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Gout exacerbation
Last reviewed: 05.07.2025

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Gout is a subtype of arthritis, the occurrence of which is associated with a failure of metabolic purine metabolism, which occurs with the formation of uric acid crystals in the joints. An exacerbation of gout brings a person excruciating pain, accompanied by other pathological symptoms. If the patient's health deteriorates, he needs urgent medical care, which can only be provided by specialists.
Causes of exacerbation of gout
Depending on the catalyst that caused the attack (and the increase in uric acid levels in the blood), the disease in question is divided into primary and secondary pathologies. But as experience shows, the source of hyperuricemia, which provokes the development of primary gout, in most cases remains undefined. One of the assumptions of modern doctors is the version of a complex imposition of hormonal and genetic factors that worked on the basis of certain characteristics and human preferences in nutrition.
The causes of exacerbation of secondary gout are due to the following sources:
- Drug therapy. Long-term use of some drugs can provoke the development of this pathological process. For example, such consequences of taking can be given by thiazide diuretics, aspirin, nicotinic acid, pyrazinamide,
- Excess weight. As statistics show, people with extra pounds have this problem three times more often than people with a thin build.
- Genetic predisposition of the patient. If a close relative in his family had such a problem. Every fifth patient with this diagnosis has a relative with gout.
- Excessive consumption of alcoholic beverages. They provoke an increase in the level of uric acid in the drinker's body, which ultimately leads to the pathology discussed in this article.
- Organ transplantation.
- Leukemia is a group of malignant diseases that affect cells involved in the process of hematopoiesis.
- Psoriasis is a presumably autoimmune non-infectious pathology that primarily affects the patient’s skin.
- Lymphoma is a cancerous pathology that affects the human lymphatic system.
Risk factors include the patient's age and gender. Gout mostly affects men over forty years of age. But this does not exclude the occurrence of this disease in women, such cases are simply diagnosed much less frequently.
Pathogenesis
To effectively treat a disease, doctors must understand its pathogenesis, only then can one expect a complete cure or transfer of the disease to the remission stage. Otherwise, therapy affects only the symptomatic indicators of the disease, which can somewhat improve the patient's condition, but not solve the problem as a whole.
The basis of the problem is the growth of uric acid levels in the blood, which can be caused by various reasons. Also, hyperuricemia is not a single symptom of gout, it is present in the symptoms of a fairly wide range of diseases.
Therefore, the pathogenesis of the disease considered in this article is based on a triumvirate of factors:
- Deposition of uric acid compounds in tissue structures.
- Modified transition of these compounds into crystalline structures.
- Inflammatory processes affecting the joint tissues of the human body, that is, the places where substances accumulate that form into gouty granules (tophi).
Failures in purine metabolism lead to activation of the process of uric acid formation. The source of such a phenomenon can be endogenous purines produced directly by the patient's body and exogenous purines that a person receives with food.
Almost all mammals have an enzyme called uricase. It works to break down uric acid and remove it from the body. If the process of uricase production was disrupted genetically or during development in the patient's body, then, accordingly, there is a failure in the destruction of the acid, which provokes its accumulation in the human body.
Symptoms of gout flare-up
As practice shows, doctors divide the disease in question into stages, each with its own symptoms:
- Asymptomatic hyperuricemia.
- Acute gouty arthritis.
- Monoarticular gout.
- Polyarticular gout.
- Intercritical gout.
- Chronic gout.
The symptoms of an exacerbation of gout, perhaps, have the most pronounced symptomatic coloring:
- High intensity pain localized in the area of joints and adjacent tissues.
- The pain increases with any movement in the problem area. Sometimes even a minor load is unbearable. For example, a blanket that the patient covers himself with while resting.
- The pain syndrome mainly bothers at night and in the morning.
- Swelling of the joint and, in some cases, adjacent tissues.
- An increase in temperature readings locally at the site of the lesion.
- Hyperemia of the skin. The dermis becomes smooth and glossy.
- Chills and a slight increase in body temperature are possible.
- Deterioration of the general condition of the body and appetite.
The symptoms mainly affect one joint.
First signs
If we talk directly about the disease, its first signs are manifested by the emergence and growth of peculiar growths in the joint area. When the disease worsens, a person begins to feel increasing pain in the affected area. Sometimes, after several pain attacks, the exacerbation may stop. And further development of the pathology is also possible, in which the entire spectrum of pathological symptoms gradually begins to manifest.
