Gout

Causes of gout

A consultant rheumatologist explains how high levels of uric acid can cause gout.

Sex: Male

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Well typically people will have high uric acid levels for a variable period of time which may be up to several years or even decades, and during this time they may well not know that there's anything wrong with them. Then out of the blue, all of a sudden, somebody will experience an attack which comes on very, very suddenly, and causes excruciating pain in the joints, most typically the bunion joint at the base of the big toe. Typically the joint will be very, very swollen, very red, and very tender.

That attack will last for anything from a few days up to a couple of weeks and then will start to get better, even without treatment. The person then often goes back to normal, the attack goes away completely, and then over a variable period of time, which may be a few months or even a couple of years, they may not have another attack. And then all of a sudden they’ll have another attack, which again gets better. Over the course of years people will go on to have recurrent attacks, and these may become closer together and start to involve different joints. With the passage of time people may also start to develop lumps of uric acid crystals underneath the skin, typically around the elbows, in the feet, or affecting the ears.

Once uric acid crystals have started to form in and around people's joints, uric acid crystals are usually found packed within the cartilage that’s lining the end of the bones. What happens then is that the crystals can be shaken loose into the joint space, and it's then that they can lead to an attack of gout. So crystals of uric acid are very irritant to the joint, and they are rapidly recognised by the body's immune system and by the cells of the immune system, and that leads to a very quick and very severe inflammatory reaction, which causes the very intense pain that’s associated with gout.

People commonly think that gout is caused mainly by eating rich foods or drinking too much alcohol – lifestyles that were often associated with rich people or kings in past centuries like Henry VIII. The people we interviewed often had these ideas too when they were first diagnosed, though others had no idea what caused gout. While diet can play a part in making attacks more likely, there are other factors involved.

A consultant rheumatologist explains who can get gout and what the most common causes are.

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Sex: Female

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Anyone can get gout - it's one of the commonest reasons for inflamed joints. About one in 100 people in the UK have gout. We know gout affects more men than women, and it's unusual in women before they have their menopause. People with gout often have other health conditions, like being overweight, or having kidney disease or diabetes. But people often think that gout is self-inflicted and caused by eating the wrong types of food or drinking too much alcohol, whereas in fact for most people, their gout is caused by a combination of their genetic makeup, or their other health conditions, or the tablets they take.

When Jill was diagnosed she thought that gout was caused by rich living. She then found out about uric acid and that gout was more common in patients with kidney problems.

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Age at interview: 53

Sex: Female

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When you first found out that you'd got gout, what were the reactions of other people around you when you told them?

Well to be honest with you I think my brother laughed, and said, "Isn't that a rich man's disease?" and I'm like, “Well I've no idea”. And he was laughing and he was saying, “Yeah, it's all that cheese and wine you have”. Well, I don’t say I don’t have a glass of wine, because I do, but it's not constant and cheese, we don’t eat cheese, well we do but not that often. So I was fed up of the stigma of gout, it's an old man's disease, so I asked a friend of mine who lives over the road to get it up on the laptop, and she had a look at it and did a bit - got a bit of information off for me, and apparently what it says on the laptop now is it's nothing to do with an old man's, you know, cheese and red wine, it is uric acid and it's a build-up of uric acid. And then when I looked further into it, and I told one of the renal consultants they said renal patients, uric acid build-up, quite normal. So for me, along with everything else that’s happened in the past, it's something I know I will have to live with, but I am very aware of my uric acid, so now every time I have my bloods done, which is every six weeks, I always ask what my uric acid is.

Gout occurs when people have a higher than normal level of uric acid in their blood. Uric acid (urate) is a normal substance in the bloodstream. It comes from the breakdown of chemicals known as called purines. A small amount of uric acid in the bloodstream comes from the breakdown of purines in food, but most comes from the natural breakdown of purines in cells in the body. When levels of uric acid begin to build up, the kidneys usually remove the surplus and it is passed out of the body in urine.

When the kidneys don't remove enough uric acid, or the body is producing unusually high levels of it, it can build up and turn into small crystals in the joints. It is these crystals that cause the pain, tenderness and swelling that people with gout.

Blood tests showed that Shirley had high levels of uric acid. She started taking allopurinol to keep her levels within the normal range.

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Age at interview: 77

Sex: Female

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Following that, she (GP) arranged blood tests, which showed, I think, uric acid was a very high level. So she put me on allopurinol for a, sort of, long-term medicine, and I had a number of follow-up blood tests, and because the uric acid didn’t subside, she upped the dose of allopurinol. So I’m now on 200mg a day, and I’ve been taking that ever since and that seems to have kept it under control. I’ve had no major outbursts. I still get a, the odd twinge in my big toe joint, just to remind me not to get complacent, but nothing I can’t live with. So that’s it, really.

