What is podagra?
Podagra, which in Greek translates to ‘foot trap’, is gout which affects the joint located between the foot and the big toe, known as the metatarsophalangeal joint.
Gout, also known as gouty arthritis, results in recurrent, acute attacks of joint pain and inflammation. This is normally caused by hyperuricemia, chronically high levels of uric acid in the blood, which can cause small urate crystals to form in and around the joints. Gout tends to start in one joint, often that of the big toe, before spreading to others. Podagra is the first joint manifestation in about half of all cases of gout and is eventually seen in about 90 percent of cases.
Certain foods, especially red meat or organ meats such as liver or kidneys, as well as oily fish, drinking alcohol, and conditions such as high blood pressure or obesity may lead to the production of higher than normal levels of urate - a salt of uric acid - in the body. Gout mainly affects people over 30 years old and tends to affect more men than women.
Podagra causes severe pain in the metatarsophalangeal joint, which is the joint at the base of the big toe. The onset of podagra is characterized by intense attacks of pain, usually sudden and often at night. It is not clear how, but even without treatment, the body normally resolves a gout flare on its own. Untreated attacks normally last about 5-10 days, though the pain is most severe in the first 12-24 hours, after which time it usually improves over a few days to several weeks.
- Severe pain
- Sensation of heat
- Difficulty moving the joint
- Tophi: uric acid crystal deposits appearing as firm, yellowish nodules on the joint
Without preventive measures, the average time between the first attack and a recurrence is about one year, though podagra may recur much sooner, or it may never happen again. Subsequent attacks of podagra may last longer than the initial one, and may lead to damage in the metatarsophalangeal joint, with difficulty walking becoming permanent in some cases. In cases of chronic gout, also known as chronic gouty arthritis, a person may experience symptoms of inflammation most or all of the time.
Podagra is a manifestation of gout, in which uric acid crystallizes and settles in one or more joints. This is often caused either by excess amounts of uric acid being produced, or not enough being excreted from the urine on a chronic basis. Any abrupt increase in the level of uric acid in the blood may also trigger an attack of podagra or gout.
Most people with elevated blood levels of uric acid will never develop podagra and gout, and gout is not always associated with elevated uric acid blood levels; the condition can also occur despite there being normal levels of uric acid at the point in time when blood levels are measured.
It is thought to develop due to an immune response. White blood cells and joint-lining cells may attempt to surround and digest urate crystal deposits. The chemical signals sent out by these cells contribute to the characteristic inflammation of podagra specifically and gout in general.
Uric acid crystals tend to settle in the big toe, as in the case of podagra. This joint is where there tends to be increased impact from walking and supporting the weight of the body. Uric acid crystals are also less soluble under acid conditions and in cooler temperatures, as occur in the big toe and other extremities, such as the hands and feet. Attacks tend to happen at night and are thought to be made more likely by a lower body temperature.
Podagra risk factors
- Fasting or overeating protein rich foods
- High blood pressure
- Taking medications that alter urate blood levels, especially diuretics, such as for heart failure or high blood pressure
- Kidney disease, especially chronic kidney disease
- Being a man older than about 30
- Being a woman who has experienced menopause
- Regularly drinking excessive amounts of alcohol, especially rum, whisky, vodka, gin and beer
- Eating large amounts of red meat or organ meats, such as liver or kidneys, or certain oily fish such as anchovies or trout
- Consuming large amounts of fructose, such as in beverages containing high fructose corn syrup
Some rare medical conditions may increase the risk of developing gout in general and podagra as a special form of gout, such as conditions which result in:
High cell turnover: This may be caused by certain autoimmune conditions, such as psoriasis, a scaly skin condition, or as a side effect of certain medications, such as with tumor lysis syndrome, in which large amounts of tumor cells are killed off (lysed) by treatment, releasing their contents into the bloodstream.
Enzyme defects: This may be caused by certain genetic disorders which cause disordered processing of uric acid , such as Lesch-Nyhan syndrome, also known as juvenile gout.
In people who have had a gout flare-up, there are factors that may increase the risk of recurrence, including:
- Injury to the foot
- Drinking excessive amounts of alcohol.
- Fasting or overeating protein rich foods
- Taking medications that alter urate blood levels. These medicines are necessary for the management of other conditions, and should not be stopped or adjusted without a doctor’s supervision.
There are many conditions that may cause joint inflammation. Podagra is suspected if risk factors are present and a person has an acute attack of pain in the joint of the big toe.
The most definitive way for a doctor to make a diagnosis of gout and podagra is by taking a sample of fluid from a swollen joint and to look for evidence of gout crystals in the joint, using a needle and syringe to withdraw a small amount of joint fluid. Tophaceous gout – chronic gout in which hard lumps made of uric acid crystals (tophi) form around a joint – may be diagnosed by sampling the tophi, located right beneath the skin.