Consequences
The essence of the issue directly depends on the actions that were taken or not taken against the background of an exacerbation of gout. If adequate measures were taken in a timely manner to stop the attack, then the consequences of the exacerbation are represented by the attenuation of the inflammatory process. Gradually, the pain and all accompanying symptoms begin to go away. Over time, the person returns to his usual life.
But not everything is as rosy as it seems at first glance. Over time, the destructive process progresses, involving new joints. Uric acid substances begin to accumulate, destroying them too, but for the time being the disease does not manifest itself. Crystalline deposits (tophi) grow and, under certain circumstances, a new, but already larger-scale, exacerbation occurs.
The areas of predominant accumulation are the joints of the phalanges of the fingers and toes, knees, elbow joints, forearm area, helices of the auricles and a number of others.
Complications
With proper therapeutic treatment, you can count on a fairly high quality of life. Timely treatment, disease prevention and regular medical monitoring are the three pillars on which the normal life of a person with a history of gout rests.
But with improper care, ignoring the doctor's recommendations or in the case of an advanced disease, complications may be observed. They can be expressed by such deviations in the patient's health:
- Transition of the disease to a chronic form.
- Destruction of cartilage and bone tissue occurs.
- Deformation of the articular apparatus.
- Immobilization of the joint.
- Almost constant, never-ending pain.
- Difficulty walking.
- The appearance and increase in size of tophi. In the absence of adequate therapy, they can reach significant size parameters (there are known cases when the size approached the parameters of a golf ball). The growth of these bone formations leads to complete disability of a person.
- Up to 40% of patients diagnosed with gout also have kidney problems. These include kidney stones, nephrolithiasis, and, in extreme cases, renal failure.
- With prolonged course of the disease, pathological changes begin to affect the cardiovascular system, causing ischemic heart disease and cardiac dysfunction, as well as hypertensive manifestations.
- This process also influences the development of diabetes, cataracts, and dry eye syndrome in the patient.
- Although quite rare, there have been cases of complications affecting the respiratory organs, that is, the appearance of uric acid crystal deposits in the lung tissue.
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Diagnosis of exacerbation of gout
Only an experienced qualified doctor can correctly diagnose the disease. At the same time, he must have the necessary results of tests and other medical examinations, examination of the patient by the doctor himself. Directly, the diagnosis of exacerbation of gout consists of a number of studies:
- Laboratory tests.
- Synovial fluid analysis.
- Urine tests.
- Blood test to determine uric acid levels.
- Instrumental diagnostics.
- Radiography.
- Computed tomography (CT).
- Magnetic resonance imaging (MRI).
- Differential diagnosis – exclusion of other diseases with similar symptoms:
- Pseudogout is a common inflammatory arthritis that is common in older people. Initially, the pain syndrome appears in the knee, then in other joints, but usually it does not affect small joints (for example, on the fingers). Exacerbation mainly occurs in the fall or early spring.
- Septic arthritis.
- Infectious arthritis.
- Rheumatoid arthritis. Severe inflammation, pain syndrome. Diagnosis is made only on the basis of detailed tests and studies.
- Arthrosis, osteoarthritis.
- Various infections.
- Charcot's foot, neuropathic arthropathy. In the early stages, the symptoms of this disease are similar to gout: swelling of the lower limb, hyperemia, cracks in bone tissue, displacement of blood vessels.
- Bunion of the big toe.
- A number of other pathologies.
Tests
When establishing a diagnosis, the specialist must have a complete clinical picture of the disease. For this, the patient is required to undergo laboratory tests. In this case, if gout is suspected, the patient is prescribed:
- Synovial fluid examination. This analysis is a fairly informative and accurate method for diagnosing the disease discussed in this article. Synovial fluid is essentially a joint lubricant that “envelops” the entire joint, forming a protective sac. This analysis can diagnose the disease even during remission. The method involves taking fluid from the joint sac by puncture. The procedure is not so painful that even local anesthesia is required. No painkillers are used for another reason – they can reduce the reliability of the result. The fluid taken is sent to a specialized laboratory, where it is possible to identify the presence (or absence) of monosodium urate (MSU) crystals. Their presence confirms the disease described in this article.
