Understanding risk factors for gout and gout flares

You wake one morning to severe throbbing pain and swelling in your big toe. The toe joint is swollen and stiff. When you went to bed, you felt fine. Now you’re in agony. What’s going on?

You might be one of the 9.2 million Americans with gout, a form of arthritis that can cause inflammation and severe pain in the joints. The condition is characterized by painful flares, often occurring at night, that can last for days to weeks, with the worst pain usually building in the first 24 hours. Other symptoms of gout include warmth and redness of the skin around the joint and difficulty using the joint. 

When it comes to preventing gout, recognizing risk factors, seeking treatment early, and doing your best to avoid triggers are essential first steps. According to the American College of Rheumatology treatment guidelines, keeping uric acid levels in the blood below 6 mg/dl is important to prevent gout flares. Although flares are temporary, they are painful—but in the long term, gout can cause other issues.

“Hyperuricemia and gout are long-term medical problems,” says Lynn Ludmer, MD, medical director of rheumatology at Mercy Medical Center in Baltimore. “Over time, untreated gout can lead to chronic inflammation and joint damage, which may be permanent.”

What causes gout?

For centuries, doctors thought gout was predominantly caused by diet. In fact, gout was often called “the disease of kings” because it was associated with a diet heavy on rich foods and meats as well as alcohol—a diet only the wealthy class could afford. 

Scientists now know that the leading cause of gout is genetics, and having a family history of the condition is the most significant risk factor. “People should understand that gout is genetic and not their ‘fault’ just because of their diet,” says Theodore R. Fields, MD, FACP, a rheumatologist at New York City’s Hospital for Special Surgery. “Dietary and lifestyle changes will definitely help, but in only a small number of gout patients are they enough.”

8 common risk factors for hyperuricemia and gout

While genetics are the main risk factor for hyperuricemia and gout, there are other contributors. Here are eight common risk factors for gout. Knowing these—and how to address them—can help you prevent and/or manage the condition and avoid flare-ups from occurring.

1. Obesity 

The more you weigh, the harder your kidneys have to work to eliminate waste products like uric acid from your body. In one study, published in the journal Arthritis and Rheumatology, people who were overweight had an 85% greater risk of having hyperuricemia (a precursor to gout) versus healthy-weight people. Obese people were up to 3.5 times more likely than normal-weight individuals to have excess uric acid. The researchers also found that 44% of hyperuricemia cases were attributable to excess weight alone.

2. Certain foods

Because of their higher purine content, some foods can raise uric acid levels in the blood. They include:

• Red meat
• Fatty meats, such as bacon
• Organ meats—for example, kidneys, liver, and tripe
• Certain kinds of seafood, including salmon, sardines, and anchovies; and shellfish, such as mussels
• High fructose corn syrup (found in an array of products, particularly sugary drinks like sodas)
• Alcoholic beverages, which contribute to gout not just because of their purine content, but because they also make it harder for the kidneys to excrete excess uric acid

So, how much of these foods is okay to have? “We don’t object to an occasional drink at a special occasion or a small amount of red meat or shrimp, but less is better,” Dr. Fields says. “It is a quantitative issue, so we advise having as little as you can. Fortunately, a gout diet is a healthy diet, so it’s a net gain in general health to follow a gout-friendly diet.”

3. High blood pressure 

People with high blood pressure (hypertension) have a 2-to-3 fold increased risk of developing hyperuricemia and gout. What’s more, the diuretics (medications used to increase urination) that are often prescribed to treat high blood pressure can contribute to the problem by decreasing the amount of uric acid that’s excreted in urine. Although studies have shown that hypertension does not cause gout, they suggest that managing gout could prevent the risk of developing high blood pressure. 

4. Certain medications

In addition to diuretics, other medications that can increase the amount of uric acid or decrease their excretion include:

• Low-dose aspirin
• Immunosuppressant drugs—for example, those used to prevent organ rejection in transplant patients
• Drugs used to treat tuberculosis
• Nicotinic acid, used to treat niacin deficiencies (niacin is a B vitamin)

5. Diabetes

It’s a double-edged sword: The Gout Education Society notes that insulin resistance (a major risk factor for Type 2 diabetes) can lead to gout, and having too-high levels of uric acid in your blood can lead to insulin resistance. The group reports that 26% of people with gout have Type 2 diabetes.

6. Gender

Men have a fourfold increased risk of developing gout versus women. It seems that the female hormone estrogen helps women keep uric acid levels in check, but that protection starts to fade once menopause hits and estrogen drops. “There are theories about why estrogen may protect women, including that the kidneys may excrete more uric acid in the presence of estrogen,” explains Dr. Ludmer. 

7. Age

Gout risk tends to rise with age. That may be because many of the risk factors associated with gout—diabetes, obesity, and high blood pressure—also tend to rise as we age. Men are most likely to develop gout between 40 and 60. For women, it’s 60 to 80 years of age. Women are able to stave off the disease a bit longer due to the aforementioned protective effects of estrogen. 

8. Trauma to joints

People who had an injury to or surgery on a joint are more likely to develop gout in that area. “We know that physical stress can set off gout flares,” says Dr. Fields. “For example, some people get a gout flare after running. It’s thought that trauma on the big toe actually releases some of the uric acid crystals in the joint lining into the joint fluid, causing inflammation.”

6 triggers for acute gout flare-ups

There’s nothing you can do about your genetics, but you can make healthy lifestyle changes that may help reduce the likelihood of gout flare-ups. Common gout triggers include:

1. Dehydration: The Arthritis Foundation recommends drinking at least eight glasses of non-alcoholic beverages (preferably water) per day. And if you’re in the midst of a gout attack, double that amount to help flush excess uric acid from your system.
2. Alcohol: One alcoholic beer can raise uric acid levels by 6.5%; a nonalcoholic beer can by 4.4%.
3. Stress: Experts aren’t sure how, or even if, stress can lead to gout—but they do know that emotional stress can often lead people to eat and drink more, thus putting them at greater risk of gout.
4. Certain foods: In addition to limiting foods that can trigger gout, consider adding foods that may help promote the excretion of uric acid and/or have anti-inflammatory properties. According to the Arthritis Foundation, some of those foods include:
   • Low-fat dairy
   • Coffee
   • Foods rich in vitamin C (choose those that also are low in the naturally occurring sugar fructose, such as citrus fruits and strawberries)
   • Non-meat-based proteins, such as peas, lentils, tofu, and leafy green vegetables
   • Tart cherries
5. Hospitalization: People with gout are 10 times more likely to experience a gout flare during a hospital stay due to stopping gout medications and fluid shifts.
6. Medications: Certain prescriptions, like diuretics, can increase the risk of a gout attack.

How to treat an acute gout attack

If you’re experiencing gout pain, see your healthcare provider. “Even if you don’t need medication, you can talk about diet and possible weight loss and discuss when gout needs more aggressive management,” Dr. Fields advises. 

Home remedies

Self-help measures that may ease the pain of an acute flare include:

• Ice and elevate the affected joint
• Drink lots of water
• Limit activity

Medication

“In people with two or more flares of gout in a year, or gout with a history of kidney stones or decreased kidney function, or gout with tophi [deposits of uric acid under the skin around joints that resemble knobby growths], then they need their uric acid lowered with medication,” explains Dr. Fields.

To treat your flare, your healthcare provider may recommend a short course of anti-inflammatory medications as below: 

• Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and swelling
• Colchicine, which decreases swelling and the buildup of uric acid
• Corticosteroids to reduce pain and inflammation. These may be taken by mouth or given via injection.

To help lower uric acid levels in your body and prevent future attacks, you might receive the following long-term oral medications:

• Zyloprim (allopurinol)
• Uloric (febuxostat)
• Probalan (probenecid)

Or you might receive Krystexxa (pegloticase), a drug for IV infusions.

It is important to keep in mind that your healthcare provider may continue to prescribe a short-term anti-inflammatory medication like colchicine for the first three to six months after they begin prescribing the uric acid-lowering medications.

“Patients should have an open mind when discussing the possibility of taking medication for gout with their doctor,” Dr. Fields advises. “The opportunity to be ‘cured’ of gout is very high if you stay on a medication such as allopurinol.”