Several factors can affect the level of uric acid in the blood:

•   Genetic factors
Some people may have inherited genes that mean their kidneys are less efficient at removing uric acid, even though the kidneys are normal and healthy in every other way. This is one of the most common causes of gout, and is particularly likely when several family members are affected by gout.

•   Being overweight or obese
Being overweight can make the kidneys less effective at removing uric acid.

•   High blood pressure and type 2 diabetes
These conditions tend to be associated with higher levels of uric acid, and they both make the kidneys less able to get rid of uric acid effectively.

•   Kidney disease
Kidney disease can mean that the kidneys cannot get rid of uric acid as well as they should.

•   Diuretics (water tablets), low-dose aspirin and ciclosporin
These tablets reduce the kidneys’ ability to get rid of uric acid.

•   Chronic blood disorders
Uric acid produced by the breakdown of cells may be too much for the kidneys to get rid of effectively in disorders where the body produces too many blood cells.

•   Diet and alcohol
Excessive eating of foods high in purines (red meat, offal and seafood) and/or drinking of alcohol (particularly beer) can cause gout in some cases.

Some people did not know of anyone else in their family with gout, but like Hazel, many had relatives with gout.

Gout was not surprising or novel in Hazel’s family, so she felt that it was relatively normal to have it herself.

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Age at interview: 32

Sex: Female

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I started having gout about seven years ago now, and I didn't really know - I didn't bring it to the doctor or anything like that. My parents both have gout and they said before that on my father's side it's because my grandmother used to cook a lot of entrails and all of that. And then on my mother's side I don't really know, but they both have it. And so when I was in my early 20s I had it. And it was just a matter of, "Well, they both have it, so I have it. Cannot really escape it."

And then it wasn't that bad, because I have it, I don't know, once in six months, this, this little pain. Cannot really remember so much about it now, because it's progressed quite a bit now. And then a lot of my family have it, so I have a lot of my male cousins that have it. And there's a lot of boys in our family. I don't have a lot of female cousins. So I didn't really notice before that actually I was the only female that had it, apart from my mum, so on the other side. And so on my dad's side, everyone has it. Or maybe one in every family or two in every family. So it was sort of a natural thing for me, just because everyone had it.

Other factors are known to bring attacks on for people who have gout, but these factors do not cause gout themselves. These factors include:
•   An injury or knock to a joint
•   Illnesses that cause a fever, like flu or pneumonia
•   Operations
•   Dehydration

Joe was working in extreme temperatures for hours at a time. His doctor believed his attack was caused by dehydration.

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Sex: Male

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The doctor said it was I’d dehydrated, and he says that can cause gout, so I’ll take his word for it. I was mechanised casting, which, it was very easy compared to bench; bench you just, you run for 10 hours, at that time, and that was the difference, I’d gone from a nice steady job where you know, 8 hours steady; you still produce but it was a lot steadier, and your lifting was more central and everything, better lifting, whereas when I went back on a bench, you just, you know, we’d get there at 5 o’clock in the morning and you wouldn’t stop running about really until 1, you know, get the bulk of your day finished, and you’d be sweating for, and you’d be working at that time, because you had steam under your bench, under your moulds and everything to dry and everything, so you’d got steam all day, so you’re working, even in winter, you’re working in 120 degrees, no problem, every day so, yeah, with coming from an easy job back to a hard job again, you just sweat like there’s no tomorrow, you know, it really; it’s hard work.

And do you think that...

I think it could have been yeah, yeah, yeah. Because obviously I’d drink, you’d drink tea all day because you know, people, everybody brews up, so you know, you’d got like 30 blokes brewing up, so you’ve always got a cup of tea all day, but I wasn’t drinking any water or anything, so it could be, yeah, yeah. Because I went from like, not having a sweat, a bead of sweat all day, to completely covered, soaking wet all, until, well 5 or 6 hours, 7 hours, you know and I think that made a difference.

There is some evidence that people from certain ethnic backgrounds may be more likely to get gout. It is more common, for example, in Māori and Pacific people*. Runibunar, who was from the Philippines, was told by his doctor that he may have had an increased chance of getting gout because of his ethnic background.

People we spoke to sometimes wondered if other factors may have caused their gout. Arthur had experienced psoriasis at stressful times in his life, and wondered if gout was also linked with stress. When she was younger, Janette had led a more physically active life than other members of her family. She was the only one to develop gout and so wondered if the physical stress she put on her body had made a difference.

*Lennane GA et al. (1960) Gout in the Maori. Ann Rheum Dis 19: 120–125

Last reviewed Decemeber 2016
Last updated December 2016