Gout is a kind of
arthritis. It can cause an attack of sudden burning
pain, stiffness, and swelling in a joint, usually a big toe. These attacks can
happen over and over unless gout is treated. Over time, they can harm your
joints, tendons, and other tissues. Gout is most common in men.
What causes gout?
Gout is caused by
too much
uric acid in the blood. Most of the time, having too
much uric acid is not harmful. Many people with high levels in their blood
never get gout. But when uric acid levels in the blood are too high, the uric
acid may form hard crystals in your joints.
Your chances of
getting gout are higher if you are overweight, drink too much alcohol, or eat
too much meat and fish that are high in chemicals called purines. Some
medicines, such as water pills (diuretics), can also bring on gout.
What are the symptoms?
The most
common sign of gout is a nighttime attack of swelling, tenderness, redness, and
sharp pain in your
big toe. You can also get gout attacks in your foot, ankle, or knees. The
attacks can last a few days or many weeks before the pain goes away. Another
attack may not happen for months or years.
See your doctor even if
your pain from gout is gone. The buildup of uric acid that led to your gout
attack can still harm your joints.
How is gout diagnosed?
Your doctor will ask questions about your
symptoms and do a physical exam. Your doctor may also take a sample of fluid
from your joint to look for uric acid crystals. This is the best way to test
for gout. Your doctor may also do a blood test to measure the amount of uric
acid in your blood.
How is it treated?
To stop a gout attack, your doctor can give you a
shot of corticosteroids, or prescribe a large daily dose of one or more
medicines. The doses will get smaller as your symptoms go away. Relief from a
gout attack often begins within 24 hours if you start treatment right
away.
To ease the pain during a gout attack, rest the joint that
hurts. Taking ibuprofen or another
anti-inflammatory medicine can also help you feel
better. But don't take aspirin. It can make gout worse by raising the uric acid
level in the blood.
To prevent future attacks, your doctor can
prescribe a medicine to reduce uric acid buildup in your blood. If your doctor
prescribes medicine to lower your uric acid levels, be sure to take it as
directed. Most people continue to take this medicine for the rest of their
lives.
Paying attention to what you eat may help you manage your
gout. Eat moderate amounts of a healthy mix of foods to control your weight and
get the nutrients you need. Avoid regular daily intake of meat, seafood, and
alcohol (especially beer). Drink plenty of water and other fluids.
Gout is caused
by too much
uric acid in the blood (hyperuricemia). Hyperuricemia
usually does no harm, and many people with high levels of uric acid in the
blood never develop gout. The exact cause of hyperuricemia sometimes is not
discovered, although inherited factors (genes) seem to
play a role. When uric acid levels in the blood are too high, uric acid may
form crystals that build up in the joints. Gout can seem to flare up without
specific cause or can be brought on by factors such as:
Certain conditions related to diet and body
weight, such as:
Having been born with a rare condition that
causes high blood uric acid levels. People with Kelley-Seegmiller syndrome or
Lesch-Nyhan syndrome have a partial or complete deficiency in an
enzyme that helps to control uric acid levels.
Some people may not experience gout as many painful
attacks but rather develop chronic gout. Chronic gout in older adults may be
less painful and can be confused with other forms of
arthritis.
Gout may first appear as
nodules (tophi) on the hands, elbows, or ears. There may be no
classic symptoms of a gout attack.
By the time you experience the symptoms of a gout attack,
uric acid has been building up in your blood, and uric acid deposits have been
forming on one or more of your joints.
The big toe joint is most
commonly affected. But the joints of the feet, ankles, knees, wrists, fingers,
and elbows may also be involved. Inflammation of the fluid sacs (bursae) that cushion tissues may develop, particularly
in the elbow (olecranon
bursitis) and knee (prepatellar bursitis).
Gout usually
develops after a number of years of buildup of
uric acid crystals in the joints and surrounding
tissues. A gout attack usually starts during the night with moderate pain that
grows worse. A gout attack typically causes pain, swelling, redness, and warmth
(inflammation) in a single joint, most often the big
toe (this symptom is called podagra), followed by the eventual disappearance of
all symptoms.
Mild attacks may stop after several hours or
last for 1 to 2 days. These attacks are often misdiagnosed as "tendinitis" or "sprain" even
though there was no trauma or overuse.
Severe attacks may last up
to several weeks, with soreness lasting for up to 1 month.
