For those who suffer from gout, it is well known that there are classic triggers, such as sweet wines, beer, sugary beverages, sweet fruits, red meats, seafood, and rich desserts. In the 1800s, it was common to link this with an evening of “revelry and debauchery”, but for most of us, it is more commonly just a night in which we may have ingested too much of a food or drink that we just tend to like a bit too much!
Classically, the attack occurs several hours after a meal, often awakening its victim in the middle of the night with the development of excruciating pain in the joint, commonly in the big toe. This times well with studies suggesting that uric acid levels commonly rise two to four hours following a purine-rich meal (1). This, of course, has placed a lot of focus on eating the right foods to minimize gout attacks, in addition to making sure your uric acid levels are well controlled by diet or medication (with a target of getting your serum uric acid less than 6 mg/dl or lower)
An 1800s caricature of a “portly” gentleman with obesity and likely metabolic syndrome who is partaking of just a bit too much alcohol and sweets. Mount Vesuvius is erupting in the background, presaging the visit of the gouty devil who is about to instill his hot prong into the foot of the man who is still unwary of what lies ahead. George Cruikshank, 1818, the Wellcome Collection. (Part of the public domain).
While food is an important trigger for gout, there is another factor, often unrecognized, that is also important in triggering gout attacks, and this is obstructive sleep apnea (abbreviated as OSA). OSA is the frequent cessation of breathing during sleep due to the airway closing for many seconds at a time, which may also be the reason that gout attacks at night. OSA results in periods of uneven breathing in which oxygen levels can fall in the body.
These periods of low oxygen, or hypoxia, stimulates the production of uric acid levels as well as lactic acid, and hence might provide another stimulus for raising uric acid. Indeed, subjects with sleep apnea tend to have high blood uric acid levels and an increased risk for gout (2, 3). One reason is that as many as half of patients with gout have obesity and the “metabolic syndrome” (4) in which they also have other conditions such as elevated blood pressure, insulin resistance, an increase in waist circumference, and elevated blood triglycerides, and in turn one-half of subjects with metabolic syndrome turn out to have OSA (5). However, gout is also associated with sleep apnea even without the presence of obesity and metabolic syndrome (3). In fact, in subjects who presented with gout and clinically were suspected of having OSA, nearly 90% were found to have OSA when they underwent sleep studies to determine if they had OSA (6).
Thus, perhaps it is not always diet that is triggering your gout attacks in the middle of the night. So consider discussing with your physician whether you might need to be assessed for OSA, which is readily treatable. And remember, that treatment of sleep apnea has many benefits. In addition to giving you better sleep and possibly reducing gout attacks, overcoming OSA also is associated with an overall improvement in metabolic and cardiovascular health, and a longer lifespan.
Burton Abrams MS, Peter Delannoy, PhD, and Richard J Johnson MD
References
1. Brulé D, Sarwar G, Savoie L. Changes in serum and urinary uric acid levels in normal human subjects fed purine-rich foods containing different amounts of adenine and hypoxanthine. J Am Coll Nutr. 1992 Jun;11(3):353-8. doi: 10.1080/07315724.1992.10718238. PMID: 1619189.
2. Hira HS, Shukla A, Kaur A, Kapoor S. Serum uric acid and lactate levels among patients with obstructive sleep apnea syndrome: which is a better marker of hypoxemia? Ann Saudi Med. 2012 Jan-Feb;32(1):37-42. doi: 10.5144/0256-4947.2012.37. PMID: 22156638; PMCID: PMC6087645.
3. Singh JA, Cleveland JD. Gout and the Risk of Incident Obstructive Sleep Apnea in Adults 65 Years or Older: An Observational Study. J Clin Sleep Med. 2018 Sep 15;14(9):1521-1527. doi: 10.5664/jcsm.7328. PMID: 30176977; PMCID: PMC6134232.
4. Rho YH, Choi SJ, Lee YH, Ji JD, Choi KM, Baik SH, Chung SH, Kim CG, Choe JY, Lee SW, Chung WT, Song GG. The prevalence of metabolic syndrome in patients with gout: a multicenter study. J Korean Med Sci. 2005 Dec;20(6):1029-33. doi: 10.3346/jkms.2005.20.6.1029. PMID: 16361817; PMCID: PMC2779304.
5. Parish JM, Adam T, Facchiano L. Relationship of metabolic syndrome and obstructive sleep apnea. J Clin Sleep Med. 2007 Aug 15;3(5):467-72. PMID: 17803009; PMCID: PMC1978322.
6. Cantalejo Moreira M, Veiga Cabello RM, García Díaz V, Racionero Casero MA, Zapatero Gaviria A. Gout, hyperuricaemia, sleep apnoea-hypopnoea syndrome and vascular risk. Rheumatology (Oxford). 2013 Sep;52(9):1619-22. doi: 10.1093/rheumatology/kes418. Epub 2013 Feb 14. PMID: 23418048.
