Possible Connection Between Gout and Sleep Apnea
Gout is a strange ailment. The typical attack occurs after a large meal full of purines and accompanied by alcoholic drinks. The poor soul goes to sleep and wakes up with an acute gout attack. This is usually after hours of sleep and not after thirty minutes or an hour. Clearly, something has to build up in the body.
The physicians would point to the purines in the meal and the fact that they had to be digested and turned to uric acid. This makes sense but aren’t purine rich meals eaten earlier in the day? Why not more daytime attacks? There are far more that happen at night. There has to be more to this than purines and uric acid?
People who are classified as having normal uric acid levels suffer the night attacks as well as hyperuricemics. This thing that happens at night must explain this as well.
Ninety percent of all of the people who are classified as hyperuricemic never experience gout attacks or kidney stones. If asked “why me”, most physicians will say genetic abnormalities or if they are frank will say that they don’t know. There is more to the attacks than purines and uric acid.
Gout targets middle-aged men and postmenopausal women but it has been known to affect younger people, even children. It does have a familial connection but it is not overwhelming. The ailment also favors overweight and obese people. By itself, purines and uric acid, just don’t answer why gout attacks occur as they do to the people that they do. It needs something else.
Hyperuricemia is one part of the answer but I believe sleep patterns is the other part. Basically, any sleep disturbance that interferes with respiration would contribute to a gout attack. The big one is “obstructive sleep apnea”.
Like gout, apnea is more common in men than in women. Like gout, it increases after menopause. Like gout, it is familial particularly as regards the size of the air passageway. Like gout, alcohol consumption makes it worse.
Keep in mind that whether uric acid crystallizes depends on a number of factors. The two chief ones are the serum uric acid level and the ph level of the blood and synovial fluid. At any given ph level, you can bring on a gout attack by increasing the uric acid level. The reverse is true also. At any given uric acid level, you can bring on a gout attack by lowering the ph level. Sleep apnea both increases the uric acid level and lowers the ph level. Just how much depends on the severity of the apnea. If it is severe enough, even someone with normal uric acid level can get gout attacks.
Sleep apnea is far more common than most people realize and oftentimes it goes undiagnosed. Each episode is marked by a closed air passageway and empty lungs. Most snorers have some apnea episodes but not that many. The number of episodes increase with age and obesity. Some of the cases involve hundreds of such episodes each night. Each episode leaves the blood a little more acidic so that the level builds during the night. This would explain why the attacks occur after a number of hours of sleep instead of right away.
Hyperuricemia is part of the answer but adding sleep disturbances is the other. When you are looking for answers, look at diet but also consider sleep disturbances. Also, severe sleep apnea is life-threatening in its own right. The more you can learn about it, the better. It really is worth it.
Thanks to Brian for his comments regarding Gout!
Whoever was the author of this write-up relating gout and sleep apnea did a beautiful job. The connection is one that I have written about also, but never with the lucidity in this write-up.
The one issue that I would mention is that the same pathway described for obstructive sleep apnea exists for central sleep apnea as well because it also results in frequent periods of oxygen deprivation during sleep. Central sleep apnea is much less common, and is much more difficult to treat effectively. Gout is often the result of sleep apnea, not just obstructive sleep apnea.
Thanks writing this article on sleep apnea and gout. I agree that for those with sleep apnea, this may be a major, if not primary cause of hyperuricemia and gout. However, I believe that this is true for only a very small portion of those suffering from gout.
You pointed out that gout attacks primarily come on in the middle of the night. This is true, and for those with sleep apnea, this may be due to a rise in uric acid levels as body tissues are starved of oxygen and die. We know that cell death can significantly increase uric acid levels. We also know that fluctuations in uric acid levels can bring on gout attacks. However, for most people (those with and without sleep apnea) the major reason why gout attacks come on in the middle of the night is because sleep lowers body temperature. Temperature has a major effect on uric acid crystallization, even more so than pH. The lower the temperature, the more likely it is that crystals will form. This is also why gout attacks typically hit the feet and hands and why tophus (large collections of uric acid crystals) usually form in the feet, hands and outer rim of the ear. These areas of the body are most effected by the lowering of body temperature caused by sleep.
You also mentioned that uric acid levels do not explain everything and that some people with normal uric acid levels get gout attacks. Actually, gout is defined by the formation of uric acid crystals (no uric acid crystals = no gout) and that can only happen when uric acid levels are high enough for crystals to form. Many people that have uric acid levels tested during or shortly after an attack show having normal uric acid levels. And some may be forming tophus, which may act as a “sink” for uric acid, causing them to show lower levels in blood tests. Also, most blood test results show very high levels of uric acid as “normal.”
Thanks for posting this message and getting the word out about gout and its connection to sleep apnea. This area has been little studied and the more attention that can be brought to it, the more likely additional research will be done.
-Victor Konshin
Author of, “Beating Gout: A Sufferer’s Guide to Living Pain Free”
My view is that sleep apnea is a major, not a minor, contributor to gout attacks. The latest epidemiological studies in the USA show that about 20% of the adult population has sleep apnea in at least its mild form. Only about .25% have gout. Most people with sleep apnea have never been diagnosed with it. No medical studies have been published about the coincidence of gout and sleep apnea. My view is based on the results that my doctor reported to me from screening all his gout patients for sleep apnea. He found that a large majority of those patients did indeed have sleep apnea, when neither he nor they suspected it ahead of time.
When my mild sleep apnea was diagnosed and overcome, my gout attacks ceased completely. During the time that I suffered from gout, I tested the theory that overnight attacks were caused by the drop in body temperature, particularly in the extremities. I started sleeping with an electric heating pad covering my feet. They were the warmest part of my body. It didn’t help – I still got a gout attack in my foot. At least for me, the theory of overnight temperature drop causing gout was debunked. The extremities are also at the end of the blood conduit, where oxygen depletion may be most severe due to its being extracted along the conduit path.
The higher blood uric acid level caused by apneic events during sleep may subside shortly after awakening, after the kidneys have had time to dispose of the excess uric acid. Even though blood uric acid levels are known to be highly variable, medical practice has done nothing to standardize the conditions under which it is measured (eg. time elapsed since awakening, time elapsed since last eating, what was eaten and how much). Standards like these have been adopted for the measurement of blood sugar. Until there are such standards for uric acid, I believe that its measurement has little significance.
I neglected to mention that I also authored a book, “The Perils of Sleep Apnea – An Undiagnosed Epidemic”. It includes a discussion of the connection of sleep apnea to gout, and to many other diseases.
So true
Sleep apnea is the major cause of gout.
Please read my story below.
I am 50 years old. Suffering from gout for the last 30 years. Taken every pain killer and upto 20 tablets a day. Voltaren, neprosol, Indocid R,Brufin and colchicin at least 3 a day for 20years. Cortisone when nothing helped. I was a dead man walking. Then I moved onto to herbal medicine for 5 years. My medical bills just went up and up but my gout never came down. Attacks became more frequent, more painful until I saw a deformity in my big toe and knee. I gave up until I went to an ordinary dentist for a filling.He checked my teeth and noticed extreme wear on all the teeth. He suspected I was grinding my teeth during sleep. He suggested I wear gumguards before going to bed but these would not do the job because of my orthodontic problem. The bottom row of teeth needed serious repair work. So until these teeth were not aligned, the filling on the back tooth would not be effective.
My wife also told me that I slept most of the night with my mouth open, snored a lot too.
Of course, my mouth would stay open, because my teeth were crooked and my bite was uneven so my mouth automatically stayed open daytime and during my sleep. My gout attacks occurred at 3am and 5am and they were very severe. SLEEP APNEA and the GOUT ATTACK theory.
I started with my orthodontic treatment in 2008 Jan.
I was 48 at the time. Will not want to describe the pain and discomfort during the treatment but sure was better than the gout pain.
To cut the long story short, my treatment came to and in February 2009, and so did the occurrence of gout attacks.
I now sleep with my mouth closed.
Stopped all medication for the last 6 months.
Eat everything and no gout.
Spent USD1000 on my orthodontic treatment and this has solved my gout problem.
Does it make sense?
Ask me.