- Urine tests. If the patient shows signs of hyperuricemia, even if he is a young man, this test will determine the amount of uric acid in the urine. If this parameter is higher than the accepted standards, the attending physician will refer the patient for additional tests. After all, such an indicator may indicate both gout and the formation of sand and stones in the kidneys or bladder. The fluid to be tested is collected during the period of pain relief, after the patient has started a purine diet. During this period, the patient should not take even low-alcohol drinks or any pharmacological agents. These substances can change the veracity of the result.
- Blood test. This study is conducted to determine the level of uric acid in this fluid. If the parameter in question has a low level of the characteristic, then this diagnosis is immediately dismissed as invalid. If the obtained indicator is significantly higher than the norm, we are talking about hyperuricemia and, accordingly, about the suspicion of gout. In this case, an analysis of the accompanying symptoms is carried out. But it is worth remembering that the presence of hyperuricemia is not necessarily a sign of the disease in question, and in the case of an exacerbation of gout, the level of uric acid is not always higher than normal. It can be within acceptable limits or even slightly lower. But still, as medical statistics show, in more than 80% of cases of increased content of uric acid in urine, the diagnosis of gout was confirmed.
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Instrumental diagnostics
Modern medicine cannot do without additional research conducted using specialized medical equipment. Instrumental diagnostics of the disease in question can be expressed in a number of methods, but the most popular are:
- X-ray, which gives a complete picture of the condition of bone tissue and the presence, as well as the degree, destruction and deformation of the joint. This technique allows you to identify other, concomitant diseases. An X-ray image reflects the real state of the musculoskeletal system, the presence of tophi even before they are visible to the naked eye.
- Computer tomography. This technique visualizes the processes occurring in the area of interest.
- Magnetic resonance imaging (MRI). The method is similar to the previous one. It allows to examine the joint in 3D dimension. At the same time, the produced photo frame package allows to use the obtained examination results more than once.
- Ultrasound Dopplerography is an examination performed to study the state of blood flow in the vessels invaded in the area of interest.
Differential diagnostics
Even having all the results of the research and analysis, having received a complete picture of the disease, only a qualified experienced doctor can make a correct diagnosis. They conduct differential diagnostics, the essence of which is to exclude diagnoses with similar symptoms and confirm one.
Most often, people who are far from medicine confuse the diagnosis considered in this article with pseudogout. The symptoms of these diseases are very similar. Therefore, in order to differentiate the disease, a physicochemical analysis of urate crystals is carried out.
An analysis is prescribed to identify infectious lesions of the body, leading to diseases such as infectious arthritis, Lyme disease, fungal, bacterial, tuberculous, septic, viral arthritis, osteomyelitis.
The doctor must also exclude such pathologies as rheumatoid arthritis, big toe bursitis, systemic vasculitis, Reiter's syndrome, Still's disease, Charcot's foot, neuropathic arthropathy and many other pathologies with similar symptoms.
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Treatment of exacerbation of gout
Once the diagnosis is established, the doctor can begin to prescribe a treatment protocol for the disease. Treatment of gout exacerbation is conventionally divided into two main stages. First, it is necessary to reduce the intensity of pathological symptoms. In the second stage, doctors begin to treat the pathology or preventive measures that allow the disease in question to enter the remission stage, which will help avoid a relapse.
In the modern protocol of gout treatment, doctors introduce mild drugs to at least partially protect the stomach from their effects. The most commonly used drugs are celecoxib, meloxicam or nimesulide, which belong to the pharmacological group of selective blockers.
Until recently, doctors relieved the severity of attacks with drugs that have anti-inflammatory properties: diclofenac or indomethacin. But as further observations show, these drugs have a negative effect on the functioning of the kidneys and liver, which is unacceptable, especially in the case of gout, in which these organs already undergo negative changes.
Colchicine is sometimes prescribed, but it is not as popular as the drugs mentioned above. This is due to its fairly wide side effects and negative impact on the kidneys, digestive tract and liver.
But some patients do not require drug correction; it is enough to limit your diet during an exacerbation, excluding food products that bring uric acid into the body. It will also be useful to monitor your weight, preventing the development of obesity.
In case of exacerbation, the patient may be prescribed drugs with pain-relieving properties. These may be: no-shpa, analgin, diclofenac, paracetamol, mig 400, aspirin, ketanov, nurofen, bral, tramadol and others.