Most
people have a second attack of gout within 6 months to 2 years after their
first attack but there may be intervals of many years between attacks. If
untreated, the frequency of attacks usually increases with time.
The uric acid level in the blood may be higher
than normal, but there are no symptoms of gout.
High uric acid in
the blood (hyperuricemia) may never progress beyond this stage, and symptoms of
gout may never develop.
Some people may have kidney stones before
having their first attack of gout.
Second stage: Acute gout arthritis
Uric acid crystals begin to form in the joint
fluid, usually in one joint—most commonly the big toe—and the body often
responds with a sudden inflammatory reaction: a gout attack.
Although the big toe is the most common site for a gout attack,
gout may develop in other joints, including the knee, ankle, and joints in the
foot, wrist, and fingers.
After the gout attack is over, the
affected joint and surrounding tissues feel normal within days until the next
attack, which often occurs within 2 years.
Third stage: Interval gout
If you have previously had an attack of gout,
you will very likely have another.
In this type of gout, you have
no symptoms for a period of time between acute attacks.
In many
people this period becomes progressively shorter as attacks occur more often.
Later attacks may be more severe, last longer, and involve more than one
joint.
Fourth stage: Chronic tophaceous gout
If gout symptoms have occurred off and on
without treatment for several years, they may become ongoing (chronic) and
frequently affect more than one joint. There may no longer be periods of time
between attacks. This stage of gout is frequently confused with other forms of
arthritis, most commonly
osteoarthritis.
By this time, enough uric
acid crystals have accumulated in the body to form gritty nodules called
tophi. When located just under the surface of the
skin, these deposits are usually firm and movable. The overlying skin may be
thin and red. Tophi that are very near the skin may appear cream-colored or
yellow.
At first, tophi are usually found on or near the elbow,
over the fingers and toes, or on the outer edge of the ear.
If the
condition progresses without treatment, tophi may form in the
cartilage of the external ear or the tissues around
the joint (bursae,
ligaments, and
tendons), resulting in pain, swelling, redness, and
warmth (inflammation). Progressive crippling and destruction of cartilage and
bone is possible.
This stage of gout is uncommon because of
advances in the early treatment of gout.
Gout is caused by too much
uric acid in the blood (hyperuricemia). The following
risk factors can either cause hyperuricemia or make joints more susceptible to
the formation of uric acid crystals:
Lead exposure (may occur through work, diet, or
hobbies)
Very low-calorie diets
Injury to a
joint
Gout and other conditions
Certain other conditions and diseases appear more often in people who
have gout than in people who don't, though studies have not shown a clear
relationship. It is thought that gout shares risk factors (such as obesity,
hypertension, and high levels of
triglycerides) with certain diseases,
including:
Severe pain in a single joint that comes on
very quickly.
Swollen, tender joints with overlying warm, reddened
skin.
Watchful Waiting
During an acute gout attack, you may be able to
relieve some of your discomfort by taking
nonsteroidal anti-inflammatory drugs (NSAIDs) or
colchicine and resting the affected joint until the attack eases. You can use
ice to reduce the swelling.
Although aspirin is an NSAID, don't
take it for gout. Aspirin can actually make gout worse by abruptly changing the
uric acid level in the blood.
It is important that you see your
doctor even if the pain from gout has disappeared. The uric acid buildup that
caused your gout attack may still be irritating your joints and could
eventually cause serious damage. Your doctor can prescribe medicines that will
prevent and even reverse the uric acid buildup.
Who To See
The following health professionals can diagnose and
prescribe treatment for
gout:
The only certain way to diagnose
gout is to have a joint fluid aspiration
(arthrocentesis) test to see whether uric acid crystals are present. But for
people with an acutely swollen, red, painful big toe, where it is often
difficult to obtain joint fluid, a diagnosis can be made by the presence of a
high blood
uric acid level.
The following
examinations and tests may help with diagnosis and treatment of gout:
While
X-rays of extremities (hands and feet) are sometimes
useful in the late stages of the disease, X-rays are not usually helpful in the
early diagnosis of gout. When gout is in a late stage, nodules (tophi) or even
“punched-out” (worn away or eroded) areas of bone near joints may be seen. The
pain of gout often causes people to seek medical attention before any long-term
changes can be seen on an X-ray. But X-rays may help to rule out other causes
of arthritis. See an
X-ray of gout in the foot.
