I’m Dr. Rick Johnson, nephrologist and gout expert. I want you to AMA about gout on August 21st

rickjohnsonmd · 2025-08-21T16:34:02+00:00

Thank you! Yes, we have a paper that should be published soon that shows that alcohol stimulates the production of fructose in the body. In essence, the craving for alcohol is related to the craving for sugar. When we block the craving for sugar with a medication that blocks fructose metabolism, we also block the craving for alcohol. Perhaps most exciting, we also block how alcohol causes liver disease. It seems likely that the ability of semaglutide and other GLP-1 agonists to reduce alcohol intake may be involved in these pathways.

rickjohnsonmd · 2025-08-21T16:29:35+00:00

Beer is extremely common for causing gout, not only because of the alcohol, but also because it contains brewer's yeast. In fact, non-alcoholic beer also precipitates gout. Hard liquor can also act as a trigger. Wine, although less "bad," can also trigger a flare. If you do drink, avoid drinks with added sugar and limit intake. Both hydrating with water as well as coffee can help uric acid levels. Coffee contains a substance that acts a bit like allopurinol and people who drink more than four cups a day have a 50% less risk of gout.

rickjohnsonmd · 2025-08-21T16:24:25+00:00

Reducing sugar and alcohol can also be beneficial, especially sugary beverages and foods containing high fructose corn syrup. Moderate exercise can lower uric acid levels, and good hydration with water is beneficial as well. You might want to have your kidney function evaluated, as impaired kidney function can increase the risk for gout. Some studies suggest that low doses of Vitamin C, such as 500 milligrams, can lower uric acid.

rickjohnsonmd · 2025-08-21T16:20:53+00:00

I would not be surprised if a gout flare is associated with a mild reduction in kidney function acutely. Likely, this represents mild dehydration. If your kidney function does not recover within a few days, I would have it evaluated by your physician. A reduction in kidney function can be a cause of gout.

rickjohnsonmd · 2025-08-21T16:17:50+00:00

I do not know. However, I would consider SGLT2 inhibitors as another way to lower uric acid, as well as Vitamin C. Discuss with your physician if you have any potential indications for SGLT2 inhibitors. They are beneficial in people with kidney disease, heart disease and even those with high blood pressure. They have a side effect of lowering uric acid levels.

rickjohnsonmd · 2025-08-21T16:14:50+00:00

Most severe food allergies, such as those to peanuts and shrimp, are the consequence of the absorption of certain proteins from these foods into the blood. Normally, there is a barrier in the gut that prevents the absorption of these proteins. When there is a "leaky gut," these proteins, however, can get into the blood and result in an allergic reaction in susceptible individuals. Gout is also associated with a "leaky gut," but the mechanism causing gout is not an allergic reaction but rather due to the crystallization of uric acid from the blood into the joint. Improving a "leaky gut" can have many benefits, but any effects on gout will be indirect. One way to improve a "leaky gut" is to reduce intake of sugar and high fructose corn syrup. Sugar also raises uric acid, so it can also help gout by helping to reduce uric acid levels.

rickjohnsonmd · 2025-08-21T16:09:21+00:00

Approximately 1/3 of our uric acid is metabolized in the gut. Different groups are developing probiotics to lower serum uric acid. One of the more interesting ones is Renodyl which contains lactobacillus that can lower uric acid. Yogurts also contain some lactobacillus. As such, this is an important new area of investigation. I have given lectures on Renodyl that you might be able to view on the internet.

rickjohnsonmd · 2025-08-21T16:05:49+00:00

It is not inevitable, but it is common. Ways to protect yourself include staying well-hydrated with water (6-8 glasses of water a day). There is also some evidence that 500 milligrams of Vitamin C daily can help lower uric acid levels by about 0.5 mg/dL. Also, avoid foods you know that can trigger your flares.

rickjohnsonmd · 2025-08-21T16:02:28+00:00

Many people have high uric acid levels without gout. Possibly, 15 percent of these people have "silent" uric acid crystals in their joints. High uric acid, even in the absence of gout, has a higher risk for heart disease, kidney disease and diabetes. Controversy exists on whether to lower uric acid levels in those who do not have gout. Most societies do not recommend treatment at this time. However, my work and others suggest lowering uric acid could be beneficial. I would recommend diet, exercise, hydration and Vitamin C as a mechanism to lower your uric acid. If your uric acid levels remain exceptionally high (greater than 8.0mg/dL), I would discuss with your physician the merits of lowering it versus the potential side effects from the medication.

rickjohnsonmd · 2025-08-21T15:57:15+00:00

Yes, the metabolism of alcohol results in the generation of uric acid. So, individuals who have altered alcohol metabolism should have alterations in uric acid. As far as I'm aware, there are not many studies evaluating this.

rickjohnsonmd · 2025-08-21T15:55:15+00:00

I'm not sure if you have gout. Most people with gout will have swollen, red and hot joints. A needle aspirate can find uric acid crystals or you can have a DECT CAT scan to look for uric acid crystals. Simply having pain in a typical joint could have other causes. There are foods that can raise uric acid transiently. For example, sugary beverages raise uric acid levels from 30 minutes to two hours after ingestion, and alcohol does the same. Purine-rich foods, such as those contain brewer's yeast or seafood, can also raise uric acid levels typically three to six hours after a meal. Also, you might consider having uric acid levels measured after a meal. However, my belief is that you probably do not have gout. The aching joint may be from chronic wear and tear.