Medicines
As already mentioned above, the patient is prescribed the following anti-gout medications
Such as purinol, allopurinol, alopron, egis, allupol, sanfipurol and others.
The essence of drug therapy is to reduce the level of uric acid in the patient's blood. And here allopurinol, an active anti-gout drug, shows high efficiency.
It is prescribed in an amount directly dependent on the level of uric acid environment. The minimum dosage of the drug is 100 mg, the maximum is 800 mg. Usually, on average, this level is 200 - 400 mg per day, divided into one or two doses.
Monthly monitoring of serum uric acid levels is necessary here.
Contraindications for this drug include hypersensitivity to the components of the drug, renal failure, pregnancy and breastfeeding.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are included in the treatment protocol for patients who do not have any particular health problems, as they have a significant impact on the liver and excretory organs. These include: ibuprofen (in low doses), motrin, naproxen, indomethacin, diclofenac, sulindac, ketoprofen, voltaren, dexibuprofen and a number of others.
Indomethacin is the strongest inhibitor of prostaglandin biosynthesis and is usually taken after meals in the amount of 25 mg two to three times a day. If necessary, this dosage can be increased to 100-150 mg daily, divided into three to four doses.
Contraindications for this pharmacological agent include hypersensitivity to the components of the drug, ulcerative disease of the mucous membrane of the digestive organs, renal failure, bronchial asthma, pregnancy and breastfeeding.
Drugs of this pharmacological focus are used in a limited manner due to their negative impact on the functioning of the excretory system and liver.
The anti-inflammatory and antirheumatic drug nimesulide is prescribed to adult patients at a dosage of 100 mg twice a day. For maximum effectiveness, it is recommended to take it after meals. The drug is not prescribed to children under twelve years of age, and the dosage for older adolescents is calculated using the formula 5 mg per kilogram of the patient's weight, divided into two daily doses.
Contraindications to nimesulide include hypersensitivity of the patient's body to its components, significant disruptions in the functioning of the kidneys and liver, the presence of internal gastric bleeding, ulcerative or erosive lesions of the gastric mucosa or duodenum (especially during an exacerbation), as well as the period of pregnancy and lactation in women.
The treatment protocol may also include uricolytic drugs, which are designed to protect the patient's kidneys from reabsorbing uric acid substances, which facilitates their better removal from the body.
Such drugs include, for example, sulfinpyrazone (anturane) and probenecid (benemid, probalan).
The starting dosage of probenecid is 0.25 g two to three times a day for a month. The dosage is increased gradually. At the same time, an experienced specialist knows that greater efficiency can be achieved by introducing colchicine into the treatment protocol together with probenecid.
People suffering from gout often have problems with blood pressure. Therefore, such a patient may be prescribed antihypertensive drugs.
Ointment for exacerbation of gout
When the symptoms of an attack increase, its blockade is initially performed. Then, therapy is carried out aimed at restorative processes in bone and connective tissues. An ointment with anti-inflammatory, anti-gout and analgesic properties can be prescribed for an exacerbation of gout. In this regard, the ointment Fulflex has proven itself well.
The ointment should be rubbed into the affected joint tissues twice a day. It is recommended to do this immediately after waking up in the morning and before going to bed. The drug is used until the inflammation is relieved and the pain symptoms disappear.
To optimize treatment, it is recommended to use Fulflex ointment, together with oral administration of Fulflex capsules, against the background of proper nutrition.
Due to the fact that the drug in question is made on the basis of natural plant components, its contraindications are not so significant. They include only increased sensitivity or intolerance to at least one of the components of the drug, a tendency to allergic reactions, pregnancy and lactation, the patient's age under 14 years.
Other ointments are often used to relieve pain and inflammation. For example, fastum gel, niflugel and others.
Folk remedies for gout flare-ups
The experience of our ancestors allows us to use folk medicine to stop many diseases. This fact also applies to our problem.
One of the methods of treatment our ancestors considered cleansing the body, including joints. For example, this procedure can be carried out with an infusion of laurel leaves.
The medicine is prepared the day before. 5 g of raw material is poured with half a liter of boiling water, boiled for another five minutes and, poured into a thermos, left to brew overnight. In the morning, strain the medicine and drink in small sips throughout the day. This infusion should be taken for two to three days, after which it is necessary to take a week's break. Then continue the cleansing.
