Causes of gout

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

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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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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.

Age at interview 53

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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.

Age at interview 77

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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.

Age at interview 32

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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

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

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There is some evidence that people from certain ethnic backgrounds may be more likely to get gout. It is more common, for example, in Maori 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

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