High Uric Acid and Gout: Symptoms, Diet, Foods to Avoid and Treatment

Uric acid is a waste product formed when the body breaks down purines, substances found in many foods and made by the body itself. Normally uric acid dissolves in the blood and is passed out in urine. If too much is made or too little is removed, levels rise (hyperuricaemia). When needle-shaped crystals form in a joint, they cause gout, a very painful form of arthritis. Gout is becoming more common in Asia with changes in diet and rising obesity.

Causes of high uric acid

• Diet: purine-rich foods, alcohol (especially beer), and sugary drinks and fructose
• Overweight and obesity, and insulin resistance
• Kidneys not removing enough uric acid, from chronic kidney disease or medicines
• Medicines: water tablets (diuretics), low-dose aspirin, some TB medicines (pyrazinamide, ethambutol), ciclosporin
• Medical conditions: high blood pressure, diabetes, metabolic syndrome, psoriasis, and rapid cell turnover such as chemotherapy
• Dehydration, crash dieting or fasting
• Genes: gout often runs in families

Gout symptoms

• Sudden, intense joint pain, often at night, classically in the big toe, but also the ankle, knee, foot, wrist or fingers
• Red, hot, swollen and extremely tender joint, where even a bedsheet is painful
• Pain peaks at 12-24 hours and, untreated, lasts 5-10 days
• Between attacks, there may be no symptoms
• Over years, repeated attacks, joint damage, hard lumps under the skin (tophi) and kidney stones may occur

See a doctor for any hot swollen joint with fever, because joint infection can look similar and needs urgent treatment.

Diagnosis

• Blood uric acid level, though it may be normal during an acute attack
• Joint fluid test to find uric acid crystals, which confirms gout
• X-ray, ultrasound or dual-energy CT in some cases
• Kidney function tests, blood sugar and cholesterol, since these conditions often occur together

Treating a gout attack

• Start treatment quickly, within the first day.
• Anti-inflammatory painkillers (NSAIDs) such as naproxen, diclofenac or etoricoxib, if your kidneys, stomach and heart allow
• Colchicine, at low dose, taken early
• Corticosteroids (short course or joint injection) for people who cannot take NSAIDs
• Rest the joint, raise it and apply ice packs wrapped in cloth for 15-20 minutes
• Drink plenty of water
• Do not stop or start uric acid-lowering medicine during an attack unless your doctor tells you to.
• Avoid aspirin

Long-term treatment

Doctors usually advise urate-lowering therapy if you have repeated attacks, tophi, joint damage or kidney stones.

• Allopurinol (starting at a low dose and increasing slowly) or febuxostat lowers uric acid production. The aim is a level below 6 mg/dL (360 µmol/L), or lower for severe gout.
• Colchicine or low-dose NSAIDs are often given for the first 3-6 months to prevent flares.
• Take it every day, even if you feel well. Treatment is usually long term.
• Some people of Asian descent carry the HLA-B*5801 gene, which raises the risk of severe allergic reactions to allopurinol, so doctors may test for it, particularly in Han Chinese, Thai and Korean patients, and take care in others.

A gout-friendly diet

Diet helps, but usually lowers uric acid by only about 10-15%. Medicines are still needed for many people.

Limit or avoid:

• Alcohol, especially beer and spirits
• Organ meats (liver, kidney, brain), meat extracts and gravies
• Red meat such as beef and mutton, in large portions
• Shellfish and some fish: prawns, crab, sardines, anchovies, mackerel and sprats in large amounts, and dried fish
• Sugary drinks and fructose: soft drinks, packaged fruit juices and sweets
• Yeast extracts and heavy fried foods

Enjoy in moderation:

• Vegetables (including those with moderate purines, such as spinach, mushrooms, cauliflower and peas, which do not increase gout risk)
• Low-fat dairy: milk, curd and yoghurt, which may lower uric acid
• Whole grains, pulses, nuts and eggs
• Poultry and fish in moderate portions
• Fruit, especially vitamin C-rich fruit, and cherries, which may reduce attacks
• Coffee, which is associated with a lower gout risk

Habits:

• Drink plenty of water, aiming for 2-3 litres a day if kidneys and heart allow. See our water intake calculator.
• Lose weight gradually. Rapid weight loss and fasting can trigger attacks. See how to lose weight safely.
• Exercise regularly, but rest the joint during an attack.

Kidney stones and kidney health

High uric acid can cause uric acid kidney stones and can contribute to chronic kidney disease. Drinking plenty of water and keeping urine slightly less acidic helps prevent stones. See kidney stones and diabetes and kidney disease. Our eGFR calculator can help you understand kidney function results.

Related conditions

Gout often goes with high blood pressure, diabetes, fatty liver and heart disease. Have your blood pressure, sugar, cholesterol and kidney function checked. See fatty liver disease and how to lower high blood pressure.

When to see a doctor

See a doctor for a sudden painful, swollen joint, especially with fever, as soon as possible. Also seek advice if you have repeated attacks, lumps near joints, high uric acid with kidney problems, or if your medicines may be raising uric acid.

References

• American College of Rheumatology: guideline for the management of gout
• European Alliance of Associations for Rheumatology (EULAR): recommendations for the management of gout
• British Society for Rheumatology: guideline for the management of gout
• Choi HK et al. Purine-rich foods, dairy and protein intake, and the risk of gout in men. New England Journal of Medicine, 2004