Bee products are a wonderful medicine for the pathology in question. Both ointments based on bee venom and bee stings themselves, which are applied to the affected joint, are used. But this method is only suitable for a patient who is not allergic to bee products.
This recipe will also find its application: rinse three onions and place them in a liter of boiling water. Put on medium heat and cook until the bulbs begin to lose shape, falling apart. Let the mixture cool slightly, then strain it and take 150 ml before each daytime meal. The duration of onion therapy is at least two weeks. The decoction relieves pain symptoms quite well. If another attack occurs, this "medicine" can be taken again.
A significant place in the treatment of gout is given to various herbal infusions and decoctions - this is the basis of alternative treatment methods.
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Herbal treatment
Due to the fact that nature has given us a great variety of medicinal plants with diverse characteristics, herbal treatment for gout occupies a significant part of the prescription heritage. Here we will recall only a few of them.
- Chamomile - salt baths. To carry them out, you first need to prepare a decoction of 100 g of plant material and a couple of liters of water. Then dilute the liquid with another 8 liters of water, placing it in a basin. Add 200 g of salt here (it is good if it is sea salt). We carry out the procedures by lowering the sore joint into the prepared solution.
- You can do similar procedures, but take 50 g of chamomile and 50 g of black elder flowers for the decoction. You can make baths with such a decoction or apply compresses based on it to the sore joint.
- Succession has proven itself well; it should be brewed in a water bath for a quarter of an hour, diluting a tablespoon of the plant with a glass of boiling water. Drink instead of tea.
- Oatmeal decoctions are also effective, the preparation of which will take some time. Pour a glass of grain with a liter of water and put in a container on the fire, bring to a boil and keep on the fire until the volume of liquid is reduced by half. In this case, the fire should be low. Then set aside on the side and let cool slightly. Strain. Mix the resulting liquid with two glasses of whole milk. Bring to a boil again. Drink one glass of "medicine" three times a day.
- A tincture of common lilac flowers will also do. The medicine is prepared as follows: take a dark glass container and fill it completely with plant material. Then pour in alcohol or vodka. For a 0.5 l bottle of lilac flowers, approximately 200 ml of alcohol will be needed. Seal the vessel and place in a dark place for seven days. The product must be shaken periodically. The tincture is taken before meals, 20-30 drops.
- Teas brewed on lingonberry or strawberry leaves have proven themselves well. Such a drink should be drunk for two to three months, one cup twice a day. During the berry season, they can be eaten raw, at least one glass a day.
- Ginger root taken as tea is an excellent anti-inflammatory. One or two teaspoons of grated product per cup of boiling water taken three times a day is enough to feel a surge of strength and prevent the development of the disease.
There are many other recipes, but before using folk remedies, it would not be a bad idea to consult a specialist.
Homeopathy for acute gout
Today, homeopathy is gaining more and more popularity among people who are committed to treating various diseases using alternative medicine methods.
In relation to the treatment of the disease in question, homeopathic doctors are ready to offer a number of drugs that, if they do not allow a person to achieve complete recovery, will help eliminate pathological symptoms, improving the patient’s condition.
Urtica urens - this homeopathic product cleanses joints and many body systems well. Its base is stinging nettle. The drug is taken 5 drops, diluted with a small amount of water every two to three hours. By removing excess uric acid, the medicine relieves the severity of an attack well.
Benzoicum acidum is another homeopathic preparation with similar action. Its base is benzoic acid, obtained from natural raw materials.
Colchicum - relieves swelling and stops the inflammatory process. The basis of the drug is the medicinal plant colchicum.
Sarsaparilla is a pain reliever that helps with the painful symptoms of gout.
Ledum palustre - relieves inflammation of small joints of the feet and hands, tendons and heels. Helps remove excess uric acid. The basis of the drug is the medicinal plant marsh wild rosemary.
Urea pura – relief of acute manifestations of gout and gouty eczema. The basis of the medicine is urea.
Uricum acidum - allows to soften gouty conglomerates of uric acid deposits. The drug is especially effective for gout, gouty eczema, rheumatism.
