Gout Attacks Strike Mostly at Night

If you’ve had a gout attack, there is a good chance that the intense joint inflammation woke you from a sound sleep. Research suggests that gout attacks are 2.4 times more likely to occur at night. ¹ Choi HK, Niu J, Neogi T, Chen CA, Chaisson C, Hunter D, Zhang Y. Nocturnal risk of gout attacks. Arthritis Rheumatol. 2015 Feb;67(2):555-62. PMCID: PMC4360969 DOI: 10.1002/art.38917

This blog discusses why gout attacks are more likely to occur at night and steps you can take to prevent them.

Why gout attacks occur at night

A painful gout attack occurs when uric acid crystals collect in a joint and trigger an inflammatory response. The tiny crystals form when there is too much uric acid, or urate, in the body—a condition called hyperuricemia.

See Gout Symptoms

Experts aren’t sure why uric acid crystals tend to collect in joints overnight. It may be one or a combination of reasons, including:

Drop in body temperature

The body’s temperature drops slightly during sleep, and this temperature drop catalyzes the formation of uric acid crystals in the joint. ² Neogi T, Chen C, Niu J, et al. Relation of temperature and humidity to the risk of recurrent gout attacks. Am J Epidemiol. 2014;180(4):372-377. DOI: 10.1093/aje/kwu147 ^{, 3} Roddy E. Revisiting the pathogenesis of podagra: why does gout target the foot?. J Foot Ankle Res. 2011;4(1):13. Published 2011 May 13. PMID: 21569453 doi:10.1186/1757-1146-4-13 This factor may also help explain why gout often affects joints in the feet and fingers—these extremities tend to maintain a lower temperature than the rest of the body.

Changes in breathing

Sleep can induce changes in breathing patterns that influence the production of uric acid in two ways:

1. Your breathing slows down during sleep, and the lungs expel less carbon dioxide. Excess carbon dioxide can cause the blood to become slightly more acidic. This condition, called respiratory acidosis, may encourage the formation of uric acid crystals. ⁴ Martillo MA, Nazzal L, Crittenden DB. The crystallization of monosodium urate. Curr Rheumatol Rep. 2014;16(2):400. PMID: 24357445 doi:10.1007/s11926-013-0400-9
2. A sleep disorder called sleep apnea causes the body to take in less oxygen. The decrease in oxygen can cause the body to produce more purines, potentially leading to hyperuricemia ¹ Choi HK, Niu J, Neogi T, Chen CA, Chaisson C, Hunter D, Zhang Y. Nocturnal risk of gout attacks. Arthritis Rheumatol. 2015 Feb;67(2):555-62. PMCID: PMC4360969 DOI: 10.1002/art.38917 ^{, 5} Zhang Y, Peloquin CE, Dubreuil M, et al. Sleep Apnea and the Risk of Incident Gout: A Population-Based, Body Mass Index-Matched Cohort Study. Arthritis Rheumatol. 2015;67(12):3298-3302. PMID: 26477891 doi:10.1002/art.39330 and a gout attack.

If you have sleep apnea, you may be as much as 50% more likely to have gout. ⁵ Zhang Y, Peloquin CE, Dubreuil M, et al. Sleep Apnea and the Risk of Incident Gout: A Population-Based, Body Mass Index-Matched Cohort Study. Arthritis Rheumatol. 2015;67(12):3298-3302. PMID: 26477891 doi:10.1002/art.39330

Drop in cortisone levels

Your body produces less cortisone while sleeping. Cortisone suppresses inflammation, so a reduction in cortisone production during the night may be a contributing factor in gouty inflammation. ¹ Choi HK, Niu J, Neogi T, Chen CA, Chaisson C, Hunter D, Zhang Y. Nocturnal risk of gout attacks. Arthritis Rheumatol. 2015 Feb;67(2):555-62. PMCID: PMC4360969 DOI: 10.1002/art.38917 ^{, 6} Abhishek A, Valdes AM, Jenkins W, Zhang W, Doherty M. Triggers of acute attacks of gout, does age of gout onset matter? A primary care based cross-sectional study. PLoS One. 2017;12(10):e0186096. Published 2017 Oct 12. PMID: 29023487 doi:10.1371/journal.pone.0186096