The goals of treatment for
gout are rapid pain relief and prevention of future
gout attacks and long-term complications, such as joint destruction and kidney
damage. Treatment includes medicines and steps you can take at home to prevent
future attacks.
Initial treatment
Gout is treated with medicines to relieve symptoms and
measures to eliminate causes. Specific treatment depends on whether you are
having an acute attack or are trying to prevent future attacks.
To reduce the pain, swelling, redness, and warmth of the affected joint(s) in an acute gout attack:
Rest the affected joint(s).
Take one or more of the following medicines at the first sign of a gout attack,
as prescribed by your doctor.
Allopurinol
decreases production of uric acid by the body.
Take steps to reduce the risk of future
attacks.
Control your weight. Being overweight is
a risk factor for gout. If you are overweight, a diet that is low in fat may
help you lose weight. But very low-calorie diets increase the amount of uric
acid produced by the body and may bring on a gout attack. For more information,
see the topic
Weight Management.
Limit alcohol,
especially beer. Alcohol can reduce the release of uric acid by the kidneys
into your urine, causing an increase of uric acid in your body. Beer, which is
rich in
purines, appears to be worse than some other beverages
that contain alcohol.1
Limit meat and
seafood. Diets high in meat and seafood (high-purine foods) can raise uric acid
levels.
Talk to your doctor about the medicines you take. Certain
medicines that are given for other conditions reduce the amount of uric acid
eliminated by the kidneys. These include pills that reduce the amount of salt
and water in the body (diuretics, or "water pills") and
niacin. Regular use of low-dose aspirin may raise the uric acid level. Since
low-dose aspirin may be important for the prevention of stroke or heart attack,
your doctor may want you to continue to take low-dose
aspirin.
Follow a moderate exercise program.
If your doctor prescribes medicine to lower your uric
acid levels, be sure to take it as directed. Most people continue to take this
medicine for the rest of their lives.
If the blood uric acid is
high but a person has never had an attack of gout, treatment is rarely needed.
But people with extremely elevated levels may need regular testing for signs of
kidney damage, and they may need long-term treatment to lower their uric acid
levels. Your blood uric acid level may be watched by your doctor until it is
lowered to normal levels.
Ongoing treatment
If you have previously had a
gout attack, you are likely to have another,
especially if you are not managing the disease with medicines or other
treatment. The goal of treatment is to prevent future attacks, to reduce high
levels of
uric acid (hyperuricemia), and to identify and treat
the causes of your hyperuricemia. Your doctor will review your health history
and current health status to identify other medical conditions and medicines
that could be causing the elevated uric acid levels. Factors such as alcohol
consumption, diet, and body weight can be modified to lower your uric acid
levels and reduce the risk of future gout attacks.
To reduce the pain, swelling, redness, and warmth of the affected joint(s) in an acute gout attack:
Rest the affected joint(s).
Take one or more of the following medicines at the first sign of a gout attack,
as prescribed by your doctor.
Allopurinol
decreases production of uric acid by the body.
Colchicine is often prescribed to prevent flare-ups
during the first months that you are taking uric acid-lowering
medicines.
Take steps to reduce the risk of future
attacks.
Control your weight. Being overweight is
a risk factor for gout. If you are overweight, a diet that is low in fat may
help you lose weight. But very low-calorie diets increase the amount of uric
acid produced by the body and may bring on a gout attack. For more information,
see the topic
Weight Management.
Limit alcohol,
especially beer. Alcohol can reduce the release of uric acid by the kidneys
into your urine, causing an increase of uric acid in your body. Beer, which is
rich in
purines, appears to be worse than some other beverages
that contain alcohol.1
Limit meat and
seafood. Diets high in meat and seafood (high-purine foods) can raise uric acid
levels.
Making changes in your diet may help with your gout. If you
want to try an eating plan for gout, see:
Talk to your doctor about the medicines you
take. Certain medicines that are given for other conditions reduce the amount
of uric acid eliminated by the kidneys. These include pills that reduce the
amount of salt and water in the body (diuretics, or
"water pills") and niacin. Regular use of low-dose aspirin may raise the uric
acid level. Since low-dose aspirin may be important for the prevention of
stroke or heart attack, your doctor may want you to continue to take low-dose
aspirin.
Follow a moderate exercise program.