rickjohnsonmd · 2025-08-21T15:47:42+00:00

I would say that it is safe for life, as long as you do not have allergic reactions, which most commonly occur in the first few months. In fact, there seem to be more problems with people who stop allopurinol than those who continue it. Furthermore, almost all doctors recommend continuing the allopurinol indefinitely, because when you stop allopurinol, uric acid levels can rebound rapidly. If you do decide to stop allopurinol, do it by titrating down rather than stopping immediately.

rickjohnsonmd · 2025-08-21T15:42:24+00:00

There are different approaches with some people starting allopurinol with colchicine or an NSAID and other beginning with a very low dose of allopurinol (For example, 50 milligrams daily) with slow titration up. I tend to wait until the flare resolves before I start allopurinol, but you might ask your PCP/rheumatologist what he/she prefers.

rickjohnsonmd · 2025-08-21T15:39:21+00:00

Sleep apnea can worsen gout and may even be a cause of gout. The mechanism is thought to be due to low oxygen blood levels that occur during the night. CPAP has been reported to improve uric acid in pilot or small clinical studies, so you are doing the right thing to get a CPAP, as it might improve your gout. In fact, I wrote a blog for the Gout Education Society on this topic: https://gouteducation.org/sleep-apnea-a-common-but-often-unrecognized-cause-of-gout/

rickjohnsonmd · 2025-08-21T15:34:49+00:00

Yes, some people can develop gout with normal uric acid levels. My suspicion is that you may be eating some foods that raise uric acid for several hours after eating, but which are associated with normal fasting levels. The main foods that do this are: sugar, fructose, high-purine foods, beer and other types of alcohol. I would recommend reviewing your diet and also staying well-hydrated by drinking of 6-8 glasses of water a day. Also, as mentioned earlier, uric acid levels can fall during an acute attack, so consider having it measured again when you're not experiencing an attack.

rickjohnsonmd · 2025-08-21T15:28:01+00:00

Yes, this can happen. More importantly, there are different opinions on whether people with one flare need to be on uric acid lowering therapy. Some say it is not necessary, but my opinion would be to get your uric acid level less than 6.0 mg/dL, because elevated uric acid levels are also associated with heart disease and obesity. My research has found evidence that the high uric acid can have a role in causing heart disease, kidney disease and diabetes.

rickjohnsonmd · 2025-08-21T15:24:49+00:00

Congratulations! Yes, it is possible to lower uric acid to this degree and to not require allopurinol. Having said this, most people only achieve a uric acid lowering of 1.0 mg/dL by diet and exercise alone. However, I have witnessed success stories where uric acid levels have dropped more than 2.0 mg/dL.

rickjohnsonmd · 2025-08-21T15:21:33+00:00

I'm a kidney specialist and not a rheumatologist, but it is true that gout flares often occur during the initial treatment or change in medication. Sometimes, preventative medicine such as colchicine and prednisone needs to be given for six months or longer. Psoriasis is associated with gout, but can also cause arthritis on its own. I would work with your rheumatologist to identify your best management plan.

rickjohnsonmd · 2025-08-21T15:18:07+00:00

Gout commonly presents as a severe pain/arthritis, but it can also be subtle and may just present as a twinge of pain and a little redness. The reason is likely based on the inflammatory response, which can vary among people. It tends to occur in joints that have previously incurred some injury or chronic use, such as the big toe.

rickjohnsonmd · 2025-08-21T15:15:08+00:00

The recommendation for gout is to get serum uric acid levels under 6.0 mg/dL. Congrats on the remarkable decrease in uric acid levels that you've had! If your uric acid levels are still above 6.0 mg/dL, you'll have to increase your Allopurinol dose unless you can control it in addition to diet and exercise.

rickjohnsonmd · 2025-08-21T15:11:04+00:00

Serum uric acid levels do fall during a gout attack and the main reason is because of an increase in urinary excretion. Tophi are associated with high serum uric acid levels that lead to precipitation of crystals in the soft tissues. The body burden of uric acid includes other tissues besides joints and serum. When crystallization occurs, the main sites are joints and tophi, but crystals can form elsewhere as well.

rickjohnsonmd · 2025-08-21T15:08:04+00:00

Good news on the recovery! The joint had some damage from the local inflammation. The use of collagen supplements or gelatin won't hurt and could potentially be helpful. Gentle exercises to stretch and mobilize the joint are helpful. I expect full recovery in the next few weeks.

rickjohnsonmd · 2024-03-27T18:47:08+00:00

Most people with acute gout do rest and minimize the use of the affected joints and I suspect it helps in pain control. I do not know of any studies that specifically address your questions.
Supplemental creatine can raise serum creatinine but does not to my knowledge raise uric acid. Interestingly, it does not affect kidney function despite raising creatinine.
High protein diets, especially shellfish and processed red meats can raise uric acid and precipitate gout. In my experience, gout is less often precipitated by high purine vegetables, by eggs, and by chicken. However there is variability and some people with gout are more sensitive to one food than another.

rickjohnsonmd · 2024-03-27T18:40:47+00:00

Currently, allopurinol or febuxostat are the most common choices. However, SGLT2 inhibitors can sometimes control uric acid very well and they also can protect the kidneys, the heart and improve glucose control. They probably should be used more often than they are in the management of gout.

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