Managing Gout: It’s About More Than Just Uric Acid
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Many people believe that gout happens only because of high uric acid levels. While that’s part of the story, a new study published in Nature Reviews Rheumatology shows that gout flares are influenced by many other factors too — including genetics, lifestyle, time of day, and even the weather!
Let’s dive into what really causes gout flares and how you can better manage them.
Gout Flares: More Than Just Crystals
Gout is a very painful type of arthritis caused when monosodium urate (MSU) crystals build up in the joints. These crystals form when uric acid levels in the blood stay high for a long time.
But here’s the surprise: many people have these crystals without any pain. So why do some people get flares while others don’t?
The answer lies in other “hidden” factors that affect how the immune system reacts to these crystals.
Why Flares Happen
Researchers have found that several things can trigger a painful gout flare:
- Genetics: Some people have genes that make their immune system more sensitive to urate crystals.
- Body’s Clock (Circadian Rhythm): Gout flares are more common at night because anti-inflammatory hormones like cortisol are lower then.
- Cold Weather: Gout attacks happen more often in winter because cold temperatures help crystals form faster.
- Lifestyle Triggers: Eating too much rich food, drinking alcohol, starting certain medications like diuretics, hospitalizations, injuries, and even air pollution can trigger flares.
Even starting urate-lowering therapy (ULT) — the treatment meant to dissolve crystals — can paradoxically cause a temporary increase in flares if not handled correctly.
How Urate-Lowering Therapy (ULT) Should Be Managed
Urate-lowering therapy is important to dissolve the MSU crystals over time. But it must be handled carefully:
- Start ULT at a low dose to avoid sudden changes that might trigger inflammation.
- Use flare prevention medicines (like colchicine or NSAIDs) for at least 6 months when starting ULT.
- Inform patients that early flares are normal and sticking to therapy is essential.
New research suggests flare prevention might need to continue until all crystals are gone, which can take much longer than just reaching a target uric acid level.
What You Eat and Drink Matters
Food and drink can strongly influence gout:
- Limit alcohol, especially beer and spirits, which raise uric acid.
- Cut back on purine-rich foods like red meat, shellfish, and organ meats.
- Avoid sugary drinks and highly processed "Western" diets, which increase inflammation.
- Stay hydrated to help the kidneys flush out uric acid.
Diet changes support medicine and help reduce the frequency and severity of flares.
The Role of the Immune System
Gout isn’t just a mechanical problem of crystals poking joints. It’s an immune system issue too.
When crystals form, immune cells like macrophages release inflammatory substances like IL-1β, which cause pain and swelling.
Certain body rhythms, like lower immune regulation at night, make flares worse during sleep.
Cold temperatures and stress can also tip the immune system into a flare response.
New findings even show that a high-calorie Western diet can "train" immune cells to become more inflammatory — making flares worse over time.
Final Takeaways: Managing Gout Effectively
Managing gout successfully means looking beyond just uric acid levels:
- Start urate-lowering therapy at a low dose.
- Use preventive medication during early treatment.
- Aim to dissolve all crystals — not just lower blood uric acid.
- Adopt a healthy diet and lifestyle to reduce risks.
- Understand that flares may still happen early on, but long-term control is possible.
By addressing all the hidden factors — genes, diet, environment, immune system — people with gout can achieve better relief and improve their quality of life.