Surgical treatment
But, as sad as it sounds, it is not always possible to get by with just dietary adjustments, medication or folk medicine. If the clinical picture of the disease is represented by tophus or tophuses of large sizes, and the area of pathology is infected, causing the patient a lot of inconvenience (pain and difficulty in movement), such a patient is indicated for surgical treatment.
If the immobilization of the joint is aggravated by infection, the situation is associated with a high risk of complications that can only be prevented by performing an operation to remove uric acid from the soft tissues adjacent to the joint. In some cases, such an operation can affect the joint itself. The deformed organ can be replaced with a prosthesis.
Diet for exacerbation of gout
If a person has a history of gout, it is very important to eat right, because a number of foods bring an additional amount of uric acid into the human body, which is already in excess, which only worsens the pathological picture. Therefore, a diet during an exacerbation of gout is an integral part of treatment.
Such a patient needs to control the intake of excess purines into his body.
The following should be excluded from the diet of such a patient (or reduced to a minimum):
- Alcohol.
- Smoking (nicotine).
- Strong tea.
- Offal: liver, tongue, brains, kidneys.
- Reduce meat consumption, even lean meats, to 200-300 g per week.
- Daily salt intake – no more than 5 g.
- Fatty fish.
- Spices and pickles.
- Strong coffee.
- Canned and smoked foods.
- Any rich broths.
- Mushrooms.
- Legumes.
- Fresh fruits and vegetables. Only thermally processed products are allowed.
- Chocolate.
- Fresh baked goods.
- Caviar.
- Cocoa.
- Dried fruits.
It is permissible to leave in the diet:
- Porridges and soups based on any cereals.
- Eggs.
- Fermented milk products.
- Only thermally processed vegetables and fruits are allowed.
- Milk in small quantities.
- Natural freshly squeezed juices, compotes, fruit drinks.
- Berries.
- Whole grains.
- Stale bread from yesterday.
Doctors recommend that such patients have one or two fasting days a week, during which they should only drink kefir or cottage cheese with kefir. Apple fasting (or another mono-product) is also allowed.
Avoid overeating (switch to five or six meals a day) and fasting. The volume of one serving is no more than 200 ml.
If you eat according to the diet and follow the rest of the doctor's recommendations, then the exacerbation of the disease can be quickly stopped, and then the disease can be put into remission.
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Prevention of gout flare-ups
It is better to prevent any disease or attack than to deal with the problem that has arisen. To prevent a relapse, disease prevention is necessary. Doctors recommend:
- Monitor your diet and avoid consuming foods with high purine content.
- Exercise. It should not be a heavy load. It is quite enough to do a morning jog, walk or light exercises that would form a muscular corset. It will reduce the load on the joints, taking over some of the effort.
- Avoid putting too much strain on your joints.
- Drink enough fluids to allow you to remove excess uric acid promptly and completely.
- Intense twisting is prohibited.
- If the patient has a sedentary job, it should be compensated for by regular exercise.
- Monitor your weight. Extra pounds are an excessive load on the musculoskeletal system.
- Avoid injury to joints.
- You should not wear narrow and uncomfortable shoes. They injure the joints of the foot.
- The same applies to clothing.
- If the patient has undergone chemotherapy, then to prevent uric acid deposits in the body, he is prescribed antihyperuricemic therapy. This is mainly the use of the drug allopurinol.
Forecast
As statistics show, the prognosis for gout is quite favorable. Almost all patients with this diagnosis suffer more from the symptoms of accompanying pathologies than from the disease itself, the exception being the period of exacerbation. But the sooner adequate measures are taken, the easier it will be for the patient to endure an attack.
It is also known that such patients, in most cases, suffer from nephrolithiasis (stones and sand in the kidneys) or urolithiasis (metabolic disorder leading to the formation of urinary stones), as well as from renal failure, and it is this that can cause death, and not the disease discussed in this article.
If you have read this article, we hope you have drawn the right conclusions that an exacerbation of gout can be avoided. If all the doctor's recommendations are followed, patients usually live happily to a ripe old age, leading a quality, normal life. To do this, you should put in a little effort: proper nutrition, an active lifestyle, positive emotions and attention to your body guarantee this. But if an exacerbation does occur, you should not brush off the problem by resorting to self-treatment. It would be right to seek help from a qualified specialist who, having assessed the clinical picture of the attack, will help find the most effective and fastest solution to the problem. And we wish you good health and a full, fulfilling life!
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