Long-term medication treatment depends on how high your
uric acid levels are and how likely it is that you will have other gout attacks
in the future. If your doctor prescribes medicine to lower your uric acid
levels, be sure to take it as directed. Most people continue to take this
medicine for the rest of their lives.
Treatment if the condition gets worse
Gout can
usually be successfully treated by eliminating its causes and taking medicines
to relieve symptoms. But if gout symptoms have occurred off and on without
treatment for several years, they may become ongoing (chronic) and may affect
more than one joint.
Uric acid crystals may have built up in the joints to
form gritty, chalklike nodules called
tophi. Treatment of gout that has advanced to this
stage includes medicines.
Take one or more of the following medicines,
as prescribed by your doctor:
Allopurinol medication, which may shrink the
tophi until they disappear.
In rare cases, surgery to remove large
tophi that are causing deformity.
What To Think About
After an acute attack of gout,
talk with your doctor about the causes of the elevated uric acid levels in your
blood. A review of your overall health may reveal diseases, medicines, and
habits that could be contributing to your uric acid levels.
Most
doctors will wait several days to weeks after a gout attack is over to begin
medicine to lower the high uric acid levels. These medicines can cause uric
acid stored elsewhere in the body to begin moving through the bloodstream and
could make symptoms worse if treatment begins during a gout attack.
If there is swelling that causes pressure in a large joint such as a knee
or ankle, your doctor may relieve the pain and pressure by aspiration, in which
a needle is inserted into the joint and fluid is drawn out (aspirated) with a
syringe connected to the needle.4
Gout usually
develops after a number of years of buildup of
uric acid crystals in the joints and surrounding
tissue. You probably won't know that you have an elevated uric acid level in
your blood until you have had your first gout attack. But you can help prevent
or reduce the severity of future gout attacks.
If you have been prescribed medicines for gout,
it is important that you take those medicines as instructed to prevent future
attacks. Most people continue to take this medicine for the rest of their
lives.
If you are overweight, take steps to lose weight. For more
information, see the topic
Weight Management.
You probably will be
advised to reduce or stop your alcohol intake or to adjust your
diet.
Making changes in your diet may help with your gout. If you
want to try an eating plan for gout, see:
Gout, an
inflammatory joint disease causing acute pain and swelling, usually develops
after a number of years of buildup of
uric acid crystals in the joints and surrounding
tissue. If you have been diagnosed with gout, take steps to:
Decrease the pain of an acute attack.
Rest the affected joint until the attack
eases and for 24 hours after the attack.
Control your weight. Being overweight is a
risk factor for gout. If you are overweight, a diet that is low in fat may help
you lose weight. But avoid fasting or very low-calorie diets. Very low-calorie
diets increase the amount of uric acid produced by the body and may bring on a
gout attack. For more information, see the topic
Weight Management.
Limit alcohol,
especially beer. Alcohol can reduce the release of uric acid by the kidneys
into your urine, causing an increase of uric acid in your body. Beer, which is
rich in
purines, appears to be worse than some other beverages
that contain alcohol.1
Limit meat and
seafood. Diets high in meat and seafood (high-purine foods) can raise uric acid
levels.
Talk to your doctor about medicines you take. Certain
medicines that are given for other conditions reduce the amount of uric acid
eliminated by the kidneys. These include pills that reduce the amount of salt
and water in the body (diuretics, or "water pills") and
niacin. Regular use of low-dose aspirin may raise the uric acid level. Since
low-dose aspirin may be important for the prevention of stroke or heart attack,
your doctor may want you to continue to take low-dose aspirin.
Modify your risk factors.
Keep your weight within the normal range
for your height.
Follow a moderate exercise program.
Avoid a diet rich in meat and seafood. Making changes in your diet
may help with your gout. If you want to try an eating plan for gout, see:
Have an evaluation for lead poisoning if you
have been exposed to lead in your job or through hobbies.
Continue to take the medicines prescribed to you
for gout. But if you have not been taking medicines that lower uric acid (such
as probenecid or
allopurinol) prior to the attack, do not begin taking
it when the attack begins. These medicines will not help relieve acute pain and
may actually make it worse.
In the past, gout was thought to be due to drinking too
much alcohol and eating too many rich foods. Although eating certain foods and
drinking alcohol may trigger a rise in the level of uric acid in the body,
these habits may not by themselves cause gout. Gout is most often caused by an
overproduction of uric acid (due to
metabolism problems) or decreased elimination of uric
acid by the kidneys.