If joint fluid analysis is not possible, tentative diagnosis may be made based on the person's medical history, symptoms, a physical examination, and urine and blood tests to assess uric acid levels. However, hyperuricemia - high levels of uric acid in the blood - is not necessarily diagnostic of gout. Uric acid levels in the blood may fluctuate over the day, and gout may also be triggered by an abrupt drop in uric acid levels, so gout could be present despite uric acid levels being normal at the point in time when blood is drawn. Blood tests may also be analyzed for other indicators of gout or factors which may increase its likelihood, such as levels of white blood cells, triglycerides, high-density lipoproteins, glucose, as well as renal and liver function.
Treating a podagra attack
In the case of a first attack, or if a person experiences attacks less than twice a year without tophi and/or very high uric acid levels, treatment is usually limited to the duration of an attack by using medication to relieve pain and inflammation. A doctor may prescribe medication to keep on hand for use in the event of a future attack. Which medication and dose to use is determined based on a number of factors, includings kidney health, ulcer history and the person’s risk of bleeding. Possible medications include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs such as e.g. ibuprofen are effective when used as early as possible in a podagra attack and when taken in higher doses to achieve anti-inflammatory, not just pain-relieving properties. A doctor will be able to recommend the appropriate type and dose. Aspirin should be avoided for podagra and gout, as it can raise or lower uric acid levels, potentially making the condition worse.
- Colchicine: This may be prescribed in pill form for those who cannot tolerate NSAIDs. Colchicine seems to be most effective when started within the first 24 hours of an attack.
- Glucocorticoids: These may be given orally, by intra-articular (into the joint) injection, or occasionally by intravenous (IV) or intramuscular injection.
Good to know: It is recommended to rest the affected foot as much as possible by avoiding walking, or using a cane or splint to avoid putting weight on the foot. The swelling may also be brought down by elevating the foot and keeping it cool with an ice pack for 20 minutes at a time.
Chronic podagra treatment and uric acid-lowering medication
Podagra may become chronic, in which there are repeated episodes of pain and inflammation, which may also spread to multiple joints and lead to joint damage and disability. In cases of chronic podagra and gout, a uric acid-lowering regimen may be recommended to prevent or reverse the crystal deposits that lead to and worsen chronic gout.
Those with more than two gouty attacks per year, joint damage as seen on a radiograph, or tophi (uric acid crystals) may be given uric acid-lowering medication, such as allopurinol.
Good to know: Allopurinol should not be taken until the end of an acute attack, as acute drops in uric acid could prolong the attack.
During the first six months of uric acid-lowering medication, medication to reduce inflammation may be provided. This is because uric acid-lowering medications change serum and tissue uric acid levels, and so may trigger acute attacks of podagra and gout. Medication to treat swelling and pain, as well as to lessen any damage caused by podagra attacks may include:
NSAIDs are sometimes given for daily use, and have an advantage for people who also have osteoarthritis. This decreases swelling and potential joint damage.
Colchicine may be given at a low dose to prevent gastrointestinal side effects which may occur at higher doses of NSAID use. Colchicine works by decreasing swelling and lessening the buildup of uric acid crystals.
- Losing weight, if overweight: Can greatly reduce urate levels. Should be combined with regular exercise. Rapid weight loss should be avoided, as this can raise urate levels.
- Drinking plenty of water: Can reduce the risk of uric acid crystals forming in the joints. Sugary drinks should be avoided, as high levels of fructose are likely to increase blood urate levels.
- Avoiding excessive alcohol consumption: Beer and spirits are especially likely to increase urate levels.
- Close management of blood pressure and diabetes management if appropriate
- Maintaining a healthy diet: Foods rich in purines, chemical compounds made naturally by the body, but also found in high levels in certain foods, may worsen podagra and gout. Foods to be avoided include red meat, organ meats and certain oily fish, such as anchovies or mackerel. Plenty of vitamin C-rich fruit and vegetables should be eaten, as they help the kidneys to remove urate.
Q: Why does gout target the big toe?
A: Podagra is the first joint manifestation in about half of all cases of gout, and is eventually seen in about 90 percent of cases. Uric acid crystals tend to settle in the big toe, where there is normally increased stress from walking and supporting the weight of the body. Furthermore these crystals are also less soluble under acid conditions and at the cooler joints in the extremities, such as the big toe.
Q: What does a podagra attack feel like?
A: Podagra typically comes on suddenly, often with a few hours and often at night, thought to be because this is when the body temperature lowers. The toe or foot becomes swollen, red, hot and can be very painful. Sometimes a person will also experience fever and fatigue. The attack usually gets better within three days, but may not completely resolve for several weeks.
Other names for podagra
- Gout in the big toe
NCBI - NIH. "Revisiting the pathogenesis of podagra: why does gout target the foot?" 13 May 2011. Accessed 28 May 2018. ↩