Dehydration

A loss of water in both the blood and the joints may play a role in gout attacks in two ways:

1. While sleeping, the body loses moisture through breathing and sweating. As this happens, the blood loses some of its water content. As water content decreases, the concentration of uric acid in the blood increases. This increase leads to or exacerbates hyperuricemia, the precursor to gout.
2. Dehydration can lead to a concentration of uric acid in joint fluid. ¹ Choi HK, Niu J, Neogi T, Chen CA, Chaisson C, Hunter D, Zhang Y. Nocturnal risk of gout attacks. Arthritis Rheumatol. 2015 Feb;67(2):555-62. PMCID: PMC4360969 DOI: 10.1002/art.38917 ^{, 9} Bouloukaki I, et al. (2014). Intensive versus standard follow-up to improve continuous positive airway pressure compliance. European Respiratory Journal, 44(5): 1262–1274. PMID: 24993911 DOI: 10.1183/09031936.00021314 When a body is sleeping, joints are at rest, and some of the water in the joints' fluid gets reabsorbed into the body. The uric acid, however, remains in the joint. The high concentration of uric acid in the joint may spur the formation of uric acid crystals.

   See How Do Synovial Joints Work?

More research is needed to understand how much these factors play a role in nighttime gout attacks.

See Gout Causes and Risk Factors

Preventing nighttime gout attacks

The best way to reduce your risk of a gout attack—at any time of day—is by making a few lifestyle changes and taking the medication your doctor prescribes, such as allopurinol and febuxostat. ⁷ Efthimiou, Petros. (2020). Absolute Rheumatology Review. 10.1007/978-3-030-23022-7. Tips that may specifically reduce the risk of nighttime attacks include:

Treating sleep apnea

Get tested for sleep apnea and treat it, if appropriate. Treatment typically includes using a continuous positive airway pressure (CPAP) machine or another treatment device to increase oxygen intake while sleeping. Increased oxygen intake may lower uric acid production and reduce the risk of a gout attack.

While the primary goals of sleep apnea treatment include improving sleep quality and heart health, ⁸ Giles TL, et al. (2006). Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database of Systematic Reviews (3). PMID: 16437429 DOI: 10.1002/14651858.CD001106.pub2 ^{, 9} Bouloukaki I, et al. (2014). Intensive versus standard follow-up to improve continuous positive airway pressure compliance. European Respiratory Journal, 44(5): 1262–1274. PMID: 24993911 DOI: 10.1183/09031936.00021314 ^{, 10} Milleron O, et al. (2004). Benefits of obstructive sleep apnoea treatment in coronary artery disease: A long-term follow-up study. European Heart Journal, 25(9): 728–734. DOI: 10.1016/j.ehj.2004.02.008 anecdotal evidence suggests that treating sleep apnea alone may significantly affect the frequency of gout episodes. ¹¹ Abrams B. Sleep apnea and gout. Can Fam Physician. 2009;55(3):243-244. PMID: 19282526

Staying well hydrated

Drink plenty of fluids during the day. Drinking fluids can increase blood volume and decrease the concentration of uric acid, lowering the risk of a gout attack. Water is the best drink to keep you hydrated.

Other lifestyle changes that may lower the risk of a gout attack include losing excess weight, getting regular exercise, and eating a whole foods, plant-based diet that is low in purines.

See What Are Purines?

If your health care provider recommends a medication, discuss its benefits as well as potential side effects, health risks, and interactions with existing medications. Once prescribed, please take your medications regularly to get the most benefit in controlling the gout disease and preventing flares.

See Gout Prevention

Learn more:

Gout Treatment

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