Medication treatment for
gout may be done in two separate stages.
First, the pain, swelling, redness, and warmth
(inflammation) during an attack of gout is treated until the symptoms have gone
away.
Second, after the inflammation has subsided, other medicines
may be used to reduce the uric acid level in the blood and reduce the frequency
of future attacks. Most doctors do not start these medicines until several days
to weeks after a gout attack is over.
Medicines to lower
uric acid levels are not given until a gout attack is
over. Starting these medicines during a gout attack can cause movement of uric
acid stored elsewhere in the body, which can make the gout attack worse.
Long-term medication treatment depends on how high your uric acid levels
are and how likely other gout attacks are. In general, the higher the uric acid
levels and the more frequent the attacks, the more likely it is that long-term
medication treatment will help.
During a gout attack
You may already be taking a medicine to lower uric
acid levels in the blood at the time of an attack. If so, you should continue
taking your medicine, even during an attack.
If you have been
prescribed a medicine to lower uric acid levels (probenecid or allopurinol) and
have not been taking the medicine, it is more likely that another gout attack
will occur. Do not start taking the medicine during an
attack. Medicines that control the uric acid levels in your blood can also make
the uric acids stored elsewhere in the body move into your bloodstream.
Starting these medicines while you are having a gout attack can make your
attack much worse.
Medication Choices
Medication treatment for gout usually involves some
combination of:
Short-term treatment, using medicines that
relieve pain and reduce inflammation during an acute attack or prevent a
recurrence of an acute attack. These medicines may include:
Nonsteroidal anti-inflammatory drugs (NSAIDs), except for aspirin, which should never be used to relieve pain
during a gout attack. Aspirin may change uric acid levels in the blood and may
make the attack worse.5
Colchicine, which may also be used for long-term
treatment.
Corticosteroids, which may be given in
pills or by a shot for cases of gout that do not respond to NSAIDs or
colchicines. They may also be given to people who cannot take NSAIDs for other
reasons, such as those with chronic kidney failure, heart failure,
gastrointestinal bleeding or those using a blood-thinner, such as
warfarin.
Long-term treatment, using medicines to lower
uric acid levels in the blood, which can reduce the frequency and severity of
gout attacks in the future. This may include:
Uricosuric agents, to increase
elimination of uric acid by the kidneys.
Allopurinol, to
decrease production of uric acid by the body.
Colchicine, to prevent flare-ups during the first
months that you are taking uric acid-lowering medicines.
What To Think About
Relief from symptoms in a gout attack often
occurs within 24 hours if treatment is started immediately.
During
a gout attack, your doctor will prescribe a maximum daily dose of one or more
medicines used for short-term treatment to stop the attack. Doses are then
reduced as the symptoms go away.
NSAIDs other than aspirin are used
most often to treat a gout attack.
Because all medicines that
lower uric acid levels in the blood have risks, an accurate diagnosis of gout
is necessary before they are used.
Aspirin should never be used to
relieve pain during a gout attack.
Some people with gout have continuing problems because
they do not take their prescribed medicine. Although most people will need
treatment for the rest of their lives to keep their uric acid levels in their
blood normal, they may feel perfectly healthy most of the time and wonder why
they should continue taking their medicine. If you stop taking your prescribed
medicine, nothing may happen at first, but after a while another gout attack is
likely to occur. Without treatment, future attacks are likely to be more severe
and occur more often.
Research is ongoing to develop new medicines
to treat the symptoms of
gout. Scientists also are studying which medicines
lower uric acid levels safely.6
Losartan is used to treat high blood pressure
(hypertension), and it also lowers uric acid levels.
Fenofibrate is
used to control certain fats in the blood (triglycerides and very low-density
lipoprotein cholesterol), and it may also increase elimination of uric acid by
the kidneys.
Urate oxidase may lower uric acid levels by changing
uric acid into an absorbable molecule. This medicine is currently being
evaluated in the United States.
Febuxostat and Y-700 medicines
decrease the amount of uric acid the body makes. These medicines are being
studied and may be used in people who cannot take allopurinol.
Gout can
usually be successfully treated by eliminating causes and taking medicines to
relieve symptoms. But if gout symptoms have occurred off and on without
treatment for more than 10 years, uric acid crystals may have built up in the
joints to form gritty, chalklike nodules called
tophi. If tophi are causing infection, pain, pressure,
and deformed joints, and medicines have been unsuccessful in shrinking or
eliminating the tophi, your doctor may recommend surgery (excision) to remove
them.
Although not proved in
scientific studies, complementary therapies may be used by some people to
relieve symptoms caused by
gout.7
Cherries and an herb called devil's claw are
folk medicine remedies that have been used as anti-inflammatories to treat
gout. Research is needed to evaluate the usefulness of these and other
complementary medicines to treat gout.
Eicosapentaenoic acid (EPA)
is known to reduce chronic inflammation. It has not yet been studied to see
whether it can help reduce inflammation from gout.
Although still
just a theory, some studies indicate that folic acid may be helpful in
inhibiting the enzyme needed to produce uric acid.
Be sure to talk with your doctor if you are considering
taking vitamins, minerals, or other remedies to help reduce future gout
attacks.
The American College of Rheumatology (ACR) and the
Association of Rheumatology Health Professionals (ARHP, a division of ACR) are
professional organizations of rheumatologists and associated health
professionals who are dedicated to healing, preventing disability from, and
curing the many types of arthritis and related disabling and sometimes fatal
disorders of the joints, muscles, and bones. Members of the ACR are physicians;
members of the ARHP include research scientists, nurses, physical and
occupational therapists, psychologists, and social workers. Both the ACR and
the ARHP provide professional education for their members.
The ACR
Web site offers patient information fact sheets about rheumatic diseases, about
medicines used to treat rheumatic diseases, and about care
professionals.
Arthritis Foundation
1330 West Peachtree Street
Suite 100
Atlanta, GA 30309
Phone:
1-800-283-7800
Web Address:
www.arthritis.org
The Arthritis Foundation provides grants to help find a cure,
prevention methods, and better treatment options for arthritis. It also
provides a large number of community-based services nationwide to make living
with arthritis easier, including self-help courses; water- and land-based
exercise classes; support groups; home study groups; instructional videotapes;
public forums; free educational brochures and booklets; the national, bimonthly
consumer magazine Arthritis Today; and continuing
education courses and publications for health professionals.
National Institute of Arthritis and Musculoskeletal and
Skin Diseases (NIAMS), National Institutes of Health
The National Institute of Arthritis and Musculoskeletal
and Skin Diseases (NIAMS) is a governmental institute that serves the public
and health professionals by providing information, locating other information
sources, and participating in a national federal database of health
information. NIAMS supports research into the causes, treatment, and prevention
of arthritis and musculoskeletal and skin diseases and supports the training of
scientists to carry out this research.
The NIAMS Web site provides
health information referrals to the NIAMS Clearinghouse, which has information
packages about diseases.
Choi HK, et al. (2004). Alcohol intake and risk of
incident gout in men: A prospective study. Lancet,
363(9417): 1277–1281.
Wortmann RL, Kelley WN (2005). Gout and hyperuricemia.
In ED Harris Jr et al., eds., Kelley's Textbook of Rheumatology, 7th ed., pp. 1402–1429. Philadelphia: Elsevier
Saunders.
Hellman DB, Stone JH (2005). Arthritis and
musculoskeletal disorders. In LM Tierney Jr et al., eds., Current Medical Diagnosis and Treatment, 44th ed., pp.
781–789. New York: McGraw-Hill.
Klippel JH, et al. (1999). Gout section of Regional
pain and monoarticular disorders. In Primary Care Rheumatology, pp. 117–124. London: Mosby.
Rott KT, Agudelo CA (2003). Gout. JAMA, 289(21): 2857–2860.
Bomalaski JS, Clark MA (2004). Serum uric
acid-lowering therapies: Where are we heading in management of hyperuricemia
and the potential role of uricase. Current Rheumatology Reports, 6: 240–247.
Murray MT, Pizzorno JE Jr (2006). Gout. In JE Pizzorno
Jr, MT Murray, eds., Textbook of Natural Medicine, 3rd
ed., vol. 2, pp. 1703–1709. St. Louis: Churchill Livingstone
Elsevier.
Other Works Consulted
Gravel J Jr, et al. (2007). Gout section of
Rheumatology and musculoskeletal problems. In RE Rakel, ed., Textbook of Family Medicine, 7th ed., pp. 933–935.
Philadelphia: Saunders Elsevier.
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