Gout: New Aspects on Managing a Very Old (and Potentially Mismanaged) Disease 

The extreme pain of a gout flare is an alarm signal that something in the body is seriously wrong. It is up to the doctor to figure out the underlying cause, as recommended by Terkeltaub and Edwards in their book about gout. If there is no investigation into the cause of gout, prescribing NSAIDs just muffles the alarm, and prescribing urate lowering drugs such as allopurinol just disables the alarm. Nowadays, in a small minority of cases gout is the warning of lead toxicity. In a large majority of cases it is the warning of chronic intermittent hypoxemia from sleep apnea, which is why most gout flares originate during sleep. The hypoxemia leads to gout by: generation of much excess uric acid from all oxygen-starved cells; serum acidosis which makes uric acid more likely to precipitate from the blood as monosodium urate; increase in serum lactate, which leads to URAT1 reducing renal reabsorption of uric acid; and gradual reduction of the glomerular filtration rate which slows the removal of uric acid from the blood. One of the first things that should be done when gout first occurs is a sleep study, followed by effective sleep apnea treatment when warranted, after which the hypoxemic causes of gout flares will no longer occur. If the sleep apnea goes unresolved for too long, the patient’s risk will be significantly elevated for developing the many life-threatening consequences of sleep apnea, which usually are misunderstood to be metabolic comorbidities of gout, and lead to a shortened lifespan, even with the use of urate lowering drugs. Gout is an early warning! Resolving the sleep apnea should result in no more gout flares. Urate lowering drugs will then probably be needed to accelerate the dissolution of all the urate crystals throughout the body that accumulated from all the previous apneic episodes. More information is available on RU-vid, titled Gout is an Early Warning of Sleep Apnea.