Does uric acid really cause gout?

[KeithTaylor]

Prompted partly by my own curiosity, but mainly by the fascinating questions asked on this forum, I like to think I’ve learned a lot about gout. I’ve always struggled with the finer points of microbiology and organic chemistry, but I thought I had the basic principles sorted.

In a recent discussion (search for coming of allopurinol started by @sicboy13), @zip2play made the comment:

I would think that if the 10.8 is accurate you would be having one attack after another so I am skeptical of the number.

At the time, I commented with uncertainty that I wondered if higher uric acid meant more attacks. This was based on my understanding that it is uric acid crystals that cause gout attacks. Therefore, a high uric acid level should not immediately cause a gout attack. Indeed, it is one of the mysteries of gout, that people can have high uric acid levels for years without showing any symptoms of gout (asymptomatic hyperuricemia).

I tried to investigate this to see if there have been new developments. I was immediately struck by an article: Purine-rich foods: an innocent bystander of gout attacks?

In this, the authors are considering why an increase in uric acid after a high-purine meal should cause a gout attack. They reach the conclusion that:

1. High purine intake long term can cause excess uric acid
2. Uric acid crystals form very slowly, so temporary increase after a high purine meal is unlikely to cause a gout attack
3. Many purine rich foods are also rich in Free Fatty Acids (FFAs) and these are the most likely candidate for causing a gout attack

There’s also some fascinating reading in the references that this work is based on. I’ve learned that uric acid crystals alone do not cause gout attacks – they require FFAs to create the inflammation pathway. I’ve learned that, because crystals grow slow but melt fast, it might be a good idea to provide uric acid lowering treatment in short periods rather than every day for life.

So, to answer my own question, does uric acid really cause gout? Clearly it does cause gout in the long term, and uric acid crystals are needed for a gout attack. But uric acid crystals alone do not cause gout flares. It seems most likely that Free Fatty Acids are needed as well. Now I need to research FFAs and how to manage them.

It might take me some time to fully understand the implications of this new thinking. You can see the full article with linked references at http://ard.bmj.com/content/71/9/1435.long

I’d love to know what you think about this.

[Keith Taylor (GoutPal Admin)]

I’ve also asked Does uric acid really cause gout? on my main gout site to try and encourage more people to join this discussion. I believe this is important for how we understand and treat gout, so I’d like to get more opinions from interested parties. Please pass it on to anyone you know who is interested in managing gout, especially your doctors and other medical professionals.

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