book: Gout: The Patrician Malady, by Roy Porter, available at: https://www.amazon.co.uk/Gout-Patrician-Malady-Roy-Porter/dp/0300073860/
• Book: Gout Relief Now: Your Quick Guide to Gout Treatment, Diet, Medicine, and Home Remedies (Natural Health & Natural Cures Series), by David Richards, available at: https://www.amazon.co.uk/Gout-Relief-Now-Treatment-Medicine/dp/1500612901/
• Book: The Gout Diet & Cookbook: An Introduction to Low Purine Foods and Meals for People with Gout, by Kenneth Martin, available at: https://www.amazon.co.uk/Gout-Diet-Cookbook-Introduction-Purine/dp/1543247695/
• Book: New Guide to Medicines & Drugs (11^th Edition), available at: https://www.amazon.co.uk/New-Guide-Medicine-Drugs-Reference/dp/0241471028/

1. Sources: (1) Dalbeth, N; Merriman, TR; Stamp, LK (April 2016). “Gout”. Lancet (Review). 388 (10055): 2039–52, and (2) “Rich Man’s Disease – definition of Rich Man’s Disease in the Medical dictionary”. Free Online Medical Dictionary, Thesaurus and Encyclopedia. ↑
2. See explanation at: https://link.springer.com/article/10.1007/s11926-013-0400-9 ↑
3. Source: Richette P, Bardin T (January 2010). “Gout”. Lancet. 375 (9711): 318–28. ↑
4. See: https://en.wikipedia.org/wiki/Metatarsophalangeal_articulations ↑
5. Source: Schlesinger N (March 2010). “Diagnosing and treating gout: a review to aid primary care physicians”. Postgrad Med. 122 (2): 157–61 ↑
6. Source: Dalbeth, N; Merriman, TR; Stamp, LK (April 2016). “Gout”. Lancet (Review). 388 (10055): 2039–52. ↑
7. Source: https://orthop.washington.edu/patient-care/articles/arthritis/gout.html ↑
8. The condition is called hyperuricemia ↑
9. Sources: (1) Hui, M; Carr, A; Cameron, S; Davenport, G; Doherty, M; Forrester, H; Jenkins, W; Jordan, KM; Mallen, CD; McDonald, TM; Nuki, G; Pywell, A; Zhang, W; Roddy, E; British Society for Rheumatology Standards, Audit and Guidelines Working, Group. (26 May 2017). “The British Society for Rheumatology Guideline for the Management of Gout”. Rheumatology (Oxford, England). 56 (7): e1–e20; and (2) Richette P, Bardin T (January 2010). “Gout”. Lancet. 375 (9711): 318–28.  ↑
10. Sources: (1) Stamp, LK (April 2016). “Gout”. Lancet (Review). 388 (10055): 2039–52; and (2) Hui, M; Carr, A; Cameron, S; Davenport, G; Doherty, M; Forrester, H; Jenkins, W; Jordan, KM; Mallen, CD; McDonald, TM; Nuki, G; Pywell, A; Zhang, W; Roddy, E; British Society for Rheumatology Standards, Audit and Guidelines Working, Group. (26 May 2017). “The British Society for Rheumatology Guideline for the Management of Gout”. Rheumatology (Oxford, England). 56 (7): e1–e20. ↑
11. Source: Stamp, LK (April 2016). “Gout”. Lancet (Review). 388 (10055): 2039–52. ↑
12. Source: Shekelle, P. G; Newberry, S. J; Fitzgerald, J. D; Motala, A; O’Hanlon, C. E; Tariq, A; Okunogbe, A; Han, D; Shanman, R (2017). “Management of Gout: A Systematic Review in Support of an American College of Physicians Clinical Practice Guideline”. Annals of Internal Medicine. 166 (1): 37–51. ↑
13. Ibid ↑
14. Sources: (1) “Questions and Answers about Gout”. National Institute of Arthritis and Musculoskeletal and Skin Diseases. June 2015; and (2) Roddy, E; Choi, HK (May 2014). “Epidemiology of gout”. Rheumatic Disease Clinics of North America. 40 (2): 155–75. ↑
15. Source: https://orthop.washington.edu/patient-care/articles/arthritis/gout.html ↑
16. Source: https://www.versusarthritis.org/about-arthritis/conditions/gout/ ↑
17. Source: Richette P, Bardin T (January 2010). “Gout”. Lancet. 375 (9711): 318–28. doi:10.1016/S0140-6736(09)60883-7. PMID 19692116. S2CID 208793280. ↑
18. Source: Dalbeth, N; Merriman, TR; Stamp, LK (April 2016). “Gout”. Lancet (Review). 388 (10055): 2039–52. doi:10.1016/S0140-6736(16)00346-9. PMID 27112094. S2CID 208790780. ↑
19. Source: Richette P, Bardin T (January 2010). “Gout”. Lancet. 375 (9711): 318–28. doi:10.1016/S0140-6736(09)60883-7. PMID 19692116. S2CID 208793280. ↑
20. Sources: (1) Richette P, Bardin T (January 2010). “Gout”. Lancet. 375 (9711): 318–28. doi:10.1016/S0140-6736(09)60883-7. PMID 19692116. S2CID 208793280, and (2) “Rich Man’s Disease – definition of Rich Man’s Disease in the Medical dictionary” (Free Online Medical Dictionary, Thesaurus and Encyclopedia). ↑
21. See: https://en.wikipedia.org/wiki/Ancient_Egypt ↑
22. See: https://footeducation.com/gout-great-toe-podagra/ ↑
23. Source: https://www.healthline.com/health/pseudogout ↑
24. Based on Table at: https://www.tristatearthritis.com/arthritis/gout/4-ways-that-gout-and-pseudogout-are-different/ ↑
25. While certain joints are more likely to be affected, both Gout and Pseudogout can affect any joint in the body, according to: https://www.arthritis-health.com/blog/4-comparisons-gout-and-pseudogout ↑
26. Source: https://www.arthritis-health.com/blog/4-comparisons-gout-and-pseudogout ↑
27. Source: Ragab G, Elshahaly M, Bardin T. Gout: An old disease in new perspective – A review. J Adv Res. 2017. Sep 1;8(5):495-511. PMCID: PMC5512152 DOI: 10.1016/j.jare.2017.04.008 ↑
28. Source: Slobodonick A, Toprover M, Pillinger M. Crystal Arthritis. In: Efthimiou P, ed. Absolute Rheumatology Review. Springer Nature Switzerland AG; 2020; chap 15. Accessed September 15, 2020. https://doi.org/10.1007/978-3-030-23022-7_15 ↑
29. Source: Sidari A, Hill E. Diagnosis and Treatment of Gout and Pseudogout for Everyday Practice. Prim Care. 2018;45(2):213-236. doi:10.1016/j.pop.2018.02.004 ↑
30. Source: Slobodonick A, Toprover M, Pillinger M. Crystal Arthritis. In: Efthimiou P, ed. Absolute Rheumatology Review. Springer Nature Switzerland AG; 2020; chap 15. Accessed September 15, 2020. https://doi.org/10.1007/978-3-030-23022-7_15 ↑
31. Ibid ↑
32. Genetic and Rare Diseases Information Center, National Institute for Advancing Translational Sciences. Chondrocalcinosis 2. Last updated January 12, 2018. Accessed August 4, 2020. https://rarediseases.info.nih.gov/diseases/1292/chondrocalcinosis-2 ↑
33. Source: https://creakyjoints.org/about-arthritis/gout/gout-overview/gout-misdiagnosis/ ↑
34. Source: https://www.nhs.uk/conditions/gout/ ↑
35. Source: https://www.versusarthritis.org/about-arthritis/conditions/gout/ ↑
36. See: https://www.nhs.uk/better-health/lose-weight/ ↑
37. Based on information at: https://www.nhs.uk/conditions/gout/ © Crown Copyright. ↑
38. Sources: https://khealth.com/learn/gout/fastest-way-to-treat-gout/, https://www.amazon.co.uk/New-Guide-Medicine-Drugs-Reference/dp/0241471028/ and https://www.nhs.uk/medicines/allopurinol/ (© Crown Copyright acknowledged) ↑
39. The proximal tubules are a major component of the kidney and are responsible for the reabsorption of the majority of the glomerular ultrafiltrate, along with the reabsorptive or secretory transport of a vast number of solutes regulating the fluid-electrolyte and acid-base regulation of the body. See: https://en.wikipedia.org/wiki/Proximal_tubule ↑
40. Source: https://en.wikipedia.org/wiki/Sulfinpyrazone ↑
41. See: https://www.webmd.com/arthritis/gout-triggers-uric-acid ↑
42. See: http://www.ukgoutsociety.org/PDFs/goutsociety-allaboutgoutanddiet-0917.pdf879kb ↑
43. See: https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/gout-diet/art-20048524 ↑
44. Source: Based on https://www.webmd.com/arthritis/gout-diet-curb-flares See also: https://www.webmd.com/diet/foods-high-in-purines#1 ↑
45. See: https://www.webmd.com/arthritis/gout-triggers-uric-acid ↑
46. Source: https://orthop.washington.edu/patient-care/articles/arthritis/gout.html ↑
47. According to: Efthimiou, Petros. (2020). Absolute Rheumatology Review. 10.1007/978-3-030-23022-7. ↑
48. Source: https://facty.com/ailments/gout-ailments/10-home-remedies-for-gout/ ↑
49. Source: https://www.arthritis-health.com/blog/gout-attacks-strike-mostly-night ↑
50. Source: Martillo MA, Nazzal L, Crittenden DB. The crystallisation of monosodium urate. Curr Rheumatol Rep. 2014;16(2):400. PMID: 24357445 doi:10.1007/s11926-013-0400-9 ↑
51. Sources: Choi HK, Niu J, Neogi T, Chen CA, Chaisson C, Hunter D, Zhang Y. Nocturnal risk of gout attacks. Arthritis Rheumatol. 2015 Feb;67(2):555-62. PMCID: PMC4360969 DOI: 10.1002/art.38917 and (2) Zhang Y, Peloquin CE, Dubreuil M, et al. Sleep Apnea and the Risk of Incident Gout: A Population-Based, Body Mass Index-Matched Cohort Study. Arthritis Rheumatol. 2015;67(12):3298-3302. PMID: 26477891 doi:10.1002/art.39330 ↑
52. Sources: Choi HK, Niu J, Neogi T, Chen CA, Chaisson C, Hunter D, Zhang Y. Nocturnal risk of gout attacks. Arthritis Rheumatol. 2015 Feb;67(2):555-62. PMCID: PMC4360969 DOI: 10.1002/art.38917 and (2) Bouloukaki I, et al. (2014). Intensive versus standard follow-up to improve continuous positive airway pressure compliance. European Respiratory Journal, 44(5): 1262–1274. PMID: 24993911 DOI: 10.1183/09031936.00021314 ↑
53. From: https://www.arthritis.org/health-wellness/healthy-living/nutrition/healthy-eating/12-best-foods-for-arthritis ↑
54. Explanation: Gout in the foot most commonly occurs at the base of the big toe, known as the metatarsophalangeal joint. Gout affecting the big toe accounts for over 50% of cases of the disease and is also known as Podagra. ↑
55. In Volume 33, June 2021, Pages 170-181, see the abstract at: https://www.sciencedirect.com/science/article/pii/S1879981721000231#abs0005 ↑
56. Sources – various, including: https://www.mkfm.com/news/strange-news/old-manuscripts-which-reveal-bizarre-medieval-medical-cures-being-shared-by-cambridge-university, Daily Telegraph, 18^th August 2022, p3, https://www.bbc.co.uk/news/uk-england-cambridgeshire-62584465, https://www.ranker.com/list/how-historical-figures-tried-to-treat-gout/genevieve